|LETTER TO EDITOR
|Year : 2013 | Volume
| Issue : 1 | Page : 138-139
Extravascular displacement of distal port tip of central venous catheter: A potentially life-threatening complication
Tanmoy Ghatak, Arvind K Baronia
Department of Critical Care Medicine, SGPGIMS, Rai Bareilly Road, Lucknow. Uttar Pradesh, India
|Date of Web Publication||26-Jun-2013|
Department of Critical Care Medicine,SGPGIMS, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ghatak T, Baronia AK. Extravascular displacement of distal port tip of central venous catheter: A potentially life-threatening complication. Anesth Essays Res 2013;7:138-9
|How to cite this URL:|
Ghatak T, Baronia AK. Extravascular displacement of distal port tip of central venous catheter: A potentially life-threatening complication. Anesth Essays Res [serial online] 2013 [cited 2020 Jun 1];7:138-9. Available from: http://www.aeronline.org/text.asp?2013/7/1/138/114023
Central venous catheterization is an essential part of critical care and like all other procedure, it is not complication free.  Recently, we encountered a potentially life threatening and under documented complication of extravascular displacement of catheter's distal port due to inadvertent loop of inner (inside the skin) part of central venous catheter (CVC).
A 58-year-old nonobese unconscious male, presented to intensive care unit with acute onset respiratory failure due to suspected myasthenic crisis and hemodynamic instability. Soon after intubation and initiating mechanical ventilation a 7-French 20-cm triple lumen CVC (AMC Thromboshield, Edwards life-sciences, Irvine, USA) was uneventfully inserted in the right subclavian vein through the infraclavicular approach using the Seldinger technique. All the three ports were checked for free flow of blood and catheter was secured by sutures at 13 cm and Tegaderm applied. Central venous waveform was appreciated on the monitor. Few hours later he developed atrial ectopics, which were thought to be due to irritation by the catheter tip. The catheter was repositioned at 12 cm at skin and fixed by similar way after checking for free flow of blood from all the ports. Ectopics stopped and central venous waveform was all right. First (proximal) port was dedicated to intravenous drug infusions and IV fluids and the second for antibiotics. We did an early tracheostomy in view of long-term ventilation. On 4 th day of tracheostomy patient developed ventilator associated pneumonia and shock requiring norepinephrine infusion. He responded to fluid given by proximal port but not to norepinephrine (20 μg/ml) started through the distal port. A close observation revealed fluid leakage from catheter insertion site and the mark at skin exit was 12 cm. Blood could not be aspirated from the distal (norepinephrine) port. Luckily, due to early detection and low concentration of noradrenaline, no skin reaction was noticed. Recent chest x-ray revealed tip of the catheter reaching up to the level of tip of the second rib with loop of inner part of CVC [Figure 1]. Soon another CVC was inserted from the left subclavian site and patient responded to norepinephrine infusion through the new catheter. The mal-positioned catheter was removed.
|Figure 1: Chest X-ray of the patient showing central venous catheter tip at 2nd rib junction (arrowed) with loop of inner part of CVC|
Click here to view
Placement of the tip of CVC at the right atrium and superior vena cava junction is necessary to decrease tip-related atrial irritation and appropriate measurement of central venous pressure.  Literature talks about the CVC length that is outside the skin. , Patient's height-based formula [(height in cm/10)-2 cm]  for catheter length to achieve the desired tip placement in right subclavian infraclavicular approach is very popular. But, wide variation in local anatomy of patient thwart guarantee of accurate placement of all the ports of CVC inside vein. Interestingly, even that outer length remains fix, accidental displacement of CVC distal port can occur by direct or indirect manipulation like coiling in subcutaneous tunnel, patient positioning during tracheostomy, daily back dressing, etc., Like in this case, even no displacement in the outer part of CVC drags the opening of distal port (5 cm from tip in this CVC) outside the vein due to movement of part of CVC under skin.
This observation suggests that even the outer (outside skin) part of CVC remains fixed, yet repositioning of patient can lead to inadvertent loop/coiling of inner part of CVC. Aspiration of free blood flow from the port of CVC is a must before using it for vasoactive drugs even if the mark at skin is unchanged. Importantly, a transparent dressing should be preferred allowing a quick check for any fluid leakage or ooze. Lastly, daily case notes should include a record of CVC mark at skin and check chest X-ray is must to locate the inner part of CVC.
| References|| |
|1.||McGee DC, Goud MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33. |
|2.||Kapoor MC, Kumar S, Gourishanker R. Fluid infusion into the pericardium resulting from accidental displacement of a subclavian venous cannula. Ann Card Anaesth 2011;14:41-4. |
|3.||Czepizak CA, O'Callaghan JM, Venus B. Evaluation of formulas for optimal positioning of central venous catheters. Chest 1995;107:1662-4. |