Chest wall necrosis and death secondary to hydrochloric acid infusion for metabolic alkalosis.

Abstract: Central line complications are common, and extravasation injuries related to infusion of caustic substances have been previously described. Although hydrochloric acid has been used for many years to treat metabolic alkalosis, there have been no reported fatal complications. We report the case of a 53-year-old female who received a fatal chemical burn due to extravasation from a subclavian central venous catheter of hydrochloric acid infused to correct severe metabolic alkalosis. This case illustrates the hazards of the infusion of caustic substances through central lines and underscores the importance of constant vigilance regarding line positioning and changes to the surrounding tissues when infusing these substances.

Key Words: Central line, complication, extravasation, hydrochloric acid

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Central venous catheterization is so commonplace in American hospitals that inherent risks may sometimes be overlooked. However, the complication rate has been reported to be about 5.9%, with half of these being major complications such as pneumothorax, hemothorax, or Subcutaneous emphysema. (1) Our patient represents a case in which the normally "minor" complication of an extravascular proximal port resulted in a major clinical consequence due to the nature of the infusion.

Metabolic alkalosis is a common condition in hospitalized patients. It may be broadly categorized as either chloride-sensitive or chloride-resistant. There are multiple causes within each of these categories, such as loss of gastric secretions (chloride-sensitive) and primary hyperaldosteronism (chloride resistant). Metabolic alkalosis can typically be managed conservatively, with hydration and addressing the underlying cause, particularly with chloride-resistant variants. However, in limited cases in which the alkalosis is extreme (pH >7.55) or in which the patient cannot tolerate sodium, potassium, or volume loading, direct treatment of the alkalosis with hydrochloric acid (HCl) infusion can be effective to reduce the alkalosis with minimal volume shifts.

This case involves the extravascular infusion of hydrochloric acid (HCl) through the proximal port of a triple-lumen catheter. HCl therapy has been used for many years as a way to aggressively correct severe metabolic alkalosis, and there have been few reported complications. Furthermore, some case series have suggested HCl therapy has a favorable complication profile when compared with other substances used to correct metabolic alkalosis, such as ammonium chloride or arginine hydrochloride. (2) One complication related to HCl infusion is the possibility of extravasation from the IV line. There have been several reports of extravasation of HCl from peripheral lines as well as reports of localized tissue necrosis associated with some of these cases. (3-6) Extravasation from a central line is a rare complication of HCl therapy, with only two other cases in the literature and no fatal cases previously reported. (7) Extravasation of tissue-damaging substances, however, occurs at a rate of approximately 5%. (8) When extravasation does occur, disastrous results can develop, as this case vividly illustrates.

Case Report

The patient was a 53-year-old, moderately obese female initially admitted to a referring facility with gallstone pancreatitis. The treatment plan at admission was for supportive therapy to resolve the pancreatitis followed by a cholecystectomy. The cholecystectomy was never performed because on hospital day 2, the patient became tachypneic and had respiratory acidosis accompanied by hypotension and oliguria. By hospital day 8, the patient had Pseudomonas pneumonia and anuric renal failure and required dopamine infusion for hemodynamic support. As a result of anuric renal failure, the patient was started on continuous veno-venous hemodialysis (CVVHD) on hospital day 8.

On hospital day 10, after 2 days on CVVHD with citrate used for anticoagulation, the patient became markedly alkalotic (pH = 7.58) and was started on a continuous infusion of HCl (neither the concentration nor rate are documented in the available records) through the proximal port of a left subclavian triple-lumen catheter, whose initial proper position, with the tip in the superior vena cava, had been verified by chest radiography.

After initiation of HCl infusion, no mention is made in the progress record of regular chest radiography confirmation of proper line positioning. On hospital day 20, the left subclavian line was changed over a wire and the radiograph was to be checked for position; the report for this radiograph is not available, and there is no mention of the result in the progress record. On hospital day 23, the patient was noted to have a focal area of blistering under and around the left breast that expanded over the course of 24 hours until much of the left anterior chest was erythematous. At this time, chest radiography demonstrated the tip of the catheter in the central left subclavian vein and a loop of the catheter in the left infraclavicular space, presumably positioning the proximal port of the catheter, through which HCl was being infused, in the SC space. At this time it was realized that the tissue erythema was due to a chemical burn from the HCl, and the patient was taken to the operating room for the first of a series of debridements of necrotic tissue, which would eventually include an area that extended from the left antebrachial fossa over the anterior arm cephalad to the clavicle and then across the chest to include the right breast to the midclavicular line and caudal to include most of the abdomen. Posteriorly, the wound extended to the midline throughout the thoracic and lumbar regions. All skin and SC tissue in these areas was debrided, along with the pectoralis major and minor and the latissimus muscles. In addition, the left subclavian vein was ligated and the subclavian artery was exposed at the base of the wound (Fig. 1).

