Haemothorax Following Internal Jugular Vein Cannulation: A Rare Event.

Catheterization of central veins is a routine technique which is widely used in emergency department, operation theater, and intensive care units. Seldinger technique is widely used to place central venous and arterial catheters and is generally considered safe. The technique does have multiple potential risks. We describe a case of hemothorax following internal jugular venous cannulation. Measures which can be taken to prevent such complications are explained in detail as well as recommended steps to remedy errors should they occur.

INTRODUCTION

The various techniques for central venous cannulation are an essential component of the armamentarium of anesthesiologist. Although the list of complications associated with central venous cannulation is quite long, proper attention to technique and patient management can reduce morbidity and mortality to an acceptable minimum. Perforation of internal jugular vein is a relatively rare but potentially lethal complication of central venous cannulation. A chest radiograph is recommended as a routine procedure after any attempted central venous catheterization (whether successful or not), which helps to determine the placement of catheter and detect any immediate complications.[1] We describe a patient with hemothorax from internal jugular vein cannulation, for whom an appropriately timed chest film might have prevented the resultant morbidity.

CASE REPORT

A 45-year-old female admitted to our hospital for the management of crush injury left upper limb. Her preoperative investigations including chest X-ray [Figure 1] were normal. She was American Society of Anesthesiologist Grade 1 female brought to operation theater for wound debridement. The patient intravenous access was poor. To provide hydration adequately, a 16-gauge single lumen central venous catheter was inserted by anterior approach in right internal jugular vein with Seldinger technique. Blood returned freely from the catheter, after insertion into the superior vena cava. During intraoperative period, the effect of muscle relaxant was not adequate. After 1 h of surgery, patient was extubated and shifted to postoperative ward. Postoperatively, patient had tachycardia and blood pressure started falling. Two pints of fluid and one pint of blood were given fast but tachycardia persisted and blood pressure decreased further. Patient was treated with noradrenaline support. Patient started complaining of chest pain. Patient oxygen saturation started decreasing; patient was immediately intubated and treated with ventilator support. Chest X-ray was done which shows massive hemothorax [Figure 2]. Cardiothoracic vascular surgeon was called who inserted chest tube with drainage of 2.5 L of blood. For further resuscitation, left external jugular vein was cannulated with 16-gauge cannula; fluid as well as blood was given. Patient vitals become normal. Central venous catheter was removed under adequate vision by cardiothoracic vascular surgeon. Patient was extubated coming morning. After 3 days, chest tube was removed and chest expanded completely.

Figure 1

Normal chest X-ray of patient

Figure 2

Intrathoracic/extravascular portion of central venous catheter tip leading to massive hemothorax

DISCUSSION

Perforation of arteries or vein inside the chest can result in hemothorax if the perforation communicates with the pleural space. The potential pleural space is up to approximately 3 L, as the lung is completely compressible. Clearly, a catheter that perforates an artery or vein and communicates with the pleural space rapidly can result in life-threatening hemorrhage. Causes of hemothorax in our patient first, although it was possible to aspirate blood from the catheter, which indicated proper vascular positioning, the tip obviously was outside the vein and communicated with the pleural space. This phenomenon has been described previously though perforation is usually suspected when infusion rates are disturbed or when blood returned is diminished through the catheter.[2] In these uncommon cases such as ours, where it is possible to aspirate blood from the catheter even though the tip has perforated the vessel, the explanation is that the perforating tip indeed lies outside the vessel lumen in a small collection of blood caused by the injury.[3] The most likely mechanism of injury is that a guide wire becomes trapped against the wall of a vein by a stiff dilator, sheath, or catheter that is being advanced over the guidewire, and the vein is perforated or torn.[4] During induction of patient, 6 mg vecuronium was given through 20-gauge intravenous cannula and effect of vecuronium was adequate. After internal jugular venous cannulation, vecuronium was given through central venous catheter leading to inadequate effect as vecuronium was going to pleural cavity and not in circulation. Patient vitals were also deteriorating in spite of giving adequate fluid and blood as fluid and blood transfused were going to pleural cavity instead of going into circulation.

CONCLUSION

Central venous catheterization is a procedure with great potential benefit to patient, and accordingly is widely used for many diagnostic and therapeutic applications. However, anesthesiologist should be aware constantly of the possibility of the patient developing an iatrogenic complication, related to the insertion, advancement, and maintenance of the catheter. Technically undemanding and uncomplicated insertion, satisfactory infusion rates, and adequate return of blood on aspiration do not guarantee correct positioning of catheter, nor do they rule out the occurrence of complications such as vascular erosions and resulting hydrothorax and hemothorax. Inadequate effect of muscle relaxants as well as hypotension in spite of giving adequate vecuronium, fluid and blood should be clinically correlated. Mechanical injuries to vein probably are due to trapping the guidewire against the wall of the vein and perforating the vein with a stiff dilator or catheter. Fluoroscopy should be helpful for avoiding this problem, but seldom is available in anesthesia, intensive care, and emergency medicine practice. Assuring that the guidewire can be moved back and forth a few centimeters during insertion of central venous catheter is an advisable practice that may help to identify a wire that is trapped against the wall of a vein. We wish to reemphasize the absolute necessity of a control chest film immediately after central venous catheter insertion. Gibson and Bodenham[5] proposed a useful aide-memoire with regard to misplaced central venous catheter, in short-term, “if in doubt, don’t take it out.” Evaluation followed by removal under vision after adequate exposure is the approach of prudence. This is in contrast with endotracheal intubation where it is said that “if in doubt take it out.”

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Conflicts of interest

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