Malpositioning of central venous cannula inserted through internal jugular vein after failed cannulation through ipsilateral subclavian vein.

The anesthesiologist is frequently involved in the task of achieving central venous access either for intraoperative uses or postoperative purposes or Intensive Care Unit care. We are usually aware of the common complications of subclavian approach, such as arterial puncture, bleeding, pneumothorax, misplacement in the ipsilateral internal jugular vein (IJV) or contralateral brachiocephalic or subclavian vein. In this case report, we highlight the possibility of malpositioning of central venous cannula inserted through IJV into the anterior extra pleural plane after failed subclavian cannulation attempts.

INTRODUCTION

Malpositioning of central venous catheter is a common problem faced by anaesthesiologists. We present a case of malpositioning which was detected only on chest X-ray even though venous blood was coming freely from two ports of a triple lumen central venous pressure line.

CASE REPORT

A 5-year-old male child (weight 20 kg) was scheduled for an emergency craniotomy and decompression of right parieto-occipital glioma. The patient had been operated 3 months earlier but lost to follow-up because of socioeconomic reasons, but presented to the neurosurgery outpatient department with worsening sensorium and weakness of the left side of the body. Examination revealed a Glasgow coma scale (GCS) of E2 V2 M3 and bilateral crackles. As this was a surgical emergency, patient was taken-up with due risks and consent for Intensive Care Unit (ICU) care and postoperative ventilator support explained to the parents. Patient was already in a fasting state as recommended by the local physician of his district, as confirmed by parents. Blood grouping and cross matching had been performed, and blood products were arranged.

As the child's sensorium was deteriorating no sedative premedication was given, and the child was taken into the operation theatre immediately. After attaching electrocardiogram (ECG), SpO2, noninvasive blood pressure, patient was premedicated with fentanyl 40 mcg intravenously and induced with injection thiopental 100 mg intravenously. After the loss of eye lash reflex, bag-mask ventilation was confirmed and then vecuronium 2 mg was given intravenously. Patient was ventilated for 3 min and trachea was intubated using 5.5 mm ID endotracheal tube. After confirming tube placement with capnography, it was secured at 15 cm. Arterial line was placed in the left radial artery using a 22-gauge cannula. As the surgeon wanted to do rapid decompression, the central line was deferred till the end of the procedure and venous access was attained through two peripheral veins of the legs (medial malleolar veins) with 18-gauge intravenous cannulas. A size 10 Foley's catheter was inserted to monitor urine output. Anesthesia was maintained with oxygen and air mixture, isoflurane and vecuronium. Propofol infusion was started as the noncontrast computed tomography showed significant midline shift and edema. Baseline arterial blood gas was done to maintain a mild hypocapnia (30–35 mm of Hg) and correct any electrolyte abnormality. Patient was given Mannitol 100 ml over 45 min in order to produce a lax dura on craniotomy, along with furosemide 10 mg intravenously. The scheduled doses of phenytoin, dexamethasone and antibiotics were given at appropriate intervals. The surgery lasted 3 h, and total blood loss was 400 ml, which was initially replaced with crystalloids but 200 ml of packed red blood cells were transfused. As the preoperative GCS was poor, it was decided to ventilate the patient in order to reduce cerebral edema. At this time central venous access was attempted inside the operation theatre, through the right subclavian approach using a 7 French, Triple lumen B Braun central venous line as smaller size central venous pressure (CVP) line was not available. After a successful pilot puncture, the anesthesiologist could not insert the guidewire into the subclavian vein. After few attempts, ipsilateral internal jugular vein (IJV) approach was attempted by the same anesthesiologist. A successful pilot puncture was achieved followed by easy insertion of the guidewire through the guidewire needle. However, as the guidewire was advanced, the operator noticed no ECG changes (as manifested by change in the rhythm of the pulse tone on ECG) despite sufficient depth. Free flow of blood was obtained from the two ports (there was no blood from the white port, which denotes the proximal hole in the cannula). However, the line was secured with sutures, and the patient was shifted to ICU for postoperative ventilator support [Figures 1 and 2]. Immediate bedside chest X-ray was advised which revealed a central venous line that was totally out of place but fortunately without any evidence of pneumothorax. Hence, it was immediately removed, and the patient was managed with peripheral venous access. Next day, a Triple lumen B Braun Central Line of 7 Fr. was inserted through the left IJV successfully in the operation theatre. The postoperative course of the patient was marked by cardiovascular instability and sepsis but eventually the patient recovered well and was removed from ventilatory support on 10th postoperative day and was shifted to the surgical ward on 14th postoperative day.

