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Major complications of percutaneous subclavian vein catheters
Major Complications of Percutaneous Subclavian Vein Catheters David V. Feliciano, MD, Houston,
Texas
Kenneth C. Mattox, MD, Houston, Texas Joseph M. Graham, MD, Houston, Arthur C. Beall, Jr, MD, Houston,
Texas Texas
George L. Jordan, Jr, MD, Houston,
Texas
Subclavian venipuncture as a venous access route was first described by Aubaniac [1,2] over 25 years ago. Adoption of this technique in the United States was slow but increased tremendously after the description of central venous pressure measurement through subclaviw vein catheters by Wilson et al [3] in 1962. Classically, catheters in the subclavian vein were used for rapid fluid and blood replacement, central venous pressure measurement, venous access in patients without available veins in the arms, and infusion of parenteral nutrition solutions. In recent years such catheters have been used as guides for the passage of ttansvenous pacemakers and Swan-Ganz catheters, and for single-needle hemodialysis access. In early reports the rate of successful cannulations was high and complications were minimal; however, multiple reports of complications related to either the venipuncture or the presence of catheters in the central venous system soon appeared [4-131. During the last 10 years, reports of new complications have appeared regularly [ 14-201. Many fatal complications have occurred, including pneumothorax, hemothorax, hydromediastinum, hydropericardium, septicemia, arrhythmias, pulmonary embolus, air embolus, and catheter embolus. In tl_reliterature review by Borja et al [16] in 1972, the complication rate ranged from 0.4 to 9.9 per cent. A recent retrospective audit by Herbst [f6a] documented an 11.1 per cent rate of complications in a university hospital. As subclavian venipuncture is successful over 95 per cent of the time and most reported complications are minor (pneumothorax, subciavian artery puncture, and improper positioning), the technique is now From the Cora and Webb Mading Department of Surgery, Baylor College of Medicine. and the Ben Taub General Hospital, Houston, Texas. Reorint reouests should be addressed to David V. Feliciano. MD. 1200 Moukund A&ue. Houston, Texas 77030. Presented at the 31st Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April 23-26. 1979.
Volume 138, December 1979
being used in a high percentage of patients in acute care institutions. At the Ben Taub General Hospital in Houston, over 250 infraclavicular subclavian venipunctures with passage of central catheters are performed in the emergency center and on the surgery wards each month. During a recent 6 month period when over 1,500 subclavian venipunctures were performed, eight patients had major complications. The purpose of this study is to review our experience with three separate categories of major complications in eight patients. Retained Catheter Fragments
Plastic catheters are easily sheared off into the central circulation by traction on the beveled tip of the inserting needle. Occasionally, fracture of the catheter may occur secondary to improper fixation and excessive movement. Catheter emboli were originally reported in hydrocephalic patients with cerebrocardiac shunts [21-251. There were simultaneous reports of accidental severing of long intravenous catheters inserted in the antecubital and femoral areas [26-331. Early reports of subclavian catheterization discussed the complication of catheter fragments being sheared off into local infraclavicular tissues [5,6]. Central venous and cardiac embolization of such fragments was inevitable [34-361. Two patients with retained catheter fragments were, seen recently on our surgical services. In a 42 year old man with blunt trauma to the head, a catheter was severed during insertion by a junior house officer. The retained fragment appeared to be located in soft tissue in the right superior mediastinum on chest x-ray film. Local exploration by way of an infraclavicular incision was unsuccessful in locating the catheter fragment. The right clavicle was then divided at the junction of its medial and middle thirds, both ends were elevated, and the retained catheter
869
Feliciano et al
Figure 1. Surgical approach the to retained subclavian vein catheter fragment. After a medial lsupraclavtcular incision, and divkkdat tk@ction tts of medial the clavkte freed is and middle thirds. Futiher disse+!on will expose the retroclavkular subclavian vein.
was removed from the adventitia of the innominate artery (Figure 1). Several weeks later, we saw a 24 year old woman with blunt trauma to the head. A left subclavian catheter had been transected when manipulated by the patient. A Ieft subclavian venogram showed a catheter fragment in the left subclavian vein surrounded by clot. Attempted retrieval by intravenous passage of a wire loop was unsuccessful. Local exploration through a supraclavicular incision was again unsuccessful in locating the catheter fragment. Therefore, the left clavicle was divided as in the previous case, and the retained catheter was removed from the wall of the left subclavian vein. The clavicular fracture was then wired for stability (Figure 2). To avoid this complication, plastic catheters should be inserted with the distal beveled tip of the needle introducer facing the patient. Unsuccessful cannulation demands simultaneous withdrawal of the catheter and needle to avoid shearing. Proper application of the needle guard, fixation to the skin, and the coverage of the introducing needle and guard are all part of the standard technique. The need to remove retained catheter fragments is generally accepted because’of the obvious problems of embolization to the heart with myocardial thrombi and recurrent episodes of septicemia [28,31,35,37]. In patients in whom retained catheter fragments cannot be localized, careful observation is necessary. If the catheter has been transected during insertion, an infraclavicular approach along the path of the inserting needle may occasionally be successful. In most other patients subclavian-innominate venography is recommended. Catheter fragments localized
870
Figbre 2. Ret&d catheter fragment in subctavian left vein. subcla vian venogram TopJroutine chest x-ray middle, film; redined demonstrating fragment; catheter bottom, fragment removed and clavicular fracture wired,
to the venous system can be removed by a variety of techniques short of surgery. Transvenous hooked catheters, wire loops, stone baskets, and endoscopic forceps have all been used [33,34,36,38]. If transvenous techniques are unsuccessful, we recommend the simple approach just described, including (1) medial supraclavicular incision; (2) division of the clavicular head of the sternocleidomastoid muscle; (3) freeing of the medial clavicle; (4) division of the clavicle at the junction of the medial and middle thirds; (5) elevation of ends of bone; (6) retrieval of the catheter fragment, using vascular clamps as necessary; and (7) application of a dynamic compression plate to the clavicular fracture. Angiographic studies may localize the catheter in the innominate vein or superior vena cava; right thoracotomy may be required in these instances. Retained fragments in the right heart are
The American Journal of Surgery
Major Complications
usually approached median sternotomy. be localized during nary bypass may be
of Subclavian Catheters
through a right thoracotomy or If the retained fragment cannot inflow occlusion, cardiopulmonecessary [23].
