Financial Support- Subharti Medical College, Meerut, U.P., INDIA.

Introduction

Placement of central venous catheters, although often considered to be a relatively safe and “junior” level procedure, may be associated with life-threatening complications. Complications ₁,₂,₃,₄ can be of an acute nature, which fell into the categories of pneumothorax, hydrothorax, cardiac tamponade, and hemothorax or manifesting later viz shearing or migration of catheter, infection at the catheter site, embolism etc. We present here a case of an eighteen year old male patient who had a central venous catheter (CVC) inserted in the right internal jugular vein during thoracotomy for hemothorax. Although the conventional techniques for checking catheter position were consistent with correct placement, the catheter was found to traverse the pleural cavity during thoracotomy.

Case report

Discussion

Central venous catheters are essential components of modern critical care. They allow delivery of medications, i.v. fluids, parenteral nutrition, hemodialysis and monitoring of haemodynamic variables.

Unfortunately, the use of central venous catheters is associated with adverse events that are both hazardous to patients and expensive to treat.₅, ₆, ₇. More than 15 percent of patients who receive these catheters have complications.₈,₉,₁₀ Mechanical complications are reported to occur in 5 to 19 percent of patients,₈,₉,₁₁ infectious complications in 5 to 26 percent,₈,₁₀,₁₂ and thrombotic complications in 2 to 26 percent.₈

In our case, CVC was placed in right internal jugular vein. At the time of procedure, patient was hypotensive and insertion was done as an emergency procedure as the patient was bleeding. Confirmation was done by freely aspirating blood from both lumens of CVC. Confirmation by chest x- ray could not be done because of lack of time. As the pleural cavity was filled with blood, so we were able to freely aspirate blood from both lumens of CVC. Diagnosis of misplacement was made only after thorax was opened and surgeon visualized the tip of CVC in the pleural cavity.

This clearly indicates that tests routinely done to confirm the position of CVC in patients with hemothorax may fail as they happened in our case.

Another approach to put CVC is by the use of real time ultrasound. During internal jugular venous catheterization, ultrasound guidance reduces the number of mechanical complications, the number of catheter-placement failures, and the time required for insertion ₁₃,₁₄,₁₅,₁₆. Ultrasound guidance for venous cannulation is expensive, time-consuming, and requires an experienced operator. As a result, this method is not used routinely but is reserved for situations where attempted central venous cannulation using anatomical landmarks has failed. Failed venous cannulation is most likely to occur when physicians with limited experience are attempting emergency venous cannulation, such as during cardiopulmonary resuscitation ₁₇, ₁₈. Unfortunately, this situation is not well suited for the use of ultrasound because of the time required and the need for experienced personnel.

This complication has not been reported so far in the literature to our knowledge but can lead to disastrous consequences.

Thus, in patients with hemothorax who require CVC placement, there can be three approaches to place CVC:

1. Avoid internal jugular/ subclavian route and put CVC by other route(femoral, basilic, cephalic, external jugular),

2. Avoid inserting CVC on the same side as injury, and

3. If available, prefer ultrasound guided placement of CVC.

Correspondence to

Dr. Amit Gupta, Mailing Address: A-5, Padam Kunj, Kishan Flour Mill, Railway Road, Meerut, U.P., INDIA. Phone No.: +91-9412101475 Fax No.: +91-0121-2767018 E-Mail- amitgupta_f2@yahoo.com