Complications of Attempted Central Venous Injections Performed by Drug Abusers

Complications of Attempted Central Venous

lnieefiens Performed by.. Drug Abusers •.., losepli W. Lewis, t-; M.D.;· Nicole Groux, P .A.-c.;· , .;'.

losephP. Ellictt,lr., M.D.;* Fernando M. lara, M.D.;· Earouck N. Oheid, M .D.;t and Donald I. Magilligan, lr-, M.D.·

Intravenous abuse of drugs has become an Integral part of various subcultures within American communities. The continued use of peripheral veins In this setting eventually leads to their obliteration through a sclerotic or infectious process. Inveterate drug abusen often turn to using larger veins In the groin and neck. Some real or imagined technical aspects of subclavian and Internal jugular venous Injections are weD known to drug abusen in many locales. Undoubtedly as these sIdIIs are passed from one user to another, the fine points of anatomy and needle positioning are distorted with resultant mishaps.

Twelve patients have been seen with complications arising from attempted supra- or subclavlcolar injections of drugs In the "street" setting: ooiIateral pneumothorax, six cases; bilateral pneumothorax, one case; mycotic subclavian carotid artery aneurysm, two cases; neck abscesses, three cases (one also listed ODder pnenmothorax); and paraplegia, one case. Since this type of Injury may occur In greater frequency due to Inc:reaslog drug abuse, recognition and proper treatment of these potentiaDy life-threatening problems may prevent mortality and rednce morbidity.

Even in skilled hands within the hospital setting, numerous complications of large vein cannulations have been documented.v" We have recently seen several mishaps arising from percutaneous at-

tension hydropneumothorax; chest tube placement yielded approximately 100 ml of blood and a large quantity of air. Total pleural drainage over the next four days was 160 mI. The chest tube was removed uneventfully on the 5th hospital day.

For editorial comment, see page 551

CASE

tempted drug injections "in the street" by drug abusers themselves, or by so-called lay "specialists.. who perform this type of injection for their drug customers. The following cases are presented to alert the medical community to these complications and how they might be managed.

2

This 25-year-old black woman presented to the hospital in acute respiratory distress. Immediately prior to her visit, she had received a right subclavian venous injection of heroin. The "stick" performed by another drug user was difficult and only a small amount of heroin could be introduced. A similar

CASE REPoRTS CASE

1

This 26-year-old black man had a ten-year history of drug abuse, primarily heroin and cocaine. After many years of peripheral intravenous injections, most accessible veins were obliterated. He then turned to the central venous route, primarily the neck. One day prior to admission, a comrade attempted to inject cocaine into the patient's right internal jugular vein. Following this, he developed right-sided chest pain,loss of voice, and progressive respiratory difficulty. On examination in the emergency room, approximately 24 hours after the injection, his blood pressure was 100/64 mm Hg, the pulse rate was 88/min and his respirations were 18. A small puncture site immediately lateral to the right sternocleidomastoid muscle approximately two fingerbreadths above the clavicle was noted. No breath sounds were heard on the right side. Chest x-ray examination (Fig 1) showed a From the Department of General Surgery, ·Division of Cardiac and Thoracic Surgery; tDivision I, Trauma Surgery; and tDivision II, Vascular Surgery, Henry Ford Hospital , Detroit. Manuscript received October 9; revision accepted November 13. Reprint requests: DI'. Lewis, Thoracic and Cardiac Surgery, Henry Ford Hospital, Detroit 48202

CHEST, 78: 4, OCTOBER, 1980

FIGURE 1. Posteroanterior chest x-ray mm demonstrating hydropneumothorax after attempted injection of cocaine into the right internal jugular vein.

COMPLICATIONS OF VENOUS INJECTIONS BY DRUG ABUSERS 813

injection was made in the left subclavian vein to complete the sale. The patient immediately became severely dyspneic and was brought to the emergency room. She was given intravenous naloxone without effect. Due to continued respiratory distress, a chest x-ray fUm was obtained which showed bilateral pneumothoraces. Closed tube thoracostomies brought immediate relief of her respiratory distress. Both pleural tubes were removed within one week with no residual pneumothorax. The patient did not return for follow-up clinic visit and was seen approximately one month later with right lower lobe pneumonia and lung abscess . She denied further intravenous heroin use. Five additional patients with pneumothoraces resulting from central venous drug injections have been seen. Their hospital courses are summarized in Table l. The predominance of left neck injection appears to be related to the dominance of hands; drug abusers who practiced self-administration were uniformly right-handed in this report and tended to inject into the left side of the neck preferentially. A mirror was frequently employed to guide the needle to its mark.

