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PNEUMOTHORAX AND CONTRALATERAL HYDROTHORAX FOLLOWING SUBCLAVIAN VEIN ATHETERIZATION
Brit. J. Anaesth. (1973), 45, 227
PNEUMOTHORAX AND CONTRALATERAL HYDROTHORAX FOLLOWING SUBCLAVIAN VEIN CATHETERIZATION M. E. WARD AND P. F. S. L E E SUMMARY
Subclavian vein puncture was first described 21 years ago (Aubaniac, 1952) but was not accepted as a routine procedure until the mid-1960s. It is a relatively easy procedure, described by many authors (Davidson, Ben-Hur and Nathen, 1963; Ashbaugh and Thomson, 1963; Niesel and Lee, 1972), and has been used for blood sampling, central venous manometry and long-term fluid therapy. In recent years, however, there have been a number of reports of complications following insertion of the catheter. Many reports of series of subclavian vein catheterization have been published (Christensen, Nerstr0m and Baden, 1967; Smith et al., 1965) with complication rates varying from negligible (Wilson et al., 1962), to 7.5% (Yarom, 1964). The commonest complication is pneumothorax but the morbidity from this alone may be lessened by routine radiography. Injection of radiopaque dye through the catheter at the time of radiography will make it possible to verify correct positioning of the catheter tip within the lumen of lie vein. Haemothorax and hydrothorax have been described (Refetoff, 1965) and transfixion of the trachea has also occurred (S. Hilding, 1971, personal communication), resulting in perforation and deflation of the cuff of an endotracheal tube of a patient undergoing IPPR. In this case no other subsequent complications followed. We report here the case of a patient who developed a left-sided pneumothorax and a right-sided hydrothorax following left infraclavicular subclavian vein catheterization. CASE REPORT The patient, a 71-year-old woman, developed a faecal fistula and ileus one week after hemicolectomy. By this
time repeated venepuncture precluded further peripheral cannulation and a central vein catheter was inserted to treat her hypovolaemic state. A subclavian catheter (subclavian vein cannula size 170x1.75 mm, manufactured by Stilles) was inserted into the left subclavian vein using the infraclavicular route with the patient lying in a slight Trendelenburg position. 14.9.71. The catheter was advanced easily into the left subclavian vein and retrograde blood flow observed. The patient did not complain of respiratory difficulty or chest pain either before or after the procedure. Routine control chest X-ray about 30 min later showed a small left apical pneumothorax, which could not be detected clinically. The catheter was not radiopaque but retrograde blood flow was observed and as the catheter was being inserted for parenteral fluid therapy rather than cv.p. manometry, a contrast injection was not carried out. Approximately 6 hrs later the patient complained of central chest pain and dyspnoea. At this time there was no hyper-resonance over the left upper zone and breath sounds were not easily detected. Chest X-ray showed an increase in size of the pneumothorax without mediastinal shift. The patient was transferred to the Intensive Care Unit; her systolic blood pressure was 90 mm Hg and her pulse rate was 120 beats/ min, and regular. A size 16 needle was inserted below the 7th rib in the postaxillary line and air was aspirated with clinical improvement; the needle was then withdrawn. Two hours later the condition of the patient had deteriorated. She was now markedly dyspnoeic, with tachypnoea (56 b.p.m.) and her systolic blood pressure was 70 mm Hg. Clinically the left chest was more resonant than the right, but there was no obvious tracheal deviation (fig. 1). A 28 f.g. Argyle chest drain was inserted through the 7th intercostal space in the postaxillary line and suction applied. Measurement of cv.p. via the previously inserted subclavian catheter showed cv.p. to be — 1 cm HiO. Chest X-ray showed considerably less air in the pleural space (fig. 2). In spite of treatment for the pneumothorax the patient's condition continued to deteriorate. Forty-five minutes after MICHAEL E. WARD,* M.B.3-S.(LOND.), MJLCS^ I_KX.S.(ENG.); PETER F. S. LEE, M.B.,B.S.(LOND.); from the Department of
Anaesthetics, Centrallasarretett, Vasterfls, Sweden. •Present address: Department of Anaesthetics, King's College Hospital, Denmark Hill, London SE5 9RS. Requests for reprints to M.E.W.
