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Subclavian vein central line catheter mistakenly placed in the aorta: a case report and how to avoid complications.

Introduction

Safely inserting a central line catheter can be a life-saving procedure. Physicians often face patients with no peripheral IV access. Sometimes these patients are hypotensive and severely dehydrated, making placement of peripheral IV access difficult or impossible. Acquiring central venous access can be life-saving.

For reasons that are unclear, many physicians are uncomfortable utilizing central lines in these situations. The following is a case report of an elderly patient who had a central line placed in the aorta. We discussed ways to avoid central line complications.

Case presentation

An 85-year-old female presented to the emergency room from an outside hospital with nausea, vomiting, and abdominal distention. The patient had acute onset abdominal pain approximately 12 hours prior to admission. In general, the patient was debilitated and somewhat cachectic. The patient had a prior history of chronic constipation. The patient was afebrile with a heart rate of 64 and blood pressure of 161/91 mmHg.

The patient's physical exam was positive for abdominal distention with a mildly tender tympanic abdomen. She had no evidence of peritoneal signs. The patient was also noted to have a stage 4 sacral decubitus ulcer, which was not infected but did reveal some exposed bone.

The patient's laboratory values were within normal limits, with the exception of a potassium of 2.9 mEq per liter (normal range 3.5-5.0 mEq per liter). Plain films as well as a CT scan from the outside hospital were consistent with a sigmoid volvulus.

The patient was admitted to the surgery service. She was hydrated and underwent a rigid proctoscopy with placement of a rectal tube.

This decompressed her sigmoid volvulus. The patient underwent sigmoid colectomy two days later. While in the ICU recovering from her colon surgery, the patient required IV access. After several attempts at peripheral IV access, it was decided to place a central line. A left subclavian central line was attempted. The physician who performed the procedure read the chest x-ray (Figure 1) and thought the central line was in a good position. The radiologist read the central line as being in the aorta.

The central line was promptly removed and the complication was explained to the patient and the patient's family. A second subclavian central line was placed without difficulty. The patient had no untoward events related to her aorta. Post-procedure chest x-ray revealed no hemopneumothorax (Figure 2). The patient had no change in her hemoglobin.

The patient had a prolonged hospital course secondary to her advanced age and disability.

She developed a post operative pneumonia as well as a urinary tract infection. She required mechanical ventilation for several days secondary to respiratory distress. With appropriate antibiotics and respiratory support, the patient was successfully weaned from the ventilator. She was eventually discharged tolerating regular diet but requiring a lot of assistance to eat, sit up and ambulate.

Discussion

Placement of central venous catheters instills apprehension in some physicians. Recent data suggest that this apprehension may be unwarranted. (1) Subclavian vein cannulation can be placed safely and easily in most patients. (2) This potentially life-threatening complication occurred because of a lack of attention to detail and ignorance of the pertinent anatomy. The initial stick was too inferior to the clavicle. It was outside the deltopectoral triangle. Also, the needle was not aimed towards the sternal notch, but instead was aimed several centimeters below the sternal notch. If you start at the wrong position and aim at the wrong location, the central venous catheter ends up malpositioned in the aorta. In this manuscript, we will describe the proper technique in placing a subclavian central line which should help avoid complications like arterial puncture and pneumothorax.

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First of all, we follow the latest CDC recommendations with regard to central lines. They state "use a subclavian site, rather than a jugular or a femoral site, in adult patients to minimize infection risk for nontunneled CVC placement." (3) Therefore, it is our practice to preferentially place subclavian central venous catheters over other locations.

