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CASE REPORT
Ahead of print publication  

Adverse hemodynamic response due to malposition of central venous catheter


1 Resident Anaesthesiology, INHS Asvini, Mumbai, Maharashtra, India
2 Classified Specialist and Professor, Cardiothoracic Anaesthesiology, INHS Asvini, Mumbai, Maharashtra, India
3 Senior Advisior and Head of the Department , Department of Anaesthesiology and Critical Care, INHS Asvini, Mumbai, Maharashtra, India

Date of Submission27-Oct-2019
Date of Decision23-Nov-2019
Date of Acceptance18-Jul-2020
Date of Web Publication01-Apr-2021

Correspondence Address:
Shaikh Azimuddin Najmuddin,
INHS Asvini, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_66_19

  Abstract 


Central venous catheter (CVC) is an inescapable requirement of any cardiac surgery for administering drugs including inotropes, cardiac pacing, and invasive monitoring during the perioperative period. Central venous access involves triple-lumen catheter inserted in the internal jugular or femoral vein. The preferred vein for CVCs is the right internal jugular vein because of straighter course to the right heart, better visibility on ultrasonography, lowest risk of the venous stenosis and thrombosis, and also keeping in mind the nature of surgery involved and patient positioning. Malposition of the catheter is a relatively common complication (5.01%) which results in the malfunction of catheters. We report a case of a malposition of a CVC in a 70-year-old male who underwent mitral and aortic valve replacement along with coronary artery grafting for the posterior descending artery on cardiopulmonary bypass.

Keywords: Central venous catheter, fluoroscopy, hemodynamic variations, internal jugular vein, malposition, ultrasonography guidance



How to cite this URL:
Najmuddin SA, Taneja S, Kulkarni SN. Adverse hemodynamic response due to malposition of central venous catheter. J Mar Med Soc [Epub ahead of print] [cited 2021 Apr 23]. Available from: https://www.marinemedicalsociety.in/preprintarticle.asp?id=312891




  Introduction Top


Central venous catheter (CVC) is an inescapable requirement of any cardiac surgery for administering drugs including inotropes, cardiac pacing, and invasive monitoring during the perioperative period.[1] Central venous access preferably involves a catheter inserted in the internal jugular or femoral vein. The preferred vein for CVCs is the right internal jugular vein (IJV)[2] because of straighter course to the right heart, better visibility on ultrasonography (USG), lowest risk of the venous stenosis and thrombosis, and also keeping in mind the nature of surgery involved and patient positioning.

Malposition of the catheter is a relatively common complication (5.01%) which results in the malfunction of catheters.[3],[4]


  Case Report Top


We report the case of a 70-year-old male who underwent mitral and aortic valve replacement along with coronary artery grafting for the posterior descending artery on cardiopulmonary bypass and had hemodynamic variations due to malposition of the catheter in the postoperative period.

Our patient, a 70-year-old Indian male, with a history of undergoing coronary artery bypass grafting in the year 2005 now presented with dyspnea on exertion in the New York Heart Association Class ll of 3-month duration. The patient is a thin built individual with a body mass index of 18 kg/m2 and well-defined anatomical landmarks in the neck. He was accepted in the American Society of Anesthesiologist Grade lV (a patient with severe systemic disease that is a constant threat to life).

After taking written informed consent, the patient was scheduled for the surgery. On establishing the invasive blood pressure monitoring on the right radial artery and left femoral artery, the patient was induced and intubated.

The right IJV was cannulated after the intubation under USG guidance and the position of the guide wire confirmed by transverse and luminal view.[5] A Swan-Ganz pulmonary artery catheter was placed through an 8 French venous sheath in the ipsilateral IJV also under USG guidance. Inotropes were connected in 7 French triple-lumen CVC. The patient's hemodynamics were stable and well maintained intraoperatively.

Postoperatively, in the intensive care unit (ICU) on day 1, the patient had sudden episodes of hypotension (80/50–60/40 mmHg), followed by spikes of hypertension (200/100–180/80 mmHg) and tachycardia (heart rate 120–130/min) as recorded by continuous invasive blood pressure and heart rate monitoring while being weaned off mechanical ventilator.

An urgent two-dimensional echocardiography was performed which not only ruled out the cardiac tamponed but also other conditions likely to result in the similar clinical picture such as myocardial dysfunction, failure of mechanical valve, and inadequacy of intravascular volume.

On postoperative chest radiograph performed in the ICU, it was seen that the triple-lumen CVC had curved upward inside the right IJV intraluminally [Figure 1], and it was envisaged that catheter was increasingly kinked probably due to neck movements. Due to this variable self-kinking, there was an obstruction to the delivery of inotropes causing hypotension, followed by autorelease on moving the neck to the other side leading to unquantifiable boluses of the accumulated drugs resulting in intermittent surge in systolic blood pressure and heart rate of the patient (pressure going up to 200 mmHg systolic and heart rate up to 130/min).
Figure 1: Upward curved central venous catheter in the right side internal jugular vein

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In the absence of bedside fluoroscopy, the triple-lumen CVC was withdrawn, and a fresh puncture was taken under USG guidance as it was envisaged that railroading a new catheter over the existing one may invariably result in similar malposition of the catheter tip. The positioning of the freshly placed CVC was re-confirmed by another chest radiograph [Figure 2]. The inotrope infusions that were continued through the venous sheath of the swan-Ganz catheter in the right-sided IJV as an interim measure were reconnected to the freshly placed CVC. There was no recurrence of surges in the systolic blood pressure, and the heart rate and the patient remained hemodynamically stable thereafter.
Figure 2: Correct position of the freshly placed central venous catheter along with venous sheath in situ inside the right internal jugular vein

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  Discussion Top


CVC has been widely adopted since 1980s as a reliable source for central venous access and has become increasingly popular, especially for the critical care.[6],[7] Several studies have demonstrated longer patency and lower infection rates of CVCs including malfunction rates against tunneled or peripheral catheters.[8],[9] Moreover, Gebauer et al.[10] reported a high level of patient satisfaction with CVCs.