Downloaded from http://bja.oxfordjournals.org/ at University of Michigan on April 18, 2015
The case history of a patient who developed a unilateral pneumothorax with contralateral hydrothorax following percutaneous subclavian vein catheterization is outlined, and suggestions are made to explain how this unusual double complication may have been produced. Recommendations for greater safety when using this technique are: routine post-procedure radiography with contrast injection, at least at weekly intervals, and withdrawal of the catheter by a few millimetres prior to fixation and daily thereafter. Constant awareness of the risk of serious complications is necessary.
BRITISH JOURNAL OF ANAESTHESIA
128
DISCUSSION
FIG.
1.
Chest radiograph prior to insertion of chest drain. Note large left pneumothorax.
i
FIG. 2. Chest radiograph some time after insertion of chest drain. Note re-expansion of left lung, but marked opacity of right lung field.
The most likely explanation for the rapid development of the large hydrothorax was penetration of the superior vena cava by the tip of the introducing stilette of the catheter, and subsequent passage of fluid from it into the pleural space. Baden (1964) described a patient who developed a right hydrothorax after a right subclavian catheter had been used for fluid therapy for 20 hours. Radiology then showed that the catheter had so curled up upon itself that it could not be within the vein and was removed. In the case being presented, microscopy of the tear in the vein wall at the junction of the right innominate vein with the superior vena cava showed the vessel wall to be damaged, but there was no evidence of oedema or fluid in the space between the pleura and vessel. It is suggested that the sequence of events was as follows. The stilette pierced the left pleura and lung, producing a slowly increasing pneumothorax. Immediately following this the stilette, when being redirected into the vessel was advanced too far so that it pierced the vein wall on the right side. However, as the stilette was withdrawn the catheter came to lie partially in the vessel wall and initially the fluid passed into the vein as planned. Later the pneumothorax on the left side became too large to remain untreated and a large chest drain was inserted. The rapid aspiration of air from the left chest then drew the mediastinum across toward
Downloaded from http://bja.oxfordjournals.org/ at University of Michigan on April 18, 2015
insertion of the chest drain there was no clinical evidence of pneumothorax, and auscultation showed equal ventilation of right and left lungs. Nevertheless, the blood pressure was unrecordable and the heart rate was 140 beats/min, and regular. Cv.p. was low, between 0 and + 1 cm HiO and she was given lanatoside C0.4 mg slowly i.v., 15% Mannitol 150 ml, and 6% Macrodex in glucose rapidly, but a bradycardia developed and the patient died 30 min later. At all times retrograde blood flow could be elicited through the subclavian catheter. Postmortem examination revealed normal parietal pleurae apart from a small puncture mark in the left pleura! dome. There was no air in the left pleural space but there was 400 ml of pale yellow serous fluid. There was 1100 ml of similar fluid in the right pleural space. The fluid was not bloodstained on either side. The left subclavian vein showed no thrombus formation or endothelial changes, but at the upper end of the superior vena cava at the entrance of the right innominate vein there was a tear 1 cm in length, adjacent to the right pleura. With a fine probe it appeared that this tear passed directly to the right pleural cavity. In spite of the large volume of fluid in the right pleural cavity, the lung was only mildly atelectatic There was no sign of excess fluid in the mediastinum. The anastomosis between the transverse colon and distal ileum had completely broken down and there was a considerable quantity of faecal matter in the peritoneal cavity.
PNEUMOTHORAX AND CONTRALATERAL HYDROTHORAX the left, thus letting the catheter pass through the vessel wall into the pleural space on the right side and allowing fluid to pass from the cannula into the right pleural space. Samples of fluid from both pleural spaces were sent to Uppsala Academiska Sjukhus laboratory for fructose analysis, but the presence of interfering substances prevented the obtaining of accurate results. Samples were also sent to Pharmacia Laboratories (Sweden) for dextran analysis. Comparison of the results with the known concentration and volume of infused fluids (table I)
Contents Time 20.20 23.20 04.00 05.10 05.15 died 05.50
Fluid
Vol (ml)
Fructose Glucose (g) Other (g) 112.5 37.5 electrolytes — amino-acids 100 — amino-acids 100 — mannitol 22.5 g —
Normodex Vamin Vamin Mannitol
1000 1000 1000 150
Macrodex 6%
250
—
3400
312.5
12.5 15 g dextran 70 50
Normodex is a physiological balanced salt+sugar solution produced by Pharmacia (Sweden). Vamin is a solution of 18 amino acids produced by Vitrum (Sweden). Macrodex is a 6% solution of dextran 70 in 5% glucose produced by Pharmacia (Sweden).