lntrapleural Instillation of Resuscitation Fluid
If the tip of a subclavian venous catheter perforates the innominate vein, superior vena cava, or right atrium, hydromediastinum and hydropericardium may result [7,16,39-411. Perforation of the subclavian vein can lead to intrapleural instillation of resuscitation fluid with associated hemothorax [16,19,42], a complication that is infrequently reported. Most house officers are aware of the technique of aspiration of blood back through the fully inserted catheter to confirm an intravenous position. Also, proper position of the catheter tip can be documented on postcatheterization chest x-ray study. In an acute care institution, this complication may occur more often than previously recognized. Four recent patients with intrapleural instillation of resuscitation fluid were seen on our surgical services. A 28 year old man with a stab wound of the right flank underwent routine hepatorrhaphy with drainage. The right thoracostomy tube that had been placed to control a pneumothorax continued to drain large amounts of blood-tinged fluid during the recovery period. Emergency right thoracotomy was planned but, using a technique previously reported from this hospital, 1 ampule of methylene blue was added to the patient’s intravenous fluids 1191. The rapid appearance of methylene blue in the chest tube confirmed the suspected intrapleural position of the tip of the subclavian catheter, and the catheter was removed. In a 22 year old man with a gunshot wound of the right side of the chest, continued postthoracotomy hemorrhage was again confirmed as originating from blood transfusions administered through a right subclavian catheter when methylene blue was infused. In another 19 year old man who underwent laparotomy for a stab wound in the left lower abdominal quadrant, acute shortness of breath developed in the early postoperative period. Chest x-ray film showed massive right hydrothorax, and rapid thoracentesis produced 5,300 ml of blood-tinged intravenous fluid (Figure 3). A recent fatality was related to this complication. A 24 year old man with a gunshot wound of the left parasternal area was brought to the emergency center. Multiple intravenous lines were inserted, including a right subclavian catheter that demonstrated free return of aspirated blood. Chest x-ray film showed bilateral hemothorax. Bilateral tube
Volume 138, December 1979
Figure 3. X-ray film demonstrating 5,300 ml of intravenous fluid hydrothorax secondary to ma/position of subctavian catheter tip.
thoracostomy was performed; the right tube initially drained 2,400 ml of blood which was then autotransfused. Rapid transfusion through all intravenous lines was begun, but the patient continued to have bleeding through the right thoracostomy tube and had a cardiopulmonary arrest. Left anterolateral thoracotomy was performed in the emergency center, and right ventriculorrhaphy was accomplished. Ventricular fibrillation was reversed after multiple cardioversions. In the operating room bleeding persisted through the right chest tube and hypotension could not be reversed. Transsternal extension to a right anterolateral thoracotomy was performed, at which time a palpable right intrapleural subclavian catheter was removed. After rapid laparotomy with hepatorrhaphy, phrenorrhaphy, and drainage, a coagulopathy was noted, refractory hypotension developed during recovery, and the patient subsequently died. Hemo- and pneumothorax may distort the course of central veins in the patient with thoracic or abdominal wounds. Also, if subclavian-innominatesuperior vena cava injury is suspected, subclavian vein catheters should not be inserted. Once inserted, central venous catheters undergo significant manipulation as critically injured patients are rolled from side to side, entrance and exit wounds are marked, and multiple x-ray views are taken. If thoracotomy is performed in the emergency center, more manipulation may occur. An abnormal position of the catheter tip seen on chest x-ray film after in-
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sertion of a subclavian vein catheter should lead $0 immediate removal. Once an ipsilateral hemothorax has been drained, repeat aspiration of blood from the subclavian catheter should be performed. A high index of clinical suspicion is necessary to diagnose this complication. The use of an intravenously administered. dye such as methylene blue may be an aid. Venous Air Embolism
In his original communication on the use of subclavian venipuncture, Aubaniac [I] stated that “the risk of embolization does not exist.” Subsequent reports documented the occurrence and sometimes fatal outcome of this complication [g-13,43]. Two recent patients with venous air embolism were seen on our surgical services. Venous air embolism occurred in a 48 year old man recovering from elective pancreatic surgery when the intravenous fluid line became disconnected from the subclavian venous catheter while he was walking. Tachypnea, air hunger, and hypotension occurred, but the symptoms were transient after the patient was placed in the Trendelenburg position with his left side down. There w&e no sequelae from this episode. Venous air embolism was also responsible for the death of a 20 year old’patient who had undergone hepatorrhaphy with drainage for blunt trauma to the abdomen. On the second postoperative day, in the presence of a floor nurse, the patient sat up, lost consciousness, and fell back-into bed. Attending physicians found the intraGenous infusion line disconnected from a right subclavian catheter. The patient was immediately turned. on his left side but quickly had a cardiopulmonary arrest. Routine cardiopulmonary resuscitation was unsucces ;ful in restoring vital signs, and the patient was placed on femorofemoral cardiopulmonary bypass at the bedside. After median sterpotomy was performed in the operating room, the left heart was found to be in a state of tetanic contraction. Despite negative exploration of the pulmonary artery, passage of Fogarty catheters into the coronary arteries (no emboli), and maximal pharmacologic support, the patient died. Venous air embolism has been described in patients undergoing head and neck or neurologic surgery with the head elevated, in patients receiving intravenous oxygen therapy, and in patients accidentally receiving intravenous air during blood transfusion [44-461. In relation to subclavian vein catheters, venous air embolism usually occurs during insertion when a finger is removed from the hub of the inserting needle to allow for passage of the catheter; however, disconnection of the subclavian 872
