Bilateral pleural effusions: unexpected complication after left internal jugular venous catheterization for total parenteral nutrition

H. G. W. Paw

Intensive Care Unit, York District Hospital, Wigginton Road, York YO31 8HE, UK

Accepted for publication: May 8, 2002


    Abstract
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
Bilateral pleural effusions occurred after total parenteral nutrition was administered via a left internal jugular venous line. The most likely explanation for the fluid passage into both pleural cavities was migration of the tip of the catheter from within the vein into the mediastinum. Fluid can pass into both pleural cavities via anatomical communications, yet to be described, which exist between the two pleural cavities.

Br J Anaesth 2002; 89: 647–50

Keywords: complications, respiratory; equipment, catheters central venous; fluids, i.v.; lung, damage; lung, interpleural space; surgery, laparotomy


    Introduction
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
Central venous catheterization can cause various complications, which are on the whole simple to explain with our current knowledge of anatomy. This case report, however, describes a complication occurring after internal jugular venous catheterization, which is difficult to explain with our current knowledge of anatomy. Reports of ipsilateral pleural effusion following misplacement of a central venous catheter are not unusual. However, communications between the two pleural cavities are not known. A similar case of bilateral pleural effusions following a left internal jugular venous cannulation has been reported.1 A second case of bilateral pleural effusions following an attempted right subclavian venous cannulation has also been reported.2 No explanation was provided for the complication in either paper.


    Case report
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
A 62-yr-old man with a 2-day history of severe abdominal pain associated with vomiting was admitted to hospital as an emergency. He underwent an uneventful laparotomy on the same day. The operative findings were a 50-cm section of infarcted terminal ileum and 10 cm of ischaemic terminal ileum in continuity with the caecum. A small bowel resection and a limited right hemicolectomy were done. A thoracic epidural was placed for postoperative pain relief. A four-lumen catheter was inserted uneventfully into the right internal jugular vein. A portable anteroposterior chest x-ray confirmed the position of the line to be satisfactory and a good central venous pressure (CVP) trace was measured with a transducer. Because this patient had a complex medical history (multiple previous myocardial infarctions and a pulmonary embolus after an inguinal hernia repair), he was admitted to intensive care after surgery. The tracheal tube was removed the next morning and transferred to the high dependency unit (HDU).

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.



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Fig 1 Chest x-ray showing the tip of the right internal jugular line in a position consistent with placement within the superior vena cava, and the tip of the left internal jugular line in a position consistent with placement within the left bronchiocephalic vein.

 
Two days after the commencement of TPN, the patient was noted to be more breathless. High flow oxygen via a face mask was needed to keep his arterial oxygen saturation above 90%. Arterial blood gas analysis showed a pH of 7.33, a carbon dioxide tension (PaCO2) of 7.6 kPa, and an oxygen tension (PaO2) of 7.1 kPa while breathing 60% oxygen. A chest x-ray showed bilateral pleural effusions (Fig. 2). Ultrasonography of the thorax confirmed large bilateral pleural effusions. A 20-F chest drain was placed into each side of the chest. Over 2 litres of white, milky fluid was drained from the right-hand side and another 2 litres of a similar milky coloured fluid was drained from the left-hand side. As the fluid was suspected to contain TPN, the infusion was immediately stopped. It was not possible to aspirate blood, air or fluid from the venous cannula. Biochemical analysis of the drained fluid from both sides suggested that it was TPN. The two samples of drained fluid had glucose concentrations of 20.0 mmol litre–1 and 22.0 mmol litre–1. The patient’s blood glucose was 4.9 mmol litre–1 at the time. The glucose concentration of the TPN was 397 mmol litre–1. The drained fluid was presumably a mixture of TPN and pleural fluid. Before the removal of the catheter, 60 ml of radiographic contrast was injected. An immediate chest x-ray showed contrast in the upper mediastinum (Fig. 3). However, a repeat chest x-ray 45 min later showed no contrast in the chest. It was assumed to have drained from the chest drains.



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Fig 2 Chest x-ray showing bilateral pleural effusions.

 


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Fig 3 Chest x-ray showing the spill of contrast into the upper mediastinum immediately following its injection into the left catheter.

 
After placing the chest drains, arterial blood gas analysis showed a pH of 7.38, PaCO2 of 6.2 kPa and PaO2 of 14.0 kPa on 60% oxygen via a facemask. The chest radiograph showed resolution of both pleural effusions and re-expansion of both lungs. Antibiotic treatment with cefotaxime and metronidazole was continued, which had been started empirically after surgery. Over the next 3 days, further drainage from both chest drains was minimal and the patient remained apyrexial and well. The chest drains were removed after 3 days and the patient was finally discharged from hospital 12 days after the laparotomy.


    Discussion
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
This is a case of bilateral pleural effusions after attempted left internal jugular venous cannulation. The most likely explanation of the bilateral effusions is the passage of TPN from the displaced catheter into the mediastinum and then into both pleural cavities via anatomical communications between them. Fortunately, the patient recovered uneventfully.

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 vein’s 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
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
1 Campagnutta E, Segatto A, Maesano A, Sopracordevole F, Viscentin MC, Scarabelli C. Bilateral hydrothorax and hydromediastinum after cannulation of the left internal jugular vein. Minerva Ginecol 1989; 41: 479–83[Medline]

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: 676–9[Abstract]

3 Rudge CJ, Bewick M, McColl I. Hydrothorax after central venous catheterization. Br Med J 1973; 3: 23–5[ISI][Medline]

4 Thomas CJ, Butler CS. Delayed pneumothorax and hydrothorax with central venous catheter migration. Anaesthesia 1999; 54: 987–90[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: 507–9

6 Dunbar RD, Mitchell R, Lavine M. Aberrant locations of central venous catheters. Lancet 1981; 1: 711–5[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: 1557–62[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: 692–7[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: 216–8[ISI][Medline]

10 Vazquez RM, Brodski EG. Primary and secondary malposition of silicone central venous catheters. Acta Anaesthesiol Scand Suppl 1985; 81: 22–6[Medline]





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