Ultrasound-guided central venous cannulation-Missing climacteric step?

Sir,

A 12-year male, diagnosed as a case of extrahepatic portal venous obstruction, was on regular endoscopic therapy at our institute for the past 5 years for recurrent haematemesis during the last 3 years. The child had recurrent haematemesis along with moderate splenomegaly, hypersplenism, and growth retardation, which warranted a surgical intervention for portal hypertension. The child was posted for splenectomy with a central end-to-side splenorenal shunt.

The anaesthetic induction was uneventful and post-induction of anaesthesia, 7 Fr triple lumen central venous catheter (CVC) was inserted in right internal jugular vein (IJV) under ultrasound guidance under all aseptic precautions. All ports were checked and properly flushed. The surgical procedure was uneventful with a duration of 6 hours and post-surgery, the child was extubated. Post-extubation it was found that there was reduced air entry on the right side of the chest and it was thought to be atelectasis due to prolonged surgery. The child was encouraged to do incentive spirometry as trained in the preoperative stage. On post-operative day (POD)-1, the child developed slight respiratory distress and his oxygen saturation fell to 90%. Oxygen was administered through nasal cannula along with chest physiotherapy and incentive spirometry.

On examination of the chest, it was found that there was decreased air entry in the right lung field, which persisted in the mid and lower zone. Further, a chest skiagram was done, which revealed opacity in the middle and lower zone of the right lung [Figure 1a]. Initially, this was managed conservatively with aggressive chest physiotherapy and incentive spirometry. The blood and sputum cultures were sent and the patient remained afebrile with a normal leukocyte count. However, the opacity persisted on follow-up chest skiagram imaging despite aggressive chest physiotherapy and incentive spirometry [Figure 1b] and therefore, an ultrasonography (USG) chest was done, which revealed a fluid collection in the right side of the chest. Following the USG chest, a USG guided needle aspiration was done and around 200 ml thick haemorrhagic fluid was drained. Repeat chest ultrasound done on the very next day again revealed persistent opacity in the right side of the chest [Figure 1c]. So, a right intercostal drain (ICD) was finally placed to drain out the residual collection and it drained out approximately 300 ml haemorrhagic fluid (a total of approximately 500 ml drained). This ICD placement was followed by an expansion of the right lung field [Figure 1d]. The ICD was further removed after 2 days.

Figure 1

Chest X ray during the entire perioperative period. (a) CXR showing opacity in the middle and lower zone of the right lung, (b) CXR showing persistent opacity on the right side of lung, (c) CXR showing opacity on right side of chest despite ultrasound drainage, (d) CXR following Intercostal drain insertion

Even in most experienced hands, complications during CVC insertion can occur, viz. pneumothorax, haemothorax, carotid artery puncture, haematoma etc.[123]

In our case, we operated upon a child with significant haemothorax for major surgery and this could have been a major event but, somehow, we were fortunate. Such iatrogenic haemothorax may lead to serious events intraoperatively and postoperatively. The cause of such haemothorax could be due to vascular injury during guidewire insertion or dilatation phase. Sometimes, even the azygous vein rupture during right-sided cannulation of IJV can be the cause.[3]

Real-time USG guided IJV cannulation significantly reduces, but does not wholly eliminate, the incidence of complications associated with central venous cannulations.[4]

Nath et al.[5] also recommended from their experience that free venous outflow must be carefully checked in all the ports of the CVC, and following placement of such a catheter, a chest radiograph should be done to confirm the position of the catheter.

We emphasise upon careful auscultation followed by a brief ultrasound of the chest after placement of CVC as chest x rays are not done immediately post-insertion of CVC in the operative rooms.

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Conflicts of Interest

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