One week later, the patient was transferred to our facility for further care. The patient remained in renal failure and on CVVHD. Eventually she was taken to the operating room for ligation of the subclavian artery, followed by coverage with a deltoid muscle flap. Despite continued aggressive therapy with broad-spectrum antibiotics and advanced ventilator treatment, the patient continued to deteriorate. Because of her dismal prognosis and her family's wishes, support was withdrawn and the patient died.

Discussion

Metabolic alkalosis is common among hospitalized patients and results from derangement in renal physiology, gastrointestinal physiology, or a combination of both. Metabolic alkalosis is relatively well tolerated up to a pH of approximately 7.48. However, when the pH exceeds this level, there are numerous consequences, as noted below. Treatment of metabolic alkalosis is generally conservative, using hydration and replacement of sodium, potassium, and chloride. In some cases, however, pH greater than 7.55 or evidence of end-organ dysfunction may justify the judicious use of HCl to stabilize the pH and prevent further derangement with a minimal infused-volume requirement.

In this case, the patient had development of metabolic alkalosis secondary to citrate used in CVVHD anticoagulation. Metabolic alkalosis, although not generally considered as dangerous as acidosis, can have deadly consequences if it becomes severe. (9) Studies have demonstrated numerous problems with a pH greater than 7.48, including respiratory depression and vasoconstriction leading to decreased tissue perfusion. (10) Furthermore, when the pH gets above approximately 7.65, the mortality rate is as great as 80%. (11) In this instance, the alkalosis was thought to be severe enough to warrant treatment with HCl. This method is used to quickly deplete stores of alkali and return serum pH toward neutral. HCl is typically administered as a 0.1 to 0.2 N solution. (12) The few case studies in the literature suggest that when properly administered in these concentrations, HCl is not associated with any significant adverse effects. (13) Further, these reports indicate that HCl therapy can be effective in correcting alkalosis as well as improving oxygenation and Pac[o.sub.2] in patients with metabolic alkalosis and coexistent respiratory acidosis, as was the case with this patient. (14) It must be kept in mind, however, that the efficacy and safety of this treatment has never been verified in a prospective trial.

Despite the overall safety of HCl infusion, it is essential that all infusions that have the potential for tissue damage, such as most chemotherapeutic agents or vasoactive drugs, be used judiciously and with great care. (15,16) In this case, for example, perhaps HCl was not needed to correct the abnormality and the metabolic alkalosis could have been treated simply with the discontinuation of citrate and electrolyte treatment. Further compounding the problem, the patient was unable to inform staff of any discomfort caused by the infusion due to intubation and sedation. Virtually all medications that cause tissue damage also cause pain. Any complaint of pain or discomfort at an infusion site should initiate immediate investigation; therefore, great care must be taken in patients who are unable to communicate to maximize the safety of potentially injurious infusions.

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Although used commonly in all hospitals, central lines carry a significant overall risk to patients, regardless of type or insertion site. A review of the literature reveals an impressive list of possible complications with central lines. (17,18) Occasionally, these complications are fatal, as in this case. One of the most critical requirements for reducing the complications of central line use is vigilant monitoring of line placement with both bedside and radiographic observation. Particularly when the line is used to infuse caustic substances, it is essential that correct position is maintained to ensure intravascular port placement. In addition, whenever possible, the distal port of a catheter should be used for caustic infusions, as this port is the least likely to be displaced into the extravascular space.

Conclusion

Central lines are essential for hemodynamic monitoring, for the infusion of large volumes, and for the infusion of substances that cannot be safely infused into peripheral veins. This case illustrates the first reported fatal complication of HCl infusion in which HCl extravasated into the SC space due to improper line placement. Simple precautions such as infusion of such substances into more distal catheter ports and at least daily assessment of correct placement of the central line are major means to reduce the chance for this type of devastating complication.