indicates the origin of the hydrothorax. The dextran on the left side (12.5 mg/ml) was approximately the calculated plasma concentration of infused dextran, whereas the fluid in the right pleural space (dextran concentration 2.5 mg/ml) was largely from the infusion, the dextran having been diluted by the other infused fluids. Correct positioning of the catheter tip in a vein was checked by applying a negative pressure to the tip, produced by sinking the drip bottle to floor level well below the patient Application of such a negative pressure (calculated as between 25-40 cm H,O) to a catheter tip lying just inside the pleural space may have sucked a little blood through the puncture site around the catheter, thus giving a false positive result. It is suggested that only a minimum negative pressure is used to test positioning of a catheter. Refetoff (1965) described a patient who developed intermittent dyspnoea after insertion of a polyethylene catheter, via a cut-down into the left
brachial vein, and who had repeated aspirations of a right pleural effusion over a 12-day period, with an average of 1,800 ml obtained each day. Analysis of the fluid gave varying results; glucose concentration on day 12 as 1,388 mg/100 ml, compared with 1.0 mg/100 ml on day 11. Injection of radiopaque dye along the catheter showed it to be lying in the pleural space, and the patient recovered after withdrawal of the catheter. The aspirated fluid is reported to have been "pink tinged and slightly cloudy". Perforation of a vein by an indwelling catheter has been described by Ashraf (1963). In his patient a polyethylene catheter was passed up from the left brachial vein, and after 7 days of satisfactory fluid therapy, retrosternal pain developed with swelling over the manubrium sterni up into the root of the neck. A small pleural effusion was detected on chest X-ray. Radiography after injection of a radiopaque dye along the catheter revealed the tip to be lying in the innominate vein with contrast leaking into the surrounding tissues. Ashraf (1963) theorized that this resulted from pressure necrosis at the tip, and recommended withdrawal of the catheter a short way prior to fixation. Galbert and Kay (1971) similarly described venous perforation by a central vein catheter producing hydrothorax, and in their patient also the aspirated pleural fluid was clear. Mahaffey and Witherspoon (1966) describe yet another example of misplacement of central vein catheters. Here the misplacement was detected when ventilation became difficult during operation, and only after aspiration of 350 ml of a bloodstained fluid, did the ventilation and colour return to normal. From our experience and from the world literature the following recommendations are made when percutaneous subclavian vein catheterization is carried out. Successful and unsuccessful catheterization must be followed by chest radiography to exclude pneumothorax. The use of radiopaque catheters should not exclude a dye injection radiograph to demonstrate the presence of the catheter tip within the vessel. Furthermore, an injection radiograph should follow the insertion of any central vein catheter even from the periphery, and this procedure should be periodically repeated if the catheter is to be used for longterm therapy. Lastly, supporting AshraPs (1963) recommendation, the catheter must be withdrawn a few milimetres both prior to fixation and then daily to guard against pressure necrosis, ulceration and perforation at the catheter tip.
Downloaded from http://bja.oxfordjournals.org/ at University of Michigan on April 18, 2015
TABLE I. Details of the infused fluids and contents.
229
BRITISH JOURNAL OF ANAESTHESIA
230 ACKNOWLEDGEMENTS
Our grateful thanks are due to Dr L. EngevOc, Department of Surgery, Centrallasarettet, Vasteris, for permission to describe his case; to Dr Alsen, Department of Pathology, for carrying out the postmortem and microscopy; and to Docent J. Kilknder, Head of the Department of Clinical Chemistry, for his advice and help with chemical analysis.
suggerent comment cette double complication inhabituelle pourrait £tre produite. Les recommandations pour atteindre une plus grande seairite en utilisant cette technique sont: radiographie de routine avec injection de substance opaque apres la procedure, au moins a intervalle hebdomadaire, et retrait du cathiter de quelques centimetres avant de le fixer et ensuite joumellement. II est necessaire d'fitre constamment aleni au risque des complications severes.