catheter from the intravenous line, as in the patient described, or cracks in the catheter hub may also be responsible [9,I 1,471. Air embolism has also occurred through the skin tract of a previously removed subclavian catheter in a cachectic patient [48]. When subclavian catheterization is to be performed electively, preliminary hydration by any route is a reasonable precaution. Venous air embolism during insertion can be prevented by placing the patient in the Trendelenburg position and releasing the occluding finger over the needle hub for as short a time as possible before the catheter is inserted. Proper skin fixation, daily dressing changes with inspection of the exposed catheter and its connecting end, and application of occlusive dressings with removal eliminate most other causes of venous air embolism related to the presence of the catheter. The characteristic sucking sound may be an important diagnostic sign of venous air embolism during insertion of the subclavian catheter. If this sound is followed by tachypnea, air hunger, pulmonary wheezing, hypotension, and the classic “mill wheel” murmur over the precordium, the diagnosis is likely. Occasionally, neurologic complications may predominate [49]. If the diagnosis is suspected, various therapeutic modalities may be performed. The patient is immediately turned onto his left side, a maneuver described by Durant et al I.501and Oppenheimer et al [51] over 25 years ago. Air bubble occlusion of the right ventricular outflow tract, the pathophysiologic mechanism of death in these patients, is relieved in this position; the addition of the Trendelenburg position further prevents the venous air from moving out of the right ventricle into the outflow tract. Supplemental oxygen should be given to the patient. If these simple maneuvers do not lead to some improvement in the patient’s condition or if cardiopulmonary arrest has occurred, advancement of the subcIavian catheter with aspiration of right ventricular air may occasionally be helpful [44,52]. Percutaneous aspiration of the right ventricle using a large spinal needle may be tried. External cardiac massage or internal cardiac massage with intermit‘tent clamping of the ascending aorta has been successful in clinical and laboratory trials, respectively [53,54]. Emergency cardiopulmonary bypass to relieve acute right heart failure should be attempted when other maneuvers fail to resuscitate the patient. Summary
New and reportedly safer techniques for subclavian venipuncture with the passage of central venous catheters appear regularly in the surgical literature The American Journal of Surgery
Major Complications
[55-591; yet reports of major complications continue to appear as well. We have reported on eight patients with major complications of percutaneous subclavian vein catheters, two of whom died. In our own hospital an improved educational program for junior house staff and nurses has been instituted. Better supervision of junior house staff when performing this potentially lethal technique is necessary. Daily inspection of catheters, early removal bf unnecessary catheters, and improved equipment should help to prevent these complications in the future. Achnouk&ment: technical
We thank Mary K. Allen, BA, for her
assistance.
References 1. Aubaniac R: Une novelle voie d’injection ou de ponction veineuse: la voie sous-claviculaire (veine sous-claviere. tronc brachiocephalique). Sem Hop Paris 28: 3445, 1952. 2. Aubaniac R: L’injection intraveineuse sous-claviculaire. Advantages et technique. Presse Med 60: 1456, 1952. 3. Wilson JN, Grow JB, Demong DV, Prevedel AE, Owens JC: Central venous pressure in optimal blood volume maintenance. Arch Surg 85563, 1962. 4. Keeri-Szanto M: The subclavian vein, a constant and consistent intravenous injection site. Arch Surg 72: 179, 1956. 5. Longerbeam JK, Vannix R, Wagner W, Jorgenson E: Central venous pressure monitoring. A useful guide to fluid therapy during shock and other forms of cardiovascular stress. Am J Surg 110: 220, 1965. 6. Malinak LR, Guide RE, Faris AM: Percutaneous subclavian catheterization for central venous pressure monitoring. Application in obstetric and gynecologic problems. Am J Obstet Gynecol93: 477, 1965. 7. Smith BE, Model1 JH, Gaub ML, Moya F: Complications of subclavian vein catheterization. Arch Surg 90: 228, 1965. 8. Schapira M, Stern WZ: Hazards of subclavian vein cannulation for central venous pressure monitoring. JAMA 201: 327, 1967. 9. Flanagan JP, Gradisar IV, Gross RJ, Kelly TR: Air embolus-a lethal complication of subclavian venipuncture. N Engl J h&d 281: 488, 1969. 10. Levinsky WJ: Fatal air embolism during insertion of CVP monitoring apparatus (letter). JAMA 209: 1721, 1969. 11. Lucas CE, lrani F: Air embolus via subclavian catheter (letter). NEnglJ Med281: 966, 1969. 12. Defalque RJ: Subclavian venipuncture: a review. Anesth Analg 47: 677, 1968. 13. Johnson CL, Lazarchick J, Lynn HB: Subclavian venipuncture: preventable complications; report of two cases. Mayo C/in Proc 45: 712, 1970. 14. Hoshal VL Jr, Ause RG, Hoskins PA: Fibrin sleeve formation on indwelling subclavian central venous catheters. Arch Surg 102: 353, 1971. 15. Langston CS: The aberrant central venous catheter and its complications. Radiology 100: 55, 1971. 16. Borja AR, Masri Z, Shruck L, Pejo S: Unusual and lethal complications of infraclavicular subclavian vein catheterization. fnt Surg 57: 42-45, 1972. 16a. Herbst CA Jr: Indications, management, and complications of percutaneous subclavian catheters. Arch Surg 113: 142 1, 1978. 17. Johnson AOB, Clark RG: Malpositioning of central venous catheters. Lancet 2: 1395, 1972. 18. Lefrak EA, Noon GP: Management of arterial injury secondary to attempted subclavian vein catheterization. Ann Thorac Surg 14: 294. 1972.