Over the last decade or so, much has been written about using ultrasound to aid with central line placement. (4-6) Ultrasound is a very useful tool but has also been proven to be very operator dependent. (2) Using the ultrasound to And the femoral vein and/or the internal jugular vein can be extremely helpful in preventing arterial puncture, malposition and pneumothorax. (7) The problem with using Doppler ultrasound in the subclavian position is that the clavicle is in the way. (2) This is not to say that Doppler ultrasound cannot be used in subclavian line placement. It simply takes more skill with Doppler ultrasound in the subclavian position. A recent Cochrane review investigated nine studies which looked at using Doppler ultrasound in the subclavian position. (8) The Cochrane review revealed no significant difference in complications, number of attempts until successful insertion, or the amount of time taken to insert the catheter. However, this review did find the incidence of arterial puncture was almost 5% using the landmark technique. The review found a statistically significant decrease in arterial puncture by using ultrasound in the subclavian position. One of the studies included in this Cochrane review needs to be singled out. (9) This was a prospective randomized study which had 200 patients in the ultrasound group and 201 patients in the landmark group. All patients underwent subclavian vein cannulation. The ultrasound group had one arterial puncture (0.5%) and three hematoma formations.

The landmark group was found to have more complications than the ultrasound group. There were no pneumothoraces or nerve injuries. In the landmark group, 5.4% of patients experienced arterial puncture, and 4.9% suffered pneumothorax. Oddly, 2.9% of patients in the landmark group suffered a brachial plexus injury and 1.5% suffered a phrenic nerve injury. One patient suffered cardiac tamponade. (9) The complication of a brachial plexus injury from a subclavian central line is unusual and usually transient. (10) In this paper, the authors reported the brachial plexus and phrenic nerve injuries to be permanent. (9)

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The technique of placing a subclavian central line is simple and straightforward. (2) The patient should be placed supine in the Trendelenburg position. The authors are aware of no data which support placing a rolled towel between the patient's shoulder blades. This actually may pinch the subclavian vein between the clavicle and the first rib, making it more difficult to cannulate. Another myth involves pulling on the patient's ipsilateral arm. Again, the authors are unaware of any data to support this maneuver. The physician should locate the angle of the clavicle and the deltopectoral triangle (bounded by the clavicle, the pectoralis major muscle medially and the deltoid muscle laterally). The skin should be prepped with chlorhexidine and alcohol. It is imperative to use sterile technique, which must include cap, gown, mask and sterile gloves. After adequately prepping and draping the patient, 1% lidocaine should be used to anesthetize the skin. An area 2-3 cm lateral to the angle of the clavicle, within the deltopectoral triangle, should be chosen to enter the skin with the introducer needle (Figure 3). The physician should aim the needle towards the sternal notch and run the needle gently and directly into the clavicle. Inject lidocaine to numb this area. Then, without tilting the needle, push the needle and syringe posteriorly, under the clavicle (Figure 4). Once under the clavicle, push the introducer needle medially towards the sternal notch while aspirating. Once you are in the vein, rotate the syringe along its axis to make sure that whole needle is in the vein. Remember that the subclavian vein is superior and anterior to the subclavian artery. It is critical for the physician to remember to aim towards the sternal notch. (2)

The ultrasound assisted technique is similar to the landmark technique. The patient is placed supine in Trendelenburg. The same area is widely prepped and draped. We use the single person technique.

The ultrasound probe should be in the operator's non-dominate hand and the syringe should be in the dominate hand. The screen for the ultrasound needs to be positioned so that the physician can easily see it without contorting. For example, if the physician is placing a right subclavian line, then the screen should be near the patient's left shoulder. The physician should be able to easily look up from the sterile field and see the screen in front of him/her. The ultrasound probe (in its sterile sheath) should be perpendicular to the skin and transverse to the subclavian vein. (11) The subclavian vein is located just before it dives under the angle of the clavicle. This should be confirmed with a flash of blood in the syringe. Once the physician is in the vein, the Seldinger technique (guidewire threaded into the vein) should be used to place the catheter.

In the author's experience, many physicians start their subclavian lines far too close to the clavicle.

If you are too close, the only way to get under the clavicle is to do a "scoop maneuver" in which you raise the back end of the syringe anteriorly which points the needle directly at the lung. This can lead directly to a pneumothorax. In order to avoid a pneumothorax start away from the clavicle as described above.