Figure 1

Chest X-ray (anterior-posterior view) of the patient

Figure 2

Chest X-ray (lateral view) of the patient

DISCUSSION

Malpositioning of central venous catheter is a common problem faced by anesthesiologist. Various instances of malpositioning have already been reported. Malpositioning of a central venous catheter can occur into the contralateral subclavian vein,[1] or it can migrate to the left pericardiophrenic vein.[2]

Catheters can also be misplaced outside veins in a patient with no anatomical defect and can have potentially disastrous consequences.[3] Central venous catheter may be misplaced in the vertebral artery during percutaneous IJV catheterization and may require endovascular graft placement for its treatment.[4] Various anatomical abnormalities for, e.g. anomalous brachiocephalic vein due to problems during embryogenesis can lead to misplacement of central venous catheter during subclavian access thus placing the catheter tip on the contralateral side.[5]

It has also been seen that catheter may migrate to the left IJV when inserted through left external jugular vein.[6] An important and common complication of subclavian central venous catheter placement is misplacement of the catheter tip in the IJV. The incidence of misplaced (other than the SVC or the right atrium) catheter tips the location is 23.3% and in 21.3% of patients, the catheter tip entered the ipsilateral IJV.[7]

Rate of misplacements of central venous cannulations (CVC) between internal jugular and subclavian access has already been evaluated in critically ill patients and it has been seen that there was no significant difference for misplacements in both access sites.[8]

It has also been seen that the catheter may migrate to the axillary vein[9] or there may be an accidental puncture of carotid artery.[10]

There are various complications associated with misplaced catheters like it increases the risk of thrombophlebitis, thrombosis, and inaccurate measurements of CVP.[11] Hence it is imperative that we confirm the correct position of CVC after placement. The most commonly used method is chest X-ray. Another method to confirm the correct placement is the IJV occlusion test in which pressure over the vein showed flattened trace and CVP rise of 5 mmHg indicating misplacement of the catheter into the IJV, while the CVP trace remains good and there will be no change in waveforms and CVP reading in cases of correct placement.[12]

In our case, after careful inspection of the chest radiographs, we have come to following two possibilities. Firstly, the central venous line was lying in an anterior extra pleural plane. A plausible explanation is that the multiple failed attempts at the subclavian cannulation damaged the superior vena cava wall at the junction of subclavian vein and IJV. Hence, when the IJV was cannulated and guide wire was advanced, the J tip may have slipped into the damaged wall at the junction of IJV and SCV, out of the venous system into the anterior extra pleural plane. Hence, the guide wire was in the extra pleural plane, and when the catheter was railroaded over it, we did not felt the resistance. However, as the lung parenchyma was intact, pneumothorax did not occurred. The tip must have gone into some vessel therefore we were able to aspirate the blood from the catheter (though only from two ports).

Second possibility is that the central venous line is lying in the pleural cavity. This is supported by the fact that there is a mild opacification of the right lung field due to the presence of transudate.

Our case highlights some pertinent points. Firstly, a high index of suspicion for malpositioning should be present if we do not get the rhythm change on ECG during guidewire insertion along with the absence of free flow of blood from any port of CVC. Secondly, easy insertion of guide wire and catheter over it do not guaranty correct placement of CVC in all cases. Thirdly, insertion of CVC by IJV route after multiple failed subclavian approach may lead to misplacement of CVC due to weakening or damage to the wall of subclavian vein. The only confusing point in our case was the presence of blood from the catheter which is quite unexplainable as it is quite difficult for a 7 Fr catheter to enter any blood vessel in the subcutaneous space or anterior extra pleural space. A computed tomography scan was required to clear the doubts and ascertain the real events, but it could not be performed because of financial constraints and due to the postoperative hemodynamic unstability of the patient.

CONCLUSION

In conclusion, we need to understand that whenever we are attempting a central venous access from IJV after failed ipsilateral SCV approach, there is always a possibility that the guidewire can go outside the venous system from the junction of IJV and SC.