[Year:2023] [Month:January-June] [Volume:8] [Number:1] [Pages:4] [Pages No:13 - 16]
Introduction: The placement of central venous catheters (CVC) is an invasive procedure done routinely in patients undergoing surgical procedures for therapeutic and diagnostic purposes. It is associated with several documented complications either during insertion of the catheter (e.g., arterial puncture, pneumothorax, arrhythmias); and/or during maintenance of the line (e.g., infection, thrombosis, or other mechanical risks). The use of postprocedure chest radiographs to confirm the correct position of the catheter and to detect other complications, such as pneumothorax or hematoma, is a regular practice.1 We report a case of intrapleural hematoma caused by the insertion of CVC in the right internal jugular vein (IJV).
Case description: A 32-year-old G2P1L1IUFD1 patient with abruption of the placenta presented with hypotension [blood pressure (BP) 76/50]. The coagulation profile, including bleeding time, clotting time, international normalized ratio, prothrombin time, partial thromboplastin time, platelet count, D dimers, and fibrinogen levels of the patient, was normal. The patient underwent an emergency lower-segment C-section under general anesthesia. Since it was an emergency, the patient did not undergo routine preanaesthetic investigations. The patient was managed intraoperatively with two wide-bore (18G) intravenous (IV) cannulas. The patient was transfused with 1000 mL colloid and one polypoidal choroidal vasculopathy (PCV) intraoperatively. Ionotropic supports were started intraoperatively. Intraoperative blood loss was 1300 mL, and urine output was 250 mL. The patient was not extubated and was shifted to intensive care unit (ICU) for further management. Placement of a triple lumen CVC through the right IJV was planned under ultrasound (USG) guidance to monitor postoperative central venous pressure (CVP) and to guide fluid therapy. Well-informed written consent from the patient's relative was taken for the same. Insertion of a 7Fr triple lumen CVC was attempted through the right IJV under USG guidance using a 16G needle. Venous blood was aspirated. There was resistance felt during guidewire insertion. Hence entire assembly was removed. The second attempt was again abandoned due to failure to advance the guidewire. One more attempt was made on the right side, but there was a spurt of blood through the distal port of the triple lumen. Hence the catheter was removed, and the pressure was applied for 5 minutes. Finally, the catheter was placed through the left IJV. The patient was stable after the procedure with a heart rate of 88 beats/minute, blood pressure of 98/76 mm Hg on injection (Inj) of noradrenaline 4 mg in 50 cc at a rate of 3 mL/hour, saturation 100% on ventilatory support and CVP of 6–8 cm of H2O. As per our institutional protocol, the patient underwent a routine chest radiograph in the postoperative period. There was a well-defined radiopaque shadow in the right upper lung field. The patient also had dextrocardia, and a fundic shadow was visible on the left side. The patient was hemodynamically stable. A bedside USG chest was done, which revealed right-sided mild to moderate pleural effusion and situs inversus. The patient underwent high-resolution computed tomography (HRCT) chest, the report of which showed a fairly large hyperdense hematoma in the right pleural space of upper hemithorax with underlying compressive atelectasis of the right lung. Hypodense filling defect in the right IJV in the supraclavicular region, 5 cm in length, was seen along with near complete luminal occlusion of the vein. Dextrocardia with a right-sided aortic arch was seen. A few sections of the upper abdomen revealed a liver on the left side and a spleen on the right side, suggestive of situs inversus. A chest medicine and cardiothoracic opinion were sought. A CT angiography of the chest showed no active bleeding. Intercostal drainage (ICD) tube was inserted on the right side. The patient was transfused with six solvent/detergent-treated plasma (SDP), four fresh-frozen plasma (FFPs), and three PCVs. The patient was weaned off the ventilatory and ionotropic supports on day 4 and extubated the next day. The patient was hemodynamically stable. ICD was removed after 15 days. The patient was discharged on the 19th postoperative day.
Conclusion: Central venous catheter (CVC) cannulation is associated with the above-mentioned complications. These complications decrease when image-guided assistance is used. However, the anatomic variation in our patient made it difficult for the guide wire to pass along smoothly. Hence the presence of such anomalies, though rare, should be kept in mind. Keeping this in mind, IJV insertion, especially in emergency situations, should be performed only by an experienced anesthetist. The number of attempts on any one side should not exceed two.