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Migration of a haemofiltration catheter: an unusual intraoperative finding.

A 42-year-old male patient presented with an acute abdomen of 24 hours duration. The patient deteriorated haemodynamically and required aggressive fluid resuscitation. He underwent an emergency laparotomy for a suspected intra-abdominal bleed. The source of the bleeding was a ruptured subcapsular haematoma of the liver. The patient lost four litres of blood which was replaced appropriately. Haemostasis was difficult to achieve, therefore the abdomen was packed and the patient was transferred to the ICU for ventilation, and the pack removal was planned after 48 hours. The patient had a known history of Crohn's disease, deep vein thrombosis and thrombophilia for which he was on prednisolone and warfarin prior to the surgery.

Postoperatively the patient became oliguric and required continuous venovenous haemodiafiltration (CVVHD). A 200 mm long (12F) radio-opaque polyurethane triple lumen catheter (Gamcath) was introduced via the right femoral vein at the second attempt. Blood was aspirated from all ports. Haemofiltration was commenced using a PRISMA haemofiltration machine. After five hours of CVVHD, the filter clotted and was restarted after the access and return ports were aspirated and flushed easily.

The CVVDH filter clotted again after six hours and was restarted after the access and return line were switched. Next day the patient was taken back to the theatre for intra-abdominal pack removal. The haemofiltration was stopped six hours prior to the surgery. During exploration of the abdomen, the surgeon noticed the distal 2 cm of the haemofiltration catheter in the pelvis, having perforated the common femoral vein. There was no active bleeding or collected blood in the pelvis. The CVVHD catheter was removed. Following the removal of intra-abdominal packs the patient's urine output gradually picked up over the next 48 hours. The patient's condition gradually improved and he was discharged to the ward after six days.

Migration of the centrally placed venous lines leading to potential complications such as mediastinal haematoma (1), pericardial tamponade (2) and pleural effusion (3) have been reported. Other complications include sepsis, local haematoma formation, catheter fragmentation (4) and knotting of the catheter (5). The CVVHD catheter (Gamcath) used in this case has three ports (Figure 1). CVVHD is possible even if the catheter tip is outside the vein, because the blood is drawn from the proximal port (arterial side) and returned through the distal port (venous side), which have multiple openings, and are proximal to the tip.

[FIGURE 1 OMITTED]

We would postulate the following explanation. The difficulty with blood flow reflected the catheter impingement and migration further through the vein wall and was corrected by manipulation and inadvertent withdrawal. This would also explain the lack of haemorrhage at the site as the tip occluded the venous tear.

Catheter-related problems are primarily related to poor insertion techniques. Catheter migration can be associated with catheter stiffness and is more likely to occur in patients on chronic steroid therapy (6). Regular checking of the catheter position with aspirations, check X-rays and if in doubt contrast study may be warranted to ensure correct placement of the catheter, particularly where problem with blood flow or clotting have occurred.

S. SHIVANNA

B. O'DONOHOE

C. F LOYDEN

Cannarthen, United Kingdom

References

(1.) Hohlrieder M, Oberhammer R, Lorenz IH, Margreiter J, Kuhbacher G, Keller C. Life-threatening mediastinal haematoma caused by extravascular infusion through a triple-lumen central venous catheter. Anesth Analg 2004; 99:31-35.

(2.) Krog M, Berggren L, Brodin M, Wickbom G. Pericardial tamponade caused by central venous catheters. World J Surg 1982;6:138-143.

(3.) Paw HGW Bilateral pleural effusions: unexpected complication after left internal jugular venous catheterisation for total parenteral nutrition. Br J Anaesth 2002; 89: 647-650.

(4.) Hu CC, Lin SC, Huang PH, Tseng SS, Tarng DC. A lady with a broken haemodialysis catheter fragment. Nephrol Dial Transplant 2002; 17:1126-1128.

(5.) Cherian VT, Faheem M. Knotting of a peripherally inserted central catheter. Can J Anaesth 2004; 51:1046-1047.

(6.) Melki PS, Pelage J, Boyer J, Legendre C, Lacombe M, Moreau J. Vascular rupture complicating transluminal angioplasty applied on a failed dialysis vascular access in a patient under chronic steroid therapy. Eur Radiol 1997; 7: 313-315.
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Article Details
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Title Annotation:Correspondence
Author:Shivanna, S.; O'Donohoe, B.; Loyden, C.F.
Publication:Anaesthesia and Intensive Care
Article Type:Clinical report
Geographic Code:4EUUK
Date:Jun 1, 2007
Words:678
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