At present, the radiologically guided placement of CVCs has become a widely accepted technique. Several studies have demonstrated a high rate of technical success and a low rate of complication for radiologic placement.[11],[12] In radiologic placement, the IJV is preferred as an access site, as it is safely accessed under ultrasound guidance and located away from the lung or nerve plexus and results in low procedural complication rates.[5],[6]

Catheter dysfunctions broadly cover any conditions where a CVC is unusable for infusion or drug and fluid administration. These conditions include thrombotic causes (occlusion at catheter tip or lumen, fibrin sheath formation or chamber thrombosis) as well as nonthrombotic causes (catheter migration, kinking of a catheter, or port rotation) which are confirmed by typical imaging findings on fluoroscopic port function check or chest radiographs.

USG guidance enables the evaluation of the patency and the size of vessels, clear visualization of a vessel to guide puncture, and therefore a high technical success rate.[13]

Fluoroscopy guidance enables the visualization of the location of a catheter tip and the course of a catheter as well as immediate evaluation of port function.

Anatomical variations, methodological inaccuracy, and interoperator variability are predisposed to catheter misplacement.[14]

Recent methodological advances, increased availability of real-time bedside imaging, guide wire manipulation, and experience in the management of complications have a huge impact on morbidity and mortality in patients.

Thus, the availability of fluoroscopy inside the operation theater will go a long way in preventing such malposition and its catastrophic effects in high-risk cardiac cases.[15]


  Conclusion Top


The case illustrates the limitations involved with the use of USG for such endovascular procedures because of its two-dimensional properties and limited plane of visualization.

Fluoroscopy-guided CVC placements would be a safer and more effective technique with a higher technical success rate, lower peri- and postoperative procedural complication rates, and a satisfactory clinical outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Polderman KH, Girbes AJ. Central venous catheter use. Part 1: Mechanical complications. Intensive Care Med 2002;28:1-7.  Back to cited text no. 1
    
2.
Trerotola SO, Kuhn-Fulton J, Johnson MS, Shah H, Ambrosius WT, Kneebone PH. Tunneled infusion catheters: Increased incidence of symptomatic venous thrombosis after subclavian versus internal jugular venous access. Radiology 2000;217:89-93.  Back to cited text no. 2
    
3.
Gibson F, Bodenham A. Misplaced central venous catheters: Applied anatomy and practical management. Br J Anaesth 2013;110:333-46.  Back to cited text no. 3
    
4.
Ambesh SP, Pandey JC, Dubey PK. Internal jugular vein occlusion test for rapid diagnosis of misplaced subclavian vein catheter into the internal jugular vein. Anesthesiology 2001;95:1377-9.  Back to cited text no. 4
    
5.
Koroglu M, Demir M, Koroglu BK, Sezer MT, Akhan O, Yildiz H, et al. Percutaneous placement of central venous catheters: Comparing the anatomical landmark method with the radiologically guided technique for central venous catheterization through the internal jugular vein in emergent hemodialysis patients. Acta Radiol 2006;47:43-7.  Back to cited text no. 5
    
6.
Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrsound guidance for placement of central venous catheters: A meta-analysis of literature. Crit Care Med 1996;24:2053-28.  Back to cited text no. 6
    
7.
Jan HC, Chou SJ, Chen TH, Lee CI, Chen TK, Lou MA. Management and prevention of complications of subcutaneous intravenous infusion port. Surg Oncol 2012;21:7-13.  Back to cited text no. 7
    
8.
Karakousis CP. Surgical technique for totally implantable access ports (TIAP) needs improvement. J Surg Oncol 2007;95:180-1.  Back to cited text no. 8
    
9.
Funaki B. Central venous access: A primer for the diagnostic radiologist. AJR Am J Roentgenol 2002;179:309-18.  Back to cited text no. 9
    
10.
Gebauer B, El-Sheik M, Vogt M, Wagner HJ. Combined ultrasound and fluoroscopy guided port catheter implantation-high success and loe complication rate.Eur J Radiol 2009;69:517-22.  Back to cited text no. 10
    
11.
Araújo C, Silva JP, Antunes P, Fernandes JM, Dias C, Pereira H, et al. A comparative study between two central veins for the introduction of totally implantable venous access devices in 1201 cancer patients. Eur J Surg Oncol 2008;34:222-6.  Back to cited text no. 11
    
12.
Biffi R, Pozzi S, Agazzi A, Pace U, Floridi A, Cenciarelli S, et al. Use of totally implantable central venous access ports for high-dose chemotherapy and peripheral blood stem cell transplantation: Results of a monocentre series of 376 patients. Ann Oncol 2004;15:296-300.  Back to cited text no. 12
    
13.
Dede D, Akmangit I, Yildirim ZN, Sanverdi E, Sayin B. Ultrasonography and fluoroscopy-guided insertion of chest ports. Eur J Surg Oncol 2008;34:1340-3.  Back to cited text no. 13
    
14.
Bodenham A. Reducing major procedural complications from central venous catheterisation. Anaesthesia 2011;66:6-9.  Back to cited text no. 14
    
15.
Ahn SJ, Kim HC, Chung JW, SB An, Yin YH, Jae HJ, et al. Ultrasound and fluoroscopy-guided placement of central venous ports via internal jugular vein:retrospective analysis of 1254 port implantations at a single center. Korean J Radiol 2012;13:314-23.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]



 

 
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