References

1. Wegener ME. Complications of central venous line placement. Contemporary Surgery 1993;42:266-268.

2. Brimioulle S, Vincent J, DuFaye P, et al. Hydrochloric acid infusion for treatment of metabolic alkalosis: effects on acid-base balance and oxygenation. Crit Care Med 1995;13:738-742.

3. Williams DB, Lyons JH Jr. Treatment of severe metabolic alkalosis with intravenous infusion of hydrochloric acid. Surg Gynecol Obstet 1980;150:315-321.

4. Rothe KF, Schimek F. Necrotic skin lesion following therapy of severe metabolic alkalosis: a case report. Acta Anaesthesiol Belg 1986;37:137-139.

5. Abouna GM, Veazey PR, Terry DB Jr. Intravenous infusion of hydrochloric acid for treatment of severe metabolic alkalosis. Surgery 1974;75:194-202.

6. Wagner CW, Nesbit RR Jr, Mansberger AR Jr. Treatment of metabolic alkalosis with intravenous hydrochloric acid. South Med J 1979;72:1241-1245.

7. Jankauskas SJ, Gursel E, Antonenko DR. Chest wall necrosis secondary to hydrochloric acid use in the treatment of metabolic alkalosis. Crit Care Med 1989;17:963-964.

8. Kahn MS, Holmes JD, Reducing morbidity from extravasation injuries. Ann Plastic Surg 2002;48:628-632.

9. Anderson LE, Henrich WL. Alkalemia-associated morbidity and mortality in medical and surgical patients. South Med J 1987;80:729-733.

10. Palmer BF. Metabolic alkalosis. J Am Soc Nephrol 1997;8:1462-1469.

11. Williams DB, Lyons JH Jr. Treatment of severe metabolic alkalosis with intravenous infusion of hydrochloric acid. Surg Gynecol Obstet 1980;150:315-321.

12. Adrogue HJ, Madias NE. Management of life-threatening acid-base disorders. N Engl J Med 1998;338:107-111.

13. Brimioulle S, Vincent J, DuFaye P, et al. Hydrochloric acid infusion for treatment of metabolic alkalosis: effects on acid-base balance and oxygenation. Crit Care Med 1995;13:738-742.

14. Brimioulle S, Berre J, DuFaye P, et al. Hydrochloric acid infusion for treatment of metabolic alkalosis associated with respiratory acidosis. Crit Care Med 1989;17:232-236.

15. Kahn JM, Kress JP, Hall JB. Skin necrosis after extravasation of low dose vasopressin administered for septic shock. Crit Care Med 2002;30:1899-1901.

16. Susser WS, Whitaker-Worth DL, Grant-Kels JM. Mucocutaneous reactions to chemotherapy. J Am Acad Dermatol 1999;40:367-398.

17. Venus B, Satish P. In: Civetta JM (ed). Vascular Cannulation: Critical Care. Philadelphia, Lippincott-Raven Publishing 1997, pp 521-544.

18. Raad II, Luna M, Khalil S, et al. The relationship between the thrombotic and infectious complications of central venous catheters. JAMA 1994;271:1014-1016.

Ian B. Buchanan, MD, Brendan T. Campbell, MD, MPH, Michael D. Peck, SCD, MD, and Bruce A. Cairns, MD

From North Carolina Jaycee Burn Center, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Reprint requests to Bruce A. Cairns, MD, Department of Surgery, UNC-CH School of Medicine, 180 Medical School Wing D, CB# 7228 Chapel Hill, NC, 27599-7228. Email: [e-mail]

Accepted March 16, 2005.

None of the authors have any proprietary, financial, or commercial interest in any drug, device, or equipment mentioned in this article.

This case report has been reviewed and approved by the institutional review board of the University of North Carolina at Chapel Hill.

RELATED ARTICLE: Key Points

* Central line complications are relatively common and vary in both their nature and severity.

* Central lines must be carefully and frequently checked for correct positioning and for any evidence of inflammation or surrounding tissue damage.

* Extra care must be taken with patients who are non-communicative for any reason (sedation, intubation, and so forth), to ensure maximal safety.

* Extreme vigilance must be used when infusing any potentially injurious substance, including hydrochloric acid, chemotherapeutic agents, or vasoactive drugs.