FIGUBE 2. Arch aortogram demonstrating a mycotic aneurysm of the right subclavian-common carotid arteries complicating heroin injections into the right neck. IA innominate artery, MA = mycotic aneurysm, SA = subclavian artery, VA vertebral artery, CCA = common carotid artery.

=

CA8E3 A 31-year-old man who had been a drug abuser for ten years, noted a small mass in the right side of the neck several days after an attempted internal jugular injection of heroin. Approximately two months later, the mass increased in size over a three-day period without further injections, producing local pain, hoarseness, and a drooping right eyelid. There was no history of chills, fever, shortness of breath, right arm pain, or other neurologic deficits. His blood pressure was 140/80 mm Hg , pulse rate 80, and temperature 38 .2·C. Ptosis of the right eyelid was noted, but the pupils were equal. A 6 em in diameter, pulsatile mass was present in the right supraclavicular fossa which deviated the trachea slightly to the left. A loud bruit could be auscultated over the mass. All peripheral pulses were normal. An arch aortogram showed a pseudoaneurysm (Fig 2) originating from the proximal right common carotid and subclavian arteries. Ampicillin, clindamycin, and gentamycin were started intravenously. The following day, the pseudoaneurysm was explored by the vascular surgery service . A midsternotomy incision was carried into the right side of the neck with a lateral extension over the right clavicle. After gaining control of the innominate, right common carotid and subclavian arteries, the pseudoaneurysm was opened, revealing presumed needle tears in the proximal common carotid and subclavian arteries. These tears communicated with the false aneurysm. An organizing hematoma indicated a contained rupture which accounted for the recent Table I-Additional C _ of Pneurnollaoras Re.uld.... from Cen'ral ."enou. Injecdo~

Chest Tube Pneumo- Placethorax ment Residual

%

Age Race Sex Site of Injection 19

B

M Lt. supraclavicular

23

B

M Rt. subclavicular

23

B

26 37

60

Yes None

100

YCd None

M Lt. supraclavicular

20

Yes None

B

F Lt. supraclavicular

15

No

Lt. neck abscess

B

M Rt. subclavicular

15

No

None

614 LEWIS ET AL

=

increase in size of the mass. The operative field was infected, and a suitable route for a remote bypass was not available; therefore, the innominate, common carotid and subclavian arteries were ligated. A retrograde pulse could be palpated in the ligated common carotid artery. Necrotic material debrided from the pseudoaneurysm grew Psetldomonat aeruginosa with synergistic sensitivities to gentamycin and carbenicillin. His antibiotic regimen was altered to these two drugs. The postoperative course was remarkably benign with no neurologic deficit or ischemia of extremities. CASE

4

This 38-year-old black male heroin addict presented to this hospital complaining of left neck swelling since his last injection in the supraclavicular area about one week prior to admission. A large, pulsatile mass palpable at the base of the left side of the neck produced some tracheal deviation to the right. Left carotid arteriogram revealed a large pseudoaneurysm of the left common carotid artery approximately 5 cm from its origin from the aortic arch (Fig 3). Intravenous cefamandole was started. One day after admission, the patient developed dyspnea and sudden, severe pain associated with progressive expansion of the left neck mass. He was transferred to the operating room where the proximal left common carotid artery was ligated through a median sternotomy. This incision was closed and a separate oblique left incision was made over the mass in the neck. Mter ligating the distal common carotid artery, the infected false aneurysm and necrotic debris were excised. Cultures of this mass produced StreptococCfJ8 fecalis and StaphlllococCfJ8 epidermidis which were treated with intravenous vancomycin. The patient had no postoperative neurologic deficit and was discharged 12 days following surgery. CASE

5

This 25-year-old black woman had a long-standing history of intravenous drug abuse. When peripheral veins sclerosed, central neck veins were used. H "bright" (arterial) blood, known in the vernacular as a "pinkie," were obtained during

CHEST, 78: 4, OCTOBER, 1980

tion. A 46-year-old black woman developed cellulitis of the left medial supraclavicular area after an attempted central venous mjectioo performed four days prior to admission. The 2 X 4 em indurated mass responded well to warm soaks, intravenous oefazolin, and later oral cephalexin.

