Lethal air embolism following removal of a double lumen jugular vein catheter

Walther H. Boer and Ronald J. Hené

Department of Nephrology, University Hospital Utrecht, Utrecht, The Netherlands

Correspondence and offprint requests to: Dr Walther H. Boer, Department of Nephrology, University Hospital (room F 03.226), P.O. Box 85500, 3508 GA Utrecht, The Netherlands.

Introduction

The use of central venous catheters introduced into the jugular or subclavian vein is common clinical practice for parenteral nutrition, administration of anti-tumour drugs, plasmapheresis or haemodialysis. Complications are usually associated with the introduction procedure itself (e.g. local haematoma, pneumothorax or haematothorax) or with the period that the catheter is being used (exit site infection, bacteraemia, sepsis). We report the uncommon, in our case lethal complication of air embolism which occurred following removal of a jugular vein catheter used for plasmapheresis and discuss preventive measures.

Case

A 36-year-old man was diagnosed as having Refsum's disease by the department of Neurology several years ago. This recessive familial disease is caused by a deficiency of phytanic acid hydroxylase and is associated with accumulation of phytanic acid in plasma and tissues. The clinical consequences are peripheral neuropathy, cerebellar ataxia and retinitis pigmentosa. Due to clinical deterioration, the patient was referred to the dialysis unit of our hospital for plasmapheresis in order to deplete tissue phytanic acid stores [1,2]. On September 24, 1997, a 12 French 13-cm long polyurethane double-lumen catheter (Arrow, Reading, PA, USA) was introduced into the right jugular vein using ultrasound guidance. The procedure was uneventful, although it was noted that a coughing reflex could be easily provoked by applying pressure to the neck. The last plasmapheresis treatment was performed on October 6, 1997. During this session, the patient received a priming dose of 5000 units of heparin followed by a maintenance dose of 500 U/h intravenously. The catheter was removed at the end of the session according to the standard procedure, which involved placement of the patient in the head-down position and control of haemostasis by applying local pressure using a gauze for 10 min. When the patient resumed the sitting position after the procedure had been completed, he started coughing, and bleeding from the exit site occurred. The patient was again placed in the supine position and pressure was applied to the exit site until bleeding had stopped. Physical examination of the chest revealed no abnormalities, the patient was normotensive and was in no apparent distress.

After the patient had been sitting again for a while he suddenly became agitated, developed seizures and lost consciousness. The hospital resuscitation team was alerted but did not have to assist because upon its arrival the patient had regained consciousness and all symptoms, including coughing, had subsided. The physician in charge of the resuscitation team made a tentative diagnosis of severe vaso-vagal collapse with cerebral hypoperfusion following manipulation on the neck in the glomus caroticum area. Although the patient was well again and wanted to go home, a neurological consultation was asked for which yielded no abnormalities. Directly after the consulting neurologist had finished his examination cardio-respiratory arrest occurred and the resuscitation team, which was still on the scene, started a resuscitation procedure which was unfortunately without success. The diagnosis of air embolism was not considered at that moment and no attempt was made to aspirate air from the circulation during the resuscitation procedure. However, no air aspiration was noted during the introduction procedure of an external pacemaker through the right subclavian vein. Because the diagnosis of air embolism was considered later, the heart was opened while it was immersed under water during the post-mortem examination which took place the following day. During this procedure, air was clearly seen to escape from the right atrium and the diagnosis of air embolism was established. No abnormalities were found in the area of the jugular vein, the carotid artery or the superior vena cava, excluding insertion-related damage.

Discussion

Air embolism is not an uncommon complication of various medical or surgical procedures and can be observed after neurosurgical, gynaecological and otolaryngological procedures [3] as well as during instrumentation of the large central veins [4]. Catheter-related venous air embolism may be caused by mechanical problems (fracture or detachment of catheter connections, inadequate function of introducer sheaths), failure to occlude the insertion needle or the catheter opening during introduction [5] or persistence of a subcutaneous tract after catheter removal [6]. The risk of venous air embolism is increased by conditions that decrease central venous pressure, such as hypovolaemia, deep inspiration or the patient being in the upright position during instrumentation.

Our patient suffered a fatal air embolism after removal of a double lumen jugular vein catheter. This was caused by an unfortunate combination of predisposing factors. To begin with, the subcutaneous tract was probably rather short because the patient was remarkably lean and hardly had any subcutaneous fat in the area of the neck. Moreover, the jugular vein was localized by ultrasound during the introduction procedure and was punctured in the direct vicinity of the ultrasound transducer in a rather perpendicular fashion which also contributed to creation of a short subcutaneous tract. Increased risk for air embolism after removal of central venous catheters has indeed been reported in lean people, specifically in patients after lung transplantation [7]. A complicating factor in these patients is that they also tend to generate low intrathoracic pressures. Furthermore, the diameter of catheters used for plasmapheresis in our centre is quite large (12 French) and the catheter had been in situ for almost 14 days, thus creating a potentially wide and well-established subcutaneous tract. As the patient was given heparin on the day of catheter removal, sealing of this probably short and wide subcutaneous tract was hampered by inadequate coagulation. To aggravate things even more, the patient developed a coughing response after removal of the catheter and application of local pressure to the neck for haemostasis, possibly as a consequence of vagal stimulation. Generation of a marked negative intrathoracic pressure during unexpected coughing probably caused the aspiration of a lethal volume of air under the specific conditions outlined above.

According to the recommendations suggested by Hanley et al. who reported a case very similar to ours [8] and Mennim et al. [9] we have adapted and changed the procedure for the removal of central venous catheters in our centre (Table 1Go). First, no heparin is given to patients on the day that removal of a catheter is planned. If removal of a catheter was not foreseen and the patient received heparin, catheter removal is postponed to the following day if possible. If the catheter has to be removed, e.g. for infectious reasons, protamine is given prior to removal. During the procedure, the patients are placed in the head-down position, making sure that the exit site is well below the right atrium. They are specifically instructed to inhale and hold their breath for a few seconds until the catheter has been removed and are warned not to cough, talk or make a deep inspiration during the actual catheter removal. The gauze used to occlude the exit site while the catheter is being pulled out is covered with a generous amount of an inert ointment to provide an instantaneous air seal. After application of local pressure for 10 min, the absence of bleeding is checked and an air-occlusive dressing is rapidly applied with the patient still in the head-down position. If the exit site is still bleeding, more time is allowed for haemostasis. The patient is observed for 30 min before leaving the dialysis facility. The air-occlusive dressing is left in place for at least 24 h. No distinction is made in this procedure between central catheters placed in the jugular or subclavian vein, although the latter may theoretically have a lower risk for air embolism following removal because the subcutaneous tract will tend to be longer. The protocol is not used during removal of catheters placed in the femoral vein because the risk of air embolism is judged to be extremely low, as sub-atmospheric intravascular venous pressures at this site are unlikely to occur.


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Table 1. Measures to prevent air embolism during and after removal of central venous catheters
 
We feel that air embolism during or after removal of a central venous catheter can be prevented by these simple measures. It may seem exaggerated to pay so much attention to the relatively simple procedure of removing a central venous catheter. However, having witnessed the dramatic and essentially preventable complication reported above makes adherence to this simple protocol aimed at preventing air embolism no burden.

References

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