Volume 138, December 1979
of Subclavian
Catheters
19. Mattox KL, Fisher RG: Persistent hemothorax secondary to malposition of a subclavian venous catheter. J Trauma 17: 387, 1977. 20. Drachler DH, Koepke GH, Weg JG: Phrenic nerve injury from subclavian vein catheterization. Diagnosis by electromyography. JAMA 236: 2880, 1976. 21. Emery JL, Hilton HG: Lung and heart complications of the treatment of hydrocephalus by ventriculoauriculostomy. Surgery 50: 309, 1961. 22. Holder TM, Crow ML: Free intracardiac foreign body: a complication of ventriculo-venous shunt for hydrocephalus. J Thorac Cardiovasc Surg 45: 138, 1963. 23. Lillehei CW, Bonnabeau RD Jr, Grossling S: Removal of iatrogenie foreign bodies within cardiac chambers and great vessels. Circulation 32: 782, 1965. 24. McSweeney WJ, Schwartz DC: Retrieval of a catheter foreign body from the right heart using a guide wire deflector system. Radiology 100: 61, 1971. 25. Delany DJ, Starer F: Recovery of catheter lost in vascular system (letter). Br Med J 1: 510, 1972. 26. Edwards WH: A hazard of embolus associated with indwelling intravenous catheters. Surgery 53: 818, 1963. 27. Edwards WH: lntracath embolus: a rare complication of indwelling catheters used for intravenous therapy. South Med J56: 1354, 1963. 28. Taylor FW, Rutherford CE: Accidental loss of plastic tube into venous system. Arch Surg 86: 177, 1963. 29. Bennett PJ: Use of intravenous plastic catheters. Br Med J 2: 1252, 1963. 30. Steiner ML, Bartley TD, Byers FM, Krovetz LJ: Polyethylene catheter in the heart. Report of a case with successful removal. JAMA 193: 138, 1965. 31. Doering RB, Stemmer EA, Connolly JE: Complications of indwelling venous catheters. With particular reference to catheter embolus. Am J Surg 114: 259, 1967. 32. Blair E. Hunziker R, Flanagan ME: Catheter embolism. Surgery 67: 457, 1970. 33. Marlon AM, Cohn LH, Fogarty TJ, Harrison DC: Retrieval of catheter fragments. Report of two cases. Calif Med 115: 6 1, 1971. 34. Massumi RA, Ross AM: Atraumatic. nonsurgical technic for removal of broken catheters from cardiac cavities. N Engi J Med 277: 195, 1967. 35. Fenn JE. Stansel HC Jr: Certain hazards of the central venous catheter. Angiology 20: 38, 1969. 36. Smyth NPD. Rogers JB: Transvenous removal of catheter emboli from the heart and great veins by endoscopic forceps. Ann Thorac Surg 11: 403, 1971. 37. Harken DE, Zoll PM: Foreign bodies in and in relation to the thoracic blood vessels and heart. Ill. Indications for the removal of intracardiac foreign bodies and the behavior of the heart during manipulation. Am Heart J 32: 1, 1946. 38. Edelstein J: Atraumatic removal of a polyethylene catheter from the superior vena cava. Chest 57: 381, 1970. 39 Davis WS, Akers DR: Catheterization of the subclavian vein. An unusual complication. Rocky Mt Med J 64: 72. 1967. 40. Adar R, Mozes M: Hydromediastinum (letter). JAMA 214: 372, 1970. 41. Gonger JD: Cardiac syncope from fluid extravasation from subclavian vein catheter (letter). JAMA 214: 373, 1970. 42. Aulenbacher CE: Hydrothorax from subclavian vein catheterization (letter). JAMA 214: 372. 1970. 43. Ordway CB: Air embolus via CVP catheter without positive pressure: presentation of case and review. Ann Surg 179: 479, 1974. 44. Michenfelder JD, Terry HR Jr, Daw EF. Miller RH: Air embolism during neurosurgery. A new method of treatment. Anesth Analg 45: 390, 1966. 45. Tunnicliffe FW, Stebbing GF: The intravenous injection of oxygen gas as a therapeutic measure. Lancet 2: 321, 1916. 46. Yeakel AE: Lethal air embolism from plastic blood-storage
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container. JAMA 204: 267, 1969. 47. Peters JL, Armstrong R: Air embolism occurring as a complication of central venous catheterization. Ann Surg 167: 375, 1979. 48. Paskin DL, Hoffman WS, Tuddenham WJ: A new complication of subclavian vein catheterization. Ann Surg 179: 266, 1974. 49. Grace DM: Air embolism with neurologic complications; a potential hazard of central venous catheters. Canad J Surg 20: 51, 1977. 50. Durant TM, Long J, Oppenheimer MJ: Pulmonary (venous) air embolism. Am Hearf J33: 269, 1947. 5 1. Oppenheimer MJ, Durant TM, Lynch PL: Body position in relation to venous air embolism and the associated cardiovascularrespiratory changes. Am J Med Sci 225: 362, 1953. 52. Sink JD. Comer PB, James PM, Loveland SR: Evaluation of catheter placement in the treatment of venous air embolism. Ann Surg 183: 58, 1976. 53. Ericsson JA, Gotllieb JD, Sweet FIB: Closed-chest cardiac massage in the treatment of venous air embolism. N Engl J Med 270: 1353, 1964. 54. Holt EP Jr, Webb WR, Cook WA, Unal MO: Air embolism. Hemodynamics and therapy. Ann Thorac Surg 2: 551. 1966. 55. Land RE, Garrett JC, Hedberg SE: Television fluoroscopy and opacification of the subclavian vein. Adjuncts to percutaneous subclavian venous catheterization. Arch Surg 101: 429,197o. 56. Gallitano AL, Kondi ES, Deckers JP: A safe approach to the subclavian vein. Surg Gynecol Obstef 135: 96, 1972.
a74
57. Goy JAE: Guide-wire technique for central vein cannulation. BrMedJ2: 21, 1976. 58. Westreich M: Preventing complications of subclavian vein catheterization. JACEP 7: 368, 1978. 59. Simon RR: A new technique for subclavian puncture. JACEP 7: 409, 1978.
Discussion Ronald P. Fischer (Tucson, AR): Several years ago we switched to internal jugular placements because I had read several enthusiastic reports of a lower incidence of complications. Although this may be true for pneumothorax, it is not true for anything else. What is the incidence of pneumothorax after subclavian placement? David V. Feliciano (closing): The incidence of pneumothorax at our institution is approximately one case every other week. We put in approximately 120 catheters every 2 weeks. Internal jugular venous catheterization is being used at Ben Taub, but much less frequently than subclavian venous catheterization. As experience increases with this technique, our use of subclavian catheterization may well decrease.