CAsE 6

FIGURE 3. Selective left common carotid arteriogram demonstrating a contained mycotic aneurysm (outlined by arrows) secondary to inadvertent injury by the drug abuser's needle. injection, the needle would be repositioned until "dark" venous blood flowed into the syringe. H blood could not be aspirated from a site immediately above the clavicle, she would reposition the needle along the course of the jugular vein, as high as the angle of the jaw. While using heroin in this manner for four days prior to admission, a large mass appeared in the right supraclavicular fossa. She had no symptoms suggestive of cardiothoraeic or neurologic injury. On admission, a 5 X 6 em warm, non-pulsatile mass was palpated in the right supraclavicular area extending under the sternocleidomastoid muscle (Fig 4) . Angiogram of the innominate artery performed through a percutaneous femoral arterial puncture, was obtained to rule out vascular injury . Introduction of this catheter into the groin was complicated by scarring from previous femoral vein injections of heroin. Aspiration of the neck mass yielded a small amount of purulent material that grew StaphylococCt/8 aureus. After several days of intravenous treatment with cefazolin, the mass became fluctuant; successful incision and drainage was performed. She was discharged to a Methadone treatment clinic after two weeks of antibiotic therapy. Two additional patients with postinjection abscesses have been seen. The fourth patient listed under pneumothorax injuries (Table 1) developed cellulitis on the left side of the neck after a supraclavicular injection. She treated this for one month with self-prescribed cephalexin with eventual resolu-

FIGURE 4. Bilateral supraclavicular injection sites for heroin. A 5 X 6 em abscess could be palpated immediately below the right injection tract.

CHEST, 78: 4, OCTOBER, 1980

This 22-year-old black woman presented to the emergency room with the complaints of partial paralysis of the left leg and arm with numbness of the right leg following injection of heroin in the left supraclavicular area . She stated that bright red blood was aspirated as the needle was introduced ("pinkie") and a hot flash and transient blindness occurred following instillation of the material. She was able to walk and move her arms for several minutes, but then developed left hemiparesis with loss of sensation in the right lower extremity. Initial examination revealed edema lateral to the left sternocleidomastoid muscle immediately above the clavicle where the needle had been introduced. The patient was well oriented, had appropriate articulation, and no deficit in cranial nerves 2 through 12. Further examination revealed a motor deficit on the left at the C., Cs level. Her initial sensory level at T 6 progressed to T 2 within 24 hours. An emergency cervical myelogram revealed no evidence of epidural hematoma or other radiologic abnormality. Cerebrospinal fluid analysis showed red blood cell count, 7,500; 2 white blood cells/en mm ; protein 63 mg/dl; glucose 88 mg/dl; and LDH 12 IU/L. Steroids were given initially with little improvement in the neurologic deficits. At the time of transfer to a rehabilitation center 26 days after injury, the patient was able to lift her left lower extremity against gravity and the right wrist drop was improved. Her right sensory deficit at T 2 was unchanged. DISCUSSION

Longterm intravenous drug abuse gradually obliterates peripheral veins by an infectious or sclerotic process.v" Inveterate drug abusers often turn to larger veins in the groin or neck in pursuit of their addiction. Some real or imagined technical aspects of subclavian and internal jugular venous injections are well known to drug abusers in many locales. Undoubtedly, as these skills are passed from one user to another, the fine points of anatomy and needle positioning are distorted with resultant mishaps. Since cannulation of these structures in a hospital setting often is associated with some hazard, use of these routes "in the street" undoubtedly will produce morbidity and mortality. Injection into the depression in the neck lateral to the sternocleidomastoid muscle immediately above the clavicle is referred to by drug abusers as "the pocket shot" to the internal jugular vein (Fig 5). When a needle is directed toward the suprasternal notch, this venous structure can be entered reliably. However, when the needle is aimed slightly laterally, the apical pleura can be lacerated with resultant pneumothorax. Attempted infraclavicular injection into the subclavian vein is more difficult and has a greater propensity for pleural and vascular injury.

COMPLICATIONS OF VENOUS INJECTIONS BY DRUG ABUSERS 615

5. The dotted circle outlines a favorite site for neck injection used by drug abusers-the so-called "pocket shot."

FIGURE

When puncture marks are found in these areas in persons with suspected drug overdose, the presence of underlying pneumothorax must be excluded, especially if respiratory distress persists despite adequate narcotic antagonistic treatment. Endotracheal intubation and positive pressure ventilation in this situation could lead to tension pneumothorax and death, if adequate pleural decompression were not performed. 6 Misguided needles by drug abusers may inadvertently injure any structure in the region injected. Arterial laceration sustained during such an injection can progress to pseudoaneurysm formation with eventual rupture. to Secondary infection will occur, due to the contaminated nature of the substances injected and the appliances used. This complication can usually be recognized by a systemic febrile response associated with a IBCal, pulsatile, tender mass. Expeditious arterial and, if indicated, venous angiography should be performed to document this potentially lethal complication. In this setting, the subclavian and common carotid arteries are usually involved. Ligation of the inflow (innominate, subclavian or common carotid arteries) and outflow (common carotid or subclavian arteries, depending on the injured side) is required. Prosthetic grafting of the interrupted vessels is contraindicated in this contaminated region. Neurologic deficit and/or disabling extremity ischemia following interruption of the common carotid and subclavian arteries may not develop if adequate collateral circulation is present. Abscess formation at the injection site without vascular involvement responds well to local care, simple incision, drainage, and type-specific antibi-