Where a physician places a central line can sometimes be a quandary. There are pros and cons to each location. As mentioned earlier, the Centers for Disease Control recommends using the subclavian position. Placing an internal jugular or femoral central line may be preferable in patients with truncal obesity, subclavian thrombosis or other condition which would make subclavian vein cannulation more difficult. (3) There is some data to suggest there are higher infection rates as well as higher rates of deep venous thrombosis when using the femoral vein. (12) A more recent study revealed the infection rates to be statistically the same among the femoral, subclavian and internal jugular vein sites. (1) Placing a central line in the internal jugular has been shown to reduce the rate of pneumothorax. (10) Because of the proximity of the carotid artery, there seems to be a higher rate of arterial sticks. (15) Also, some practitioners And it difficult to secure a central line in the internal jugular location.

At Marshall University, we have instituted a number of changes as a result of this case. Ultrasound guidance is now the preferred method for placing central lines.

If the surgeon is going to use the landmark technique, they must use the technique that has been described above. Secondly, all central line procedures performed on the general surgery service must be supervised by either a chief resident or an attending physician.

Conclusion

Placing an infraclavicular subclavian central line catheter while minimizing complications can be easily accomplished by any physician who understands the patient's anatomy and uses the appropriate landmark technique. To further decrease complications, ultrasound guidance should be used when placing central venous catheters.

References

(1.) Deshpande, K., et al. "The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population." Critical Care Medicine 2005; 33: 13-20.

(2.) Thompson, E., Calver, L. "Safe Subclavian Vein Cannulation-How I Do It." The American Surgeon 2005; 71:180-183.

(3.) O'Grady, N., Alexander, M., Burns, L,. et al. Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011, http://www.cdc.gov/hicpac/pdf/ guidelines/bsi-guidelines- 2011.pdf

(4.) Keenan, S. Use of ultrasound to place central lines. Journal of Critical Care 2002; 17(2): 126- 137.

(5.) Stachura, M., Socransky, S., Wiss, R., & Betz, M. A comparison of the supraclavicular and infraclavicular views for imaging the subclavian vein with ultrasound.

The American Journal of Emergency Medicine 2014; 32(8), 905-908.

(6.) Timsit, J,. "What is the best site for central venous catheter insertion in critically ill patients?" Critical Care 2003; 7:397.

(7.) Wigmore, T. J., et al. "Effect of the implementation of NICE guidelines for ultrasound guidance on the complication rates associated with central venous catheter placement in patients presenting for routine surgery in a tertiary referral centre." British Journal of Anaesthesia 99.5 (2007): 662-665.

(8.) Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database of Systematic Reviews 2015,

Issue 1. Art. No.: CD011447. DOI: 10.1002/14651858.CD011447.

(9.) Fragou, Mariantina, et al. "Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study*." Critical Care Medicine 39.7 (2011): 1607-1612.

(10.) Kusminsky, Roberto E. "Complications of Central Venous Catheterization." Journal of the American College of Surgeons 204.4 (2007): 681-696.

(11.) Froehlich, Curt D., et al. "Ultrasound-guided central venous catheter placement decreases complications and decreases placement attempts compared with the landmark technique in patients in a pediatric intensive care unit*." Critical Care Medicine 37.3 (2009): 1090-1096.

(12.) Merrer J, De Jonghe B, Golliot F, et al: Complications of femoral and subclavian venous catheterization in critically ill patients. JAMA 2001; 286:700-707.

Igor Wanko Mboumi, MD

Department of Surgery, Joan Edwards School of Medicine Marshall University, WV

Errington C. Thompson, MD, FACS, FCCM

Department of Surgery, Joan Edwards School of Medicine Marshall University, WV

Corresponding Author: Errington C. Thompson, MD, Marshall University, 1600 Medical Center Dr., Suite 2500, Huntington, WV 25701. Email: errington@ erringtonthompson.com.
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Title Annotation:Case Report
Author:Mboumi, Igor Wanko; Thompson, Errington C.
Publication:West Virginia Medical Journal
Date:Sep 1, 2016
Words:2239
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