REFERENCES
Downloaded from http://bja.oxfordjournals.org/ at University of Michigan on April 18, 2015
Ashbaugh, D., and Thomson, J. W. W. (1963). Subdavian vein infusion. Lancet, 2, 1138. Ashraf, M. M. (1963). Venous perforation due to polyPNEUMOTHORAX UND KONTRALATERALER ethylene catheters. Ann. Surg., 157, 375. HYDROTHORAX NACH VENENKATHETER IN Aubaniac, R. (1952). L'injection intraveineuse sousDER V. SUBCLAVIA daviculaire. Prase mid., 60, 1456. Baden, H. (1964). Perkutan vena subclavia kateterization ZUSAMMEHFASSUNG kompliceret med infusion i cavum pleurae. Nord. Med., Es erfolgt die kasuistische Mitteilung fiber einen Patienten, 72, 1416. Christensen, K. H., Nerstrem, B., and Baden, H. (1967). bei dem sich unilateral ein Pneumothorax und kontralateral Complications of percutaneous catheterisatkm of the sub- ein Hydrothorax nach perkutaner Einlegung eines Venenkatheters in die Subclavia entwickelte. Es werden Betrachclflvian vein; 129 cases. Ada. chir. scand., 133, 615. Davidson, J. T., Ben-Hur, N., and Nathen, H. (1963). Sub- tungen angestellt, durch wekhe die Entstehung dieser ungewShnlichen doppelten Komplikation zu erkHren clavian venepuncture. Lancet, 2, 1139. Galben, M. W., and Kay, J. E. (1971). Perforation of the versucht wird. Empfehlungen zur grofieren Sicherheit bei right innominate vein by a polyethylene central venous Verwendung dieser Technik sind doppelt: RoutinemSflig durchgefuhrte Rdntgendarstellung mit Kontrastmittelincatheter. Brit. J. Anaesth., 43, 713. Mahaffey and Witherspoon, S. M. (1966). An unusual jektion, und zwar zumindest in wochentlichen Abstfinden, complication following venous cutdown. Anesthesiology, ferner Zuriickziehen des Katheters um wenige mm vor dem Fixieren »"d dann weiterhin taglich. Es ist notwendig, 27, 198. Niesel, H. C , and Lee, P. F. S. (1972). Punktion der vena sich immer zu vergegenwartigen, daO diese Methode das Risiko schwerer Komplikation beinhaltec subclavia unter Verwendung von Teflon Kathetera. Z. prakt. Aniisth. Wiederbeleb., 7, 170. Refetoff, S. (1965). Iatrogenic hydrothorax. Arm. intern Med., 63, 869. Smith, B. E., Modell, J. H., Gaub, M. L., and Moya, F. NEUMOTORAX E HIDROTORAX (1965). Complications of subclavian vein catheterisation. CONTRALATERAL DESPUES DE LA Arch. Surg., 90, 228. CATETERIZAaON DE LA VENA SUBCLAVIA Wilson, J. N., Grow, J. B., Demong, C. V., Prevedel, A. T., and Owens, J. C. (1962). Central vein pressure in optimal RESUMEN blood volume maintenance. Arch. Surg., 85, 563. Yarom, R. (1964). Subclavian venepuncture. (Letter.) Se resume la anamnesis de un paciente que desarroll6 Lancet, 1, 45. un neumot6rax unilateral con hidrot6rax contralateral despujs de la cateterizacion percutanea de la vena subclavia PNEUMOTHORAX ET HYDROTHORAX y se sugiere como pucde haber sido producida esta inCONTRALATERAL APRES CATHETERISATION habitual doble complicacion. Las recomendaciones para una DE LA VEINE SOUS-CLAVIERE mayor seguridad cuando se utiliza esta tecnica son: Radiograffa postoperatoria sistcmatica con inyeccion de contraste, SOMMAIRE por lo menos a intervalos semanales, y retirada del caterer Les auteurs decrivent un patient qui apres catheterisarion en unos cuantos milimetros antes de la fijaci6n y todos percutanee de la veine sous-daviere developpa un pneumo- los dfas siguientes. Es necesario estar constantemente alerta thorax unilateral avec hydrothorax contralatiral, et al riesgo de complicaciones graves.
PNEUMOTHORAX AND CONTRALATERAL HYDROTHORAX FOLLOWING SUBCLAVIAN VEIN CATHETERIZATION M. E. WARD AND P. F. S. L E E SUMMARY
Subclavian vein puncture was first described 21 years ago (Aubaniac, 1952) but was not accepted as a routine procedure until the mid-1960s. It is a relatively easy procedure, described by many authors (Davidson, Ben-Hur and Nathen, 1963; Ashbaugh and Thomson, 1963; Niesel and Lee, 1972), and has been used for blood sampling, central venous manometry and long