Department of Internal Medicine, Division of Cardiology, Our Lady of Mercy Medical Center, 600 East 233rd Street, Bronx, NY 10466, USA
Corresponding author: 1 Shore View Dr, Apt 4, Yonkers, NY 10710, USA. E-mail: dilipu@hotmail.com
Accepted for publication: May 5, 2003
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Abstract |
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Br J Anaesth 2003; 91: 7479
Keywords: complications, left bundle branch block; equipment, catheters central venous; heart, arrhythmia; heart, catheterization
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Case report |
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Central venous cannulation was attempted via the right internal jugular vein. Soon after the guide wire was passed, the patient complained of dizziness and became bradycardic and hypotensive. The cardiac monitor showed complete heart block (CHB) with a ventricular rate of 34 beats min1, which did not respond to atropine and required temporary transvenous pacemaker insertion (Fig. 1). Plasma concentration of digoxin was 0.4 mg dl1 and cardiac enzymes were normal. The patient remained pacemaker-dependent for the next few hours and then the previous cardiac rhythm returned; the pacemaker was removed after 48 h. An echocardiogram showed a dilated heart and severe left ventricular dysfunction, with an ejection fraction of 20%.
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Discussion |
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The incidence of RBBB during passage of wires and catheters into the heart is 312%.15 Occurrence of new left fascicular blocks, anterior and posterior, along with RBBB has also been reported, and is explained by longitudinal dissociation of fibres in the bundle of His.1 5 RBBB, even transient, in a patient with LBBB can cause CHB and haemodynamic instability, as the block is usually below the bundle of Hisan unstable escape rhythm.1 2 The chance of developing CHB during pulmonary artery catheterization does not seem to be increased with pre-existing LBBB,13 but some studies have found an increased risk (23 vs 5%).6 Some authors suggest using a prophylactic temporary pacemaker in patients with LBBB undergoing right heart catheterization, because of the risk of CHB,1 7 8 but others argue that the small chance of this complication and the complications of pacemaker insertion do not warrant the delays involved.2 3
In patients with this complication, the block is probably in the right bundle branch, rather than in the AV node or bundle of His.14 9 However, when fascicular blocks accompany RBBB, the bundle of His is more likely to be the site of damage.1 5 The ease of right bundle branch involvement is probably because it is placed superficially in the right ventricular endocardium below the tricuspid valves.2 5 10 The left bundle is less susceptible because of its earlier branching in the septum and dispersed nature. Development of CHB in patients with RBBB and anterior fascicular block has been reported during left heart catheterization.9
Conduction block during insertion of a central venous cannula is rare compared with pulmonary artery or cardiac catheterization as placement should not involve entry into the heart.15 However, onset of cardiac conduction abnormalities with central cannula insertion is important as, unlike the insertion of pulmonary artery catheters or temporary pacemakers, they can be inserted without ECG monitoring. The guide wire tips are less flexible and rigid, making them more arrhythmogenic compared with conventional or flow-directed balloon-tipped catheters.1 Transient RBBB in a patient with normal baseline ECG may remain unrecognized, but in a patient with LBBB, RBBB may result in life-threatening complications; even asystole has been reported.1
Other cardiac complications from guide wire insertion include arrhythmias (premature ventricular contractions, ventricular fibrillation) or perforation resulting in cardiac tamponade.1 5 1114 Passage into the inferior vena cava can dislodge devices like vena cava filters.15 External landmarks are not reliable predictors of insertion lengths and assessments from radiographs correlate poorly with direct measurements.12 15 If the insertion of the guide wire does not exceed 22 cm, the incidence of complications is reduced by around 70%.1 The mean distance from access sites to the junction of the superior vena cava with the right atrium was 18 cm; the right internal jugular vein was the shortest (16 cm) and left subclavian vein the longest (21.2 cm).15 The usual upper limit of safe guide wire insertion in an adult patient is 18 cm,15 and the length of guide wire inserted should only extend 23 cm beyond the final position of the catheter tip.15 A catheter tip can move 13 cm with movement of the patients arms, head or neck, and the final position should provide for this movement without causing complications.15 It is generally recommended that cannulae should be inserted to a depth of 1316 cm via the right, and 1520 cm via the left jugular vein.16 Shorter cannulae catheters are available and 1516 cm catheters reduce the potential for right atrial placement.12
In summary, central venous cannulation in patients with pre-existing LBBB should be done with caution. The insertion of the guide wire should not exceed 1820 cm and the position of the catheter should be checked radiologically, at insertion and periodically, to confirm placement outside the heart.11 13 Markings on guide wires may help decrease complications from insertion too far. In the case presented, we show that conduction block was caused by transient injury to the conducting system by the guide wire.
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References |
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