The American Journal of Surgery
Texas
Kenneth C. Mattox, MD, Houston, Texas Joseph M. Graham, MD, Houston, Arthur C. Beall, Jr, MD, Houston,
Texas Texas
George L. Jordan, Jr, MD, Houston,
Texas
Subclavian venipuncture as a venous access route was first described by Aubaniac [1,2] over 25 years ago. Adoption of this technique in the United States was slow but increased tremendously after the description of central venous pressure measurement through subclaviw vein catheters by Wilson et al [3] in 1962. Classically, catheters in the subclavian vein were used for rapid fluid and blood replacement, central venous pressure measurement, venous access in patients without available veins in the arms, and infusion of parenteral nutrition solutions. In recent years such catheters have been used as guides for the passage of ttansvenous pacemakers and Swan-Ganz catheters, and for single-needle hemodialysis access. In early reports the rate of successful cannulations was high and complications were minimal; however, multiple reports of complications related to either the venipuncture or the presence of catheters in the central venous system soon appeared [4-131. During the last 10 years, reports of new complications have appeared regularly [ 14-201. Many fatal complications have occurred, including pneumothorax, hemothorax, hydromediastinum, hydropericardium, septicemia, arrhythmias, pulmonary embolus, air embolus, and catheter embolus. In tl_reliterature review by Borja et al [16] in 1972, the complication rate ranged from 0.4 to 9.9 per cent. A recent retrospective audit by Herbst [f6a] documented an 11.1 per cent rate of complications in a university hospital. As subclavian venipuncture is successful over 95 per cent of the time and most reported complications are minor (pneumothorax, subciavian artery puncture, and improper positioning), the technique is now From the Cora and Webb Mading Department of Surgery, Baylor College of Medicine. and the Ben Taub General Hospital, Houston, Texas. Reorint reouests should be addressed to David V. Feliciano. MD. 1200 Moukund A&ue. Houston, Texas 77030. Presented at the 31st Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April 23-26. 1979.
Volume 138, December 1979
being used in a high percentage of patients in acute care institutions. At the Ben Taub General Hospital in Houston, over 250 infraclavicular subclavian venipunctures with passage of central catheters are performed in the emergency center and on the surgery wards each month. During a recent 6 month period when over 1,500 subclavian venipunctures were performed, eight patients had major complications. The purpose of this study is to review our experience with three separate categories of major complications in eight patients. Retained Catheter Fragments
Plastic catheters are easily sheared off into the central circulation by traction on the beveled tip of the inserting needle. Occasionally, fracture of the catheter may occur secondary to improper fixation and excessive movement. Catheter emboli were originally reported in hydrocephalic patients with cerebrocardiac shunts [21-251. There were simultaneous reports of accidental severing of long intravenous catheters inserted in the antecubital and femoral areas [26-331. Early reports of subclavian catheterization discussed the complication of catheter fragments being sheared off into local infraclavicular tissues [5,6]. Central venous and cardiac embolization of such fragments was inevitable [34-361. Two patients with retained catheter fragments were, seen recently on our surgical services. In a 42 year old man with blunt trauma to the head, a catheter was severed during insertion by a junior house officer. The retained fragment appeared to be located in soft tissue in the right superior mediastinum on chest x-ray film. Local exploration by way of an infraclavicular incision was unsuccessful in locating the catheter fragment. The right clavicle was then divided at the junction of its medial and middle thirds, both ends were elevated, and the retained catheter
869
Feliciano et al
Figure 1. Surgical approach the to retained subclavian vein catheter fragment. After a medial lsupraclavtcular incision, and divkkdat tk@ction tts of medial the clavkte freed is and middle thirds. Futiher disse+!on will expose the retroclavkular subclavian vein.
was removed from the adventitia of the innominate artery (Figure 1). Several weeks later, we saw a 24 year old woman with blunt trauma to the head. A left subclavian catheter had been transected when manipulated by the patient. A Ieft subclavian venogram showed a catheter fragment in the left subclavian vein surrounded by clot. Attempted retrieval by intravenous passage of a wire loop was unsuccessful. Local exploration through a supraclavicular incision was again unsuccessful in locating the catheter fragment. Therefore, the left clavicle was divided as in the previous case, and the retained catheter was removed from the wall of the left subclavian vein. The clavicular fracture was then wired for stability (Figure 2). To avoid this complication, plastic catheters should be inserted with the distal beveled tip of the needle introducer facing the patient. Unsuccessful cannulation demands simultaneous withdrawal of the catheter and needle to avoid shearing. Proper application of the needle guard, fixation to the skin, and the coverage of the introducing needle and guard are all part of the standard technique. The need to remove retained catheter fragments is generally accepted because’of the obvious problems of embolization to the heart with myocardial thrombi and recurrent episodes of septicemia [28,31,35,37]. In patients in whom retained catheter fragments cannot be localized, careful observation is necessary. If the catheter has been transected during insertion, an infraclavicular approach along the path of the inserting needle may occasionally be successful. In most other patients subclavian-innominate venography is recommended. Catheter fragments localized
870
Figbre 2. Ret&d catheter fragment in subctavian left vein. subcla vian venogram TopJroutine chest x-ray middle, film; redined demonstrating fragment; catheter bottom, fragment removed and clavicular fracture wired,
to the venous system can be removed by a variety of techniques short of surgery. Transvenous hooked catheters, wire loops, stone baskets, and endoscopic forceps have all been used [33,34,36,38]. If transvenous techniques are unsuccessful, we recommend the simple approach just described, including (1) medial supraclavicular incision; (2) division of the clavicular head of the sternocleidomastoid muscle; (3) freeing of the medial clavicle; (4) division of the clavicle at the junction of the medial and middle thirds; (5) elevation of ends of bone; (6) retrieval of the catheter fragment, using vascular clamps as necessary; and (7) application of a dynamic compression plate to the clavicular fracture. Angiographic studies may localize the catheter in the innominate vein or superior vena cava; right thoracotomy may be required in these instances. Retained fragments in the right heart are
The American Journal of Surgery
Major Complications
usually approached median sternotomy. be localized during nary bypass may be
of Subclavian Catheters
through a right thoracotomy or If the retained fragment cannot inflow occlusion, cardiopulmonecessary [23].
