|Ahead of print publication
Adverse hemodynamic response due to malposition of central venous catheter
Shaikh Azimuddin Najmuddin1, Sameer Taneja2, Sachin N Kulkarni3
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 Submission||27-Oct-2019|
|Date of Decision||23-Nov-2019|
|Date of Acceptance||18-Jul-2020|
|Date of Web Publication||01-Apr-2021|
Shaikh Azimuddin Najmuddin,
INHS Asvini, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
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
| Introduction|| |
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 preferably involves a catheter inserted in the internal jugular or femoral vein. The preferred vein for CVCs is the right internal jugular vein (IJV) 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.,
| Case Report|| |
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. 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|| |
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., Several studies have demonstrated longer patency and lower infection rates of CVCs including malfunction rates against tunneled or peripheral catheters., Moreover, Gebauer et al. 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., 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.,
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.
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.
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.
| Conclusion|| |
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
Conflicts of interest
There are no conflicts of interest.
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