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MALPOSITION OF A CENTRAL VENOUS CATHETER
Br.J. Anaesth. (1982), 54, 109
CORRESPONDENCE MALPOSITION OF A CENTRAL VENOUS CATHETER
DAVID WEEDEN MARTIN ABEL London
REFERENCES
Gilner, L I (1977). The "ear gurgling" sign N. Engl. J. Med., 296, 1301 Malatinsky, J., Kadlic, T., Majek, M , and Samel, M (1976) Misplacement and loop formation of central venous catheters. Acta Anaesthenol Scand., 20, 237.
FIG. 1. Chest x-ray with contrast in catheter (tip arrowed).
PANCURONIUM AND NODAL RHYTHM
Sir,—We read with interest the letter by Saemund and Dalemus (1981) on the occurrence of nodal rhythm related to the injection of pancuronium Our studies on the haemodynamic responses to antagonism of neuromuscular block have revealed a significantly greater frequency of nodal rhythm in patients receiving pancuronium compared with tubocurarine or alcuromum. This rhythm disturbance is associated with bradycardia during the reversal of pancuronium block. We have studied healthy patients undergoing minor surgery under anaesthesia comprising thiopentone, nitrous oxide and an analgesic drug (Heinonen and Takkunen, 1977; Hcinonen, Salmenpera and Takkunen, 1981 and in preparation) After surgery, the 90°0 block was antagonized with neostigmine 0.03° o mgkg~' preceded by atropine 0.015mgkg"' A temporary nodal rhythm after neostigmine was observed m 15 of 41 pancuromum-treated patients, whereas all the patients treated with tubocurarine (n = 15) or alcuromum (n = 22) maintained sinus rhythm (pancuronium v. tubocurarine or alcuromum, P<0 01, Chi-square-test).
Downloaded from http://bja.oxfordjournals.org/ at Karolinska Institutet on July 19, 2015
Sir,—A 40-year-old man underwent mitral valve replacement, followed 4 months later by a further mitral valve replacement for infective endocarditis of the prosthesis; 6 weeks after the second operation, he developed septicaemic shock. As no peripheral veins were palpable a 13.3-cm 16-gauge Angiocath (Deseret Pharmaceuticals) was introduced via the left internal jugular vein using a low approach After entry to the vein it proved impossible to advance the catheter so aflexibleguide wire was introduced and the catheter passed easily down the vein. Oscillation responding to respiration was observed, but fast fluctuation synchronous with the pulse was not seen and aspiration of blood by syringe was less easy than normal. A diluted potassium chloride infusion caused immediate severe left shoulder tip pain which ceased on discontinuing the infusion and recurred on recommencing it The introduction of contrast medium to the catheter (fig 1) showed the tip (arrowed) filling the left pericardiophrenic veins The complications of central venous cannulation are those directly attributable to the insertion, those resulting from the presence of an indwelling catheter and those resulting from catheter malposition Malposition is least likely when the internal jugular approach has been used, but approximately 5% will not he within the superior vena cava or the right atrium (Malatinsky et al, 1976) Malposition in a persistent left superior vena cava, the azygos, internal thoracic, subclavian, axillary and hepatic veins, the inferior vena cava, the right ventricle and pulmonary artery have been reported but we believe that malposition in the pencardiophremc veins has not been recorded The guide wire directed the catheter across the left brachiocephalic vein into the left superior intercostal vein and then down to the termination of the left pencardiophremc veins. We feel that the use of a guide wire may have contributed to the malposition. A shorter cannula would not have reached this position but may not have been long enough to lie within the superior vena cava or right atrium. We assume that the shoulder tip pain was caused by irritation of the hemidiaphragm by retrograde perfusion with the potassium chloride solution Unusual complaints following insertion of a central venous catheter should raise the possibility of malposition as, for example, the "ear-gurgling sign" (Gilner, 1977) when the catheter tip lay near the middle ear.
CORRESPONDENCE MALPOSITION OF A CENTRAL VENOUS CATHETER
DAVID WEEDEN MARTIN ABEL London
REFERENCES
Gilner, L I (1977). The "ear gurgling" sign N. Engl. J. Med., 296, 1301 Malatinsky, J., Kadlic, T., Majek, M , and Samel, M (1976) Misplacement and loop formation of central venous catheters. Acta Anaesthenol Scand., 20, 237.
FIG. 1. Chest x-ray with contrast in catheter (tip arrowed).
PANCURONIUM AND NODAL RHYTHM
Sir,—We read with interest the letter by Saemund and Dalemus (1981) on the occurrence of nodal rhythm related to the injection of pancuronium Our studies on the haemodynamic responses to antagonism of neuromuscular block have revealed a significantly greater frequency of nodal rhythm in patients receiving pancuronium compared with tubocurarine or alcuromum. This rhythm disturbance is associated with bradycardia during the reversal of pancuronium block. We have studied healthy patients undergoing minor surgery under anaesthesia comprising thiopentone, nitrous oxide and an analgesic drug (Heinonen and Takkunen, 1977; Hcinonen, Salmenpera and Takkunen, 1981 and in preparation) After surgery, the 90°0 block was antagonized with neostigmine 0.03° o mgkg~' preceded by atropine 0.015mgkg"' A temporary nodal rhythm after neostigmine was observed m 15 of 41 pancuromum-treated patients, whereas all the patients treated with tubocurarine (n = 15) or alcuromum (n = 22) maintained sinus rhythm (pancuronium v. tubocurarine or alcuromum, P<0 01, Chi-square-test).
Downloaded from http://bja.oxfordjournals.org/ at Karolinska Institutet on July 19, 2015
Sir,—A 40-year-old man underwent mitral valve replacement, followed 4 months later by a further mitral valve replacement for infective endocarditis of the prosthesis; 6 weeks after the second operation, he developed septicaemic shock. As no peripheral veins were palpable a 13.3-cm 16-gauge Angiocath (Deseret Pharmaceuticals) was introduced via the left internal jugular vein using a low approach After entry to the vein it proved impossible to advance the catheter so aflexibleguide wire was introduced and the catheter passed easily down the vein. Oscillation responding to respiration was observed, but fast fluctuation synchronous with the pulse was not seen and aspiration of blood by syringe was less easy than normal. A diluted potassium chloride infusion caused immediate severe left shoulder tip pain which ceased on discontinuing the infusion and recurred on recommencing it The introduction of contrast medium to the catheter (fig 1) showed the tip (arrowed) filling the left pericardiophrenic veins The complications of central venous cannulation are those directly attributable to the insertion, those resulting from the presence of an indwelling catheter and those resulting from catheter malposition Malposition is least likely when the internal jugular approach has been used, but approximately 5% will not he within the superior vena cava or the right atrium (Malatinsky et al, 1976) Malposition in a persistent left superior vena cava, the azygos, internal thoracic, subclavian, axillary and hepatic veins, the inferior vena cava, the right ventricle and pulmonary artery have been reported but we believe that malposition in the pencardiophremc veins has not been recorded The guide wire directed the catheter across the left brachiocephalic vein into the left superior intercostal vein and then down to the termination of the left pencardiophremc veins. We feel that the use of a guide wire may have contributed to the malposition. A shorter cannula would not have reached this position but may not have been long enough to lie within the superior vena cava or right atrium. We assume that the shoulder tip pain was caused by irritation of the hemidiaphragm by retrograde perfusion with the potassium chloride solution Unusual complaints following insertion of a central venous catheter should raise the possibility of malposition as, for example, the "ear-gurgling sign" (Gilner, 1977) when the catheter tip lay near the middle ear.