lntrapleural Instillation of Resuscitation Fluid
If the tip of a subclavian venous catheter perforates the innominate vein, superior vena cava, or right atrium, hydromediastinum and hydropericardium may result [7,16,39-411. Perforation of the subclavian vein can lead to intrapleural instillation of resuscitation fluid with associated hemothorax [16,19,42], a complication that is infrequently reported. Most house officers are aware of the technique of aspiration of blood back through the fully inserted catheter to confirm an intravenous position. Also, proper position of the catheter tip can be documented on postcatheterization chest x-ray study. In an acute care institution, this complication may occur more often than previously recognized. Four recent patients with intrapleural instillation of resuscitation fluid were seen on our surgical services. A 28 year old man with a stab wound of the right flank underwent routine hepatorrhaphy with drainage. The right thoracostomy tube that had been placed to control a pneumothorax continued to drain large amounts of blood-tinged fluid during the recovery period. Emergency right thoracotomy was planned but, using a technique previously reported from this hospital, 1 ampule of methylene blue was added to the patient’s intravenous fluids 1191. The rapid appearance of methylene blue in the chest tube confirmed the suspected intrapleural position of the tip of the subclavian catheter, and the catheter was removed. In a 22 year old man with a gunshot wound of the right side of the chest, continued postthoracotomy hemorrhage was again confirmed as originating from blood transfusions administered through a right subclavian catheter when methylene blue was infused. In another 19 year old man who underwent laparotomy for a stab wound in the left lower abdominal quadrant, acute shortness of breath developed in the early postoperative period. Chest x-ray film showed massive right hydrothorax, and rapid thoracentesis produced 5,300 ml of blood-tinged intravenous fluid (Figure 3). A recent fatality was related to this complication. A 24 year old man with a gunshot wound of the left parasternal area was brought to the emergency center. Multiple intravenous lines were inserted, including a right subclavian catheter that demonstrated free return of aspirated blood. Chest x-ray film showed bilateral hemothorax. Bilateral tube
Volume 138, December 1979
Figure 3. X-ray film demonstrating 5,300 ml of intravenous fluid hydrothorax secondary to ma/position of subctavian catheter tip.
thoracostomy was performed; the right tube initially drained 2,400 ml of blood which was then autotransfused. Rapid transfusion through all intravenous lines was begun, but the patient continued to have bleeding through the right thoracostomy tube and had a cardiopulmonary arrest. Left anterolateral thoracotomy was performed in the emergency center, and right ventriculorrhaphy was accomplished. Ventricular fibrillation was reversed after multiple cardioversions. In the operating room bleeding persisted through the right chest tube and hypotension could not be reversed. Transsternal extension to a right anterolateral thoracotomy was performed, at which time a palpable right intrapleural subclavian catheter was removed. After rapid laparotomy with hepatorrhaphy, phrenorrhaphy, and drainage, a coagulopathy was noted, refractory hypotension developed during recovery, and the patient subsequently died. Hemo- and pneumothorax may distort the course of central veins in the patient with thoracic or abdominal wounds. Also, if subclavian-innominatesuperior vena cava injury is suspected, subclavian vein catheters should not be inserted. Once inserted, central venous catheters undergo significant manipulation as critically injured patients are rolled from side to side, entrance and exit wounds are marked, and multiple x-ray views are taken. If thoracotomy is performed in the emergency center, more manipulation may occur. An abnormal position of the catheter tip seen on chest x-ray film after in-
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sertion of a subclavian vein catheter should lead $0 immediate removal. Once an ipsilateral hemothorax has been drained, repeat aspiration of blood from the subclavian catheter should be performed. A high index of clinical suspicion is necessary to diagnose this complication. The use of an intravenously administered. dye such as methylene blue may be an aid. Venous Air Embolism
In his original communication on the use of subclavian venipuncture, Aubaniac [I] stated that “the risk of embolization does not exist.” Subsequent reports documented the occurrence and sometimes fatal outcome of this complication [g-13,43]. Two recent patients with venous air embolism were seen on our surgical services. Venous air embolism occurred in a 48 year old man recovering from elective pancreatic surgery when the intravenous fluid line became disconnected from the subclavian venous catheter while he was walking. Tachypnea, air hunger, and hypotension occurred, but the symptoms were transient after the patient was placed in the Trendelenburg position with his left side down. There w&e no sequelae from this episode. Venous air embolism was also responsible for the death of a 20 year old’patient who had undergone hepatorrhaphy with drainage for blunt trauma to the abdomen. On the second postoperative day, in the presence of a floor nurse, the patient sat up, lost consciousness, and fell back-into bed. Attending physicians found the intraGenous infusion line disconnected from a right subclavian catheter. The patient was immediately turned. on his left side but quickly had a cardiopulmonary arrest. Routine cardiopulmonary resuscitation was unsucces ;ful in restoring vital signs, and the patient was placed on femorofemoral cardiopulmonary bypass at the bedside. After median sterpotomy was performed in the operating room, the left heart was found to be in a state of tetanic contraction. Despite negative exploration of the pulmonary artery, passage of Fogarty catheters into the coronary arteries (no emboli), and maximal pharmacologic support, the patient died. Venous air embolism has been described in patients undergoing head and neck or neurologic surgery with the head elevated, in patients receiving intravenous oxygen therapy, and in patients accidentally receiving intravenous air during blood transfusion [44-461. In relation to subclavian vein catheters, venous air embolism usually occurs during insertion when a finger is removed from the hub of the inserting needle to allow for passage of the catheter; however, disconnection of the subclavian 872
