Intensive Care Unit, York District Hospital, Wigginton Road, York YO31 8HE, UK
Accepted for publication: May 8, 2002
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
Br J Anaesth 2002; 89: 64750
Keywords: complications, respiratory; equipment, catheters central venous; fluids, i.v.; lung, damage; lung, interpleural space; surgery, laparotomy
![]() |
Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
Case report |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
On the third day of his hospital admission, a decision was made to start parenteral feeding as he was not expected to absorb enteral feed. An experienced senior house officer in anaesthesia placed an 18-gauge single lumen 15 cm catheter LeaderCath (Vygon UK Ltd., Gloucestershire, UK) into the left internal jugular vein. The entry point was midway from a line drawn between the suprasternal notch and the mastoid process. Initial cannulation of the vein was not easy, but blood was eventually aspirated via the needle. The guidewire threaded easily and blood could be aspirated through the catheter. At this point the patient complained of feeling a lump in his throat. The anteroposterior chest x-ray showed the tip of the catheter in a position consistent with placement within the left brachiocephalic vein (Fig. 1) and total parenteral nutrition (TPN) was started. There was no reason to doubt the position of the catheter in the vein and the pressure in the cannula was not measured to ensure that a CVP trace was present. The patient made a good recovery from his operation, and on the 4th day he was discharged from HDU to the ward.
|
|
|
![]() |
Discussion |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
Reports of ipsilateral pleural effusion following misplaced central venous catheters are not unusual.3 4 Possible channels communicating between the peritoneal cavity and the pleural cavity have also been reported.5 However, no communications are known between the two pleural cavities. Hence, this case is unusual. Two similar cases of bilateral pleural effusions following attempted central venous catheter placement have been reported,1 2 although no explanations were suggested for the complication.
I.v. nutrition in patients who are unable to start enteral nutrition is a well-established clinical technique. Because of their hypertonicity, these solutions must be given into a vessel with rapid blood flow and adequate mixing. This usually involves using a central venous catheter. Complications of central venous catheter placement include pneumothorax, pleural effusion, thrombophlebitis, brachial plexus injury, mediastinal haematoma and arterial cannulation.6
Percutaneous insertion of central venous catheters are usually done by using surface anatomical landmarks (palpable or visible structures) with known relationships to the desired vein. The infraclavicular approach to the subclavian vein requires finding the correct location of the clavicle, suprasternal notch and sternocleidomastoid clavicular triangle landmarks, proper positioning of the patient and operator and correct venepuncture point depth, direction and insertion angle. Similarly, the various approaches to the internal jugular vein require thorough knowledge of this veins course in relation to the sternocleidomastoid muscle and carotid artery.
Newer techniques, such as portable ultrasound devices, provide bedside imaging of the central veins during catheter placement.7 8 The advantages of ultrasound-guided central venous catheter placement include detection of anatomical variations, exact vessel location, avoidance of central veins with pre-existing thrombosis that may prevent successful catheter placement and guidance of both guidewire and catheter placement after initial needle insertion. Although there is no doubt that these devices improve the safety of central venous catheter insertion, they may not prevent subsequent malposition or vascular perforation. Free aspiration of blood from the catheter, an appropriate pressure trace and the chest x-ray remain the routine methods of confirming the position of a catheter. Contrast studies are a gold standard for catheter position assessment.
Catheterization via the internal jugular vein may result in fewer malpositions than catheterization via the subclavian vein.6 Generally, catheterization via the left internal jugular vein results in more malposition and vascular perforation than a catheter placed from the right internal jugular vein. This is because the right internal jugular vein runs into the right brachiocephalic vein in a fairly straight course whereas the left internal jugular vein forms a greater bend when it becomes the left brachiocephalic vein. The left internal jugular vein was chosen in this case because there was already an internal jugular cannula on the right-hand side.
Catheter tip migration is a recognized phenomenon following central venous catheterization, occurring to some degree in approximately 17% of all percutaneously introduced catheters.9 Poor position or aberrant location from catheter tip migration has been shown to occur in up to 6% of catheters.10 However, only two similar cases of bilateral pleural effusions following central venous catheterization were found in the literature. This is a rare complication that is yet to be satisfactorily explained.
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() |
---|
2 Simmons TC, Henderson DR. Bilateral pleural and pericardial effusions because of mediastinal placement of a central venous catheter. J Parenteral Enteral Nutr 1991; 15: 6769[Abstract]
3 Rudge CJ, Bewick M, McColl I. Hydrothorax after central venous catheterization. Br Med J 1973; 3: 235[ISI][Medline]
4 Thomas CJ, Butler CS. Delayed pneumothorax and hydrothorax with central venous catheter migration. Anaesthesia 1999; 54: 98790[ISI][Medline]
5 Kanno T, Yoshikawa D, Tomioka A, Kamijyo T, Yamada K, Goto F. Hydrothorax: an unexpected complication after laparoscopic myomectomy. Anaesthesia 2001; 87: 5079
6 Dunbar RD, Mitchell R, Lavine M. Aberrant locations of central venous catheters. Lancet 1981; 1: 7115[Medline]
7 Denys BG, Uretsky BF, Reddy PS. Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external landmark-guided technique. Circulation 1993; 87: 155762[Abstract]
8 Gualtieri E, Deppe SA, Sipperly ME, Thompson DR. Subclavian venous catheterization: greater success rate for less experienced operators using ultrasound guidance. Crit Care Med 1995; 23: 6927[ISI][Medline]
9 Lang-Jensen T, Nielsen R, Sorensen MB, Jacobsen E. Primary and secondary displacement of central venous catheters. Acta Anaesthesiol Scand 1980; 24: 2168[ISI][Medline]
10 Vazquez RM, Brodski EG. Primary and secondary malposition of silicone central venous catheters. Acta Anaesthesiol Scand Suppl 1985; 81: 226[Medline]