818 LEWIS ET At

otics. The status of tetanus immunization in these individuals may be ascertained since Clostridium tetani organisms may be introduced by the nonsterile needle. 11,12 Two patients (Cases 1 and 6) developed hoarseness or high pitched voice lasting several days to two weeks after supraclavicular injection of drugs. This could represent recurrent laryngeal or vagal nerve involvement from the needle itself or the substance injected. Laryngoscopy during their latest admissions showed normal vocal cord motion. Any drug abuser with changes in voice following neck injection should be evaluated for possible recurrent laryngeal nerve injury. It is postulated that the postinjection paralysis sustained by patient No.6 resulted from injection of noxious material into the left subclavian artery near the vertebral artery orifice producing transient blindness with a resultant anterior spinal artery syndrome. Typical spinal cord injury in this syndrome occurs from the mid cervical (C 4•5 ) to upper thoracic (T3) levels.P The inhomogeneous distribution of neurologic findings in this patient would suggest particulate embolization or direct injury by the noxious material according to its distribution in the involved spinal arterial circulation. Thrombosis of the anterior spinal artery would probably produce a more uniform type of permanent cord injury. Angiography of the vertebral artery was not contemplated since contrast material has produced spinal cord injury itself.14 Neurologic injuries resulting from this type of injection may be amenable to treatment if seen early. Mishkin et al l S found that spinal cord injury following angiography could be modified by repeated withdrawal of cerebrospinal fluid through a lumbar puncture. Replacement of small aliquots of this fluid with normal saline solution probably reduced the concentration of noxious material in the spinal canal. This modality of therapy should be considered in the drug abuser who sustains neurologic injury following probable injections into vessels ultimately communicating with the spinal cord. The time lag from injection to definitive treatment, however, may preclude reversal of this syndrome. With the continued burgeoning of drug abuse, it is felt that increasing numbers of complications related to this type of central injection will be seen with greater frequency. Thorough evaluation and treatment of possible underlying arteriovenous, soft tissue, or pleural injury in addicts using this route of administration may prevent the development of related fatal complications. It is predicted that continued "street" injections into the neck and subclavian areas will eventually result in reports of CHEST, 78: 4, OCTOBER, 1980

injury to all of the underlying sbuctures accessible to the drug abusers' needle or material injected. ACKNOWLEDGMENT: We are indebted tD DrtJ·~ Fisher and Dhanwada Rao for referring patients 3 aDd 6, 'and to Olive Rundgren for her assistance in preparing this manuscript.

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6 Maggs PR, Schwaber JR. Fatal bilateral pneumothoraces complicating subclavian vein catheterization. Chest 1977; 71:552-553 7 Hurwitz BI, Posner ]B. Cerebral infarction complicating subclavian vein catheterization. Ann Neuroll977; 1:253254 8 Pollard R. Surgical implications for some types of drug dependence. Br Med J 1973; 1:784-787 9 Geelhoed GW, Joseph WL. Surgical sequelae of drug abuse. Surg Gyn Obst 1974; 139:749-755 10 Ho K-L, Rasse1ch ZS. Mycotic aneurysm of the right subclavian artery: A complication of heroin addiction. Chest 1978; 74:116-117 11 Litt IF, Schonberg SK. Medical complications of drug abuse in adolescents. Clin North Am 1975; 59: 14451452 12 Chembin CE. Clinical severity of tetanus in narcotic addicts in New York City. Arch Intern Med 1968; 121: 156-158 13 Walton ]N. Brain's diseases of the nervous system. Oxford: Oxford University Press, 1977:784 14 Spinal cord damage after angiography. Lancet 1973; 2: 1067-1068 15 Mishkin MM, Baun S, DiChiro G. Emergency treabnent of angiographie-induced paraplegia and tetraplegia. N Engl J Med 1972; 288:1184-1185

Moo

COMPUCATIONS OF VENOUS IJUECnONS BY DRUG ABUSERS 817