catheter from the intravenous line, as in the patient described, or cracks in the catheter hub may also be responsible [9,I 1,471. Air embolism has also occurred through the skin tract of a previously removed subclavian catheter in a cachectic patient [48]. When subclavian catheterization is to be performed electively, preliminary hydration by any route is a reasonable precaution. Venous air embolism during insertion can be prevented by placing the patient in the Trendelenburg position and releasing the occluding finger over the needle hub for as short a time as possible before the catheter is inserted. Proper skin fixation, daily dressing changes with inspection of the exposed catheter and its connecting end, and application of occlusive dressings with removal eliminate most other causes of venous air embolism related to the presence of the catheter. The characteristic sucking sound may be an important diagnostic sign of venous air embolism during insertion of the subclavian catheter. If this sound is followed by tachypnea, air hunger, pulmonary wheezing, hypotension, and the classic “mill wheel” murmur over the precordium, the diagnosis is likely. Occasionally, neurologic complications may predominate [49]. If the diagnosis is suspected, various therapeutic modalities may be performed. The patient is immediately turned onto his left side, a maneuver described by Durant et al I.501and Oppenheimer et al [51] over 25 years ago. Air bubble occlusion of the right ventricular outflow tract, the pathophysiologic mechanism of death in these patients, is relieved in this position; the addition of the Trendelenburg position further prevents the venous air from moving out of the right ventricle into the outflow tract. Supplemental oxygen should be given to the patient. If these simple maneuvers do not lead to some improvement in the patient’s condition or if cardiopulmonary arrest has occurred, advancement of the subcIavian catheter with aspiration of right ventricular air may occasionally be helpful [44,52]. Percutaneous aspiration of the right ventricle using a large spinal needle may be tried. External cardiac massage or internal cardiac massage with intermit‘tent clamping of the ascending aorta has been successful in clinical and laboratory trials, respectively [53,54]. Emergency cardiopulmonary bypass to relieve acute right heart failure should be attempted when other maneuvers fail to resuscitate the patient. Summary
New and reportedly safer techniques for subclavian venipuncture with the passage of central venous catheters appear regularly in the surgical literature The American Journal of Surgery
Major Complications
[55-591; yet reports of major complications continue to appear as well. We have reported on eight patients with major complications of percutaneous subclavian vein catheters, two of whom died. In our own hospital an improved educational program for junior house staff and nurses has been instituted. Better supervision of junior house staff when performing this potentially lethal technique is necessary. Daily inspection of catheters, early removal bf unnecessary catheters, and improved equipment should help to prevent these complications in the future. Achnouk&ment: technical
We thank Mary K. Allen, BA, for her
assistance.
References 1. Aubaniac R: Une novelle voie d’injection ou de ponction veineuse: la voie sous-claviculaire (veine sous-claviere. tronc brachiocephalique). Sem Hop Paris 28: 3445, 1952. 2. Aubaniac R: L’injection intraveineuse sous-claviculaire. Advantages et technique. Presse Med 60: 1456, 1952. 3. Wilson JN, Grow JB, Demong DV, Prevedel AE, Owens JC: Central venous pressure in optimal blood volume maintenance. Arch Surg 85563, 1962. 4. Keeri-Szanto M: The subclavian vein, a constant and consistent intravenous injection site. Arch Surg 72: 179, 1956. 5. Longerbeam JK, Vannix R, Wagner W, Jorgenson E: Central venous pressure monitoring. A useful guide to fluid therapy during shock and other forms of cardiovascular stress. Am J Surg 110: 220, 1965. 6. Malinak LR, Guide RE, Faris AM: Percutaneous subclavian catheterization for central venous pressure monitoring. Application in obstetric and gynecologic problems. Am J Obstet Gynecol93: 477, 1965. 7. Smith BE, Model1 JH, Gaub ML, Moya F: Complications of subclavian vein catheterization. Arch Surg 90: 228, 1965. 8. Schapira M, Stern WZ: Hazards of subclavian vein cannulation for central venous pressure monitoring. JAMA 201: 327, 1967. 9. Flanagan JP, Gradisar IV, Gross RJ, Kelly TR: Air embolus-a lethal complication of subclavian venipuncture. N Engl J h&d 281: 488, 1969. 10. Levinsky WJ: Fatal air embolism during insertion of CVP monitoring apparatus (letter). JAMA 209: 1721, 1969. 11. Lucas CE, lrani F: Air embolus via subclavian catheter (letter). NEnglJ Med281: 966, 1969. 12. Defalque RJ: Subclavian venipuncture: a review. Anesth Analg 47: 677, 1968. 13. Johnson CL, Lazarchick J, Lynn HB: Subclavian venipuncture: preventable complications; report of two cases. Mayo C/in Proc 45: 712, 1970. 14. Hoshal VL Jr, Ause RG, Hoskins PA: Fibrin sleeve formation on indwelling subclavian central venous catheters. Arch Surg 102: 353, 1971. 15. Langston CS: The aberrant central venous catheter and its complications. Radiology 100: 55, 1971. 16. Borja AR, Masri Z, Shruck L, Pejo S: Unusual and lethal complications of infraclavicular subclavian vein catheterization. fnt Surg 57: 42-45, 1972. 16a. Herbst CA Jr: Indications, management, and complications of percutaneous subclavian catheters. Arch Surg 113: 142 1, 1978. 17. Johnson AOB, Clark RG: Malpositioning of central venous catheters. Lancet 2: 1395, 1972. 18. Lefrak EA, Noon GP: Management of arterial injury secondary to attempted subclavian vein catheterization. Ann Thorac Surg 14: 294. 1972.
