1Service dAnesthésie-Réanimation Chirurgicale II, 2Service de Chirurgie Thoracique and 3Service de Radiologie, Centre Médico-Chirurgical de la Maison du Haut-Lévêque, Groupe Hospitalier Sud, Avenue de Magellan, F-33604 Pessac CEDEX, France*Corresponding author
Accepted for publication: October 16, 2001
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Abstract |
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Br J Anaesth 2002; 88: 298300
Keywords: complications, mediastinitis; heart, central venous catheterization; complications, hydrothorax
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Introduction |
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Case report |
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Three days later, the patient developed right upper chest pain of sudden onset, dyspnoea and a temperature of 38°C. A chest x-ray showed a right pleural effusion and a widened mediastinum. Pulmonary angiography ruled out a new pulmonary embolism. Computerized tomography (CT) showed a right pleural effusion and a widened mediastinum with enhanced density and air pockets (Fig. 1). Later the same day, she became even more unwell with severe dyspnoea, hypotension and hyperthermia. Her trachea was intubated and mechanical ventilation of the lungs was started. Norepinephine was required to maintain her blood pressure.
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Discussion |
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(i) blood, mediastinal and pleural effusions grew the same MRSA;
(ii) the tip of the central venous catheter was situated in the mediastinum;
(iii) the presence of triglyceride in the pleural fluid confirmed extravazation of the hyperalimentation fluid;2
(iv) bronchoscopy and oesophagoscopy discarded the possibility of oesophageal or tracheal fistula.
The rare occurrence of this complication may be explained by the fact that it has to combine two mechanisms. First, there must be central venous catheter-related bloodstream infection, which is not infrequent (214 episodes for 1000 catheter days).3 4 Catheter-related bloodstream infections refer to the isolation of the same organism from a quantitative culture of the distal catheter segment and from the blood of a patient with clinical symptoms of sepsis and no other apparent source of infection.4 Unfortunately, there was no catheter tip culture and no parenteral nutrition culture. There are, therefore, four possible pathways for this catheter-related infection: external bacterial colonization; internal bacterial colonization; haematogenous seeding of the catheter during bloodstream infection of any origin; or contamination of the fluids or drugs administered intravenously (so-called intrinsic catheter-related bloodstream infection).4 Involvement of S. aureus suggests the likelihood of external or internal bacterial colonization.4 The attributable mortality of catheter-related bloodstream infection is about 25%.5 6 Gram-positive cocci are responsible for at least two-thirds of the infections. Staphylococcus aureus is responsible for 515% of the infections and is associated with a higher rate of complications.7
The second mechanism involved is perforation of the superior vena cava by the catheter with extravasation of fluid into the mediastinum. Perforation of the superior vena cava by an i.v. catheter has been widely reported. This may induce haemothorax, hydrothorax, pneumothorax, hydromediastinum and pneumomediastinum.812 The incidence of this complication appears to be about 0.5% of catheter placements, but many catheter tip perforations remain undetected or unreported.9 10 13 Diagnosis is commonly delayed, which contributes to patient morbidity and mortality.10
A few cases of chemically induced mediastinitis from central venous extravasation have been reported. No infectious source has been found in these cases. In one case report, mediastinitis was the result of extravasation of hyperalimentation fluid, after migration of a central venous catheter into the mediastinum.2 In this case, it was believed that mediastinitis was secondary to chemical irritation by the hyperalimentation fluid, because all cultures (including catheter tip and pleural fluid) were negative. In three cases (one adult and two children), mediastinitis and venous thrombosis were secondary to catheter-related vesicant chemotherapy extravasation.14 15 In these cases, all the cultures were negative.
Our case emphasizes, once again, that central venous catheterization may induce potentially life-threatening complications. The prevention of catheter-related infected mediastinitis relies on the prevention of catheter-related infection and superior vena cava perforation. Perforation may be the result of mechanical trauma from the catheter tip or chemical damage from infused solutions (hypertonic or vesicant agents).11 The time from catheter insertion to vascular perforation has a range of 160 days.10 In our case, the delay of three days between the insertion of the catheter and the features of perforation (chest pain, dyspnoea) perhaps favours secondary damage.
There are many factors affecting the risk of perforation by central venous catheters. The more perpendicular the catheter tip to the wall of the vein, the greater the risk of perforation.9 12 13 Catheters inserted through the left subclavian or internal jugular vein are more at risk of perforation, because the innominate vein forms a right angle to the superior vena cava and the catheter tip may be positioned against the lateral wall of the superior vena cava with a wide angle.8 10 12 13 16 17 On insertion of a central venous catheter a return of blood through the catheter must be obtained in order to exclude venous perforation by the guidewire, but it does not exclude an extravascular position of the catheter tip, since most catheters have side holes.8 10 The best test to confirm correct tip placement is a chest x-ray, provided that the catheter is radioopaque (which was not so in our case).
In our case, the patient's symptoms included chest pain and dyspnoea. Chest pain has been reported previously in patients with chemically induced mediastinitis,2 14 but also in patients with catheter malposition against the sidewall of the superior vena cava.17 Dyspnoea has been observed only in patients with mediastinitis and central vein perforation.13 17 The chest x-ray in our case showed a widened mediastinum, as in all but one of the cases of chemical-induced mediastinitis.2 8 10 1315 Contrast infusion through the catheter may help the diagnosis (demonstrating extravazation in the mediastinum).10 13 When mediastinal extravasation occurs, our case emphasizes the need to culture the catheter tip in order to exclude infection. Any pleural effusion should be drained by thoracocentesis, and the pleural fluid cultured. If fever, bacteraemia or shock occurs, a thoracotomy to drain the mediastinal and pleural effusions should be considered.
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References |
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