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19. Mattox KL, Fisher RG: Persistent hemothorax secondary to malposition of a subclavian venous catheter. J Trauma 17: 387, 1977. 20. Drachler DH, Koepke GH, Weg JG: Phrenic nerve injury from subclavian vein catheterization. Diagnosis by electromyography. JAMA 236: 2880, 1976. 21. Emery JL, Hilton HG: Lung and heart complications of the treatment of hydrocephalus by ventriculoauriculostomy. Surgery 50: 309, 1961. 22. Holder TM, Crow ML: Free intracardiac foreign body: a complication of ventriculo-venous shunt for hydrocephalus. J Thorac Cardiovasc Surg 45: 138, 1963. 23. Lillehei CW, Bonnabeau RD Jr, Grossling S: Removal of iatrogenie foreign bodies within cardiac chambers and great vessels. Circulation 32: 782, 1965. 24. McSweeney WJ, Schwartz DC: Retrieval of a catheter foreign body from the right heart using a guide wire deflector system. Radiology 100: 61, 1971. 25. Delany DJ, Starer F: Recovery of catheter lost in vascular system (letter). Br Med J 1: 510, 1972. 26. Edwards WH: A hazard of embolus associated with indwelling intravenous catheters. Surgery 53: 818, 1963. 27. Edwards WH: lntracath embolus: a rare complication of indwelling catheters used for intravenous therapy. South Med J56: 1354, 1963. 28. Taylor FW, Rutherford CE: Accidental loss of plastic tube into venous system. Arch Surg 86: 177, 1963. 29. Bennett PJ: Use of intravenous plastic catheters. Br Med J 2: 1252, 1963. 30. Steiner ML, Bartley TD, Byers FM, Krovetz LJ: Polyethylene catheter in the heart. Report of a case with successful removal. JAMA 193: 138, 1965. 31. Doering RB, Stemmer EA, Connolly JE: Complications of indwelling venous catheters. With particular reference to catheter embolus. Am J Surg 114: 259, 1967. 32. Blair E. Hunziker R, Flanagan ME: Catheter embolism. Surgery 67: 457, 1970. 33. Marlon AM, Cohn LH, Fogarty TJ, Harrison DC: Retrieval of catheter fragments. Report of two cases. Calif Med 115: 6 1, 1971. 34. Massumi RA, Ross AM: Atraumatic. nonsurgical technic for removal of broken catheters from cardiac cavities. N Engi J Med 277: 195, 1967. 35. Fenn JE. Stansel HC Jr: Certain hazards of the central venous catheter. Angiology 20: 38, 1969. 36. Smyth NPD. Rogers JB: Transvenous removal of catheter emboli from the heart and great veins by endoscopic forceps. Ann Thorac Surg 11: 403, 1971. 37. Harken DE, Zoll PM: Foreign bodies in and in relation to the thoracic blood vessels and heart. Ill. Indications for the removal of intracardiac foreign bodies and the behavior of the heart during manipulation. Am Heart J 32: 1, 1946. 38. Edelstein J: Atraumatic removal of a polyethylene catheter from the superior vena cava. Chest 57: 381, 1970. 39 Davis WS, Akers DR: Catheterization of the subclavian vein. An unusual complication. Rocky Mt Med J 64: 72. 1967. 40. Adar R, Mozes M: Hydromediastinum (letter). JAMA 214: 372, 1970. 41. Gonger JD: Cardiac syncope from fluid extravasation from subclavian vein catheter (letter). JAMA 214: 373, 1970. 42. Aulenbacher CE: Hydrothorax from subclavian vein catheterization (letter). JAMA 214: 372. 1970. 43. Ordway CB: Air embolus via CVP catheter without positive pressure: presentation of case and review. Ann Surg 179: 479, 1974. 44. Michenfelder JD, Terry HR Jr, Daw EF. Miller RH: Air embolism during neurosurgery. A new method of treatment. Anesth Analg 45: 390, 1966. 45. Tunnicliffe FW, Stebbing GF: The intravenous injection of oxygen gas as a therapeutic measure. Lancet 2: 321, 1916. 46. Yeakel AE: Lethal air embolism from plastic blood-storage
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container. JAMA 204: 267, 1969. 47. Peters JL, Armstrong R: Air embolism occurring as a complication of central venous catheterization. Ann Surg 167: 375, 1979. 48. Paskin DL, Hoffman WS, Tuddenham WJ: A new complication of subclavian vein catheterization. Ann Surg 179: 266, 1974. 49. Grace DM: Air embolism with neurologic complications; a potential hazard of central venous catheters. Canad J Surg 20: 51, 1977. 50. Durant TM, Long J, Oppenheimer MJ: Pulmonary (venous) air embolism. Am Hearf J33: 269, 1947. 5 1. Oppenheimer MJ, Durant TM, Lynch PL: Body position in relation to venous air embolism and the associated cardiovascularrespiratory changes. Am J Med Sci 225: 362, 1953. 52. Sink JD. Comer PB, James PM, Loveland SR: Evaluation of catheter placement in the treatment of venous air embolism. Ann Surg 183: 58, 1976. 53. Ericsson JA, Gotllieb JD, Sweet FIB: Closed-chest cardiac massage in the treatment of venous air embolism. N Engl J Med 270: 1353, 1964. 54. Holt EP Jr, Webb WR, Cook WA, Unal MO: Air embolism. Hemodynamics and therapy. Ann Thorac Surg 2: 551. 1966. 55. Land RE, Garrett JC, Hedberg SE: Television fluoroscopy and opacification of the subclavian vein. Adjuncts to percutaneous subclavian venous catheterization. Arch Surg 101: 429,197o. 56. Gallitano AL, Kondi ES, Deckers JP: A safe approach to the subclavian vein. Surg Gynecol Obstef 135: 96, 1972.
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57. Goy JAE: Guide-wire technique for central vein cannulation. BrMedJ2: 21, 1976. 58. Westreich M: Preventing complications of subclavian vein catheterization. JACEP 7: 368, 1978. 59. Simon RR: A new technique for subclavian puncture. JACEP 7: 409, 1978.
Discussion Ronald P. Fischer (Tucson, AR): Several years ago we switched to internal jugular placements because I had read several enthusiastic reports of a lower incidence of complications. Although this may be true for pneumothorax, it is not true for anything else. What is the incidence of pneumothorax after subclavian placement? David V. Feliciano (closing): The incidence of pneumothorax at our institution is approximately one case every other week. We put in approximately 120 catheters every 2 weeks. Internal jugular venous catheterization is being used at Ben Taub, but much less frequently than subclavian venous catheterization. As experience increases with this technique, our use of subclavian catheterization may well decrease.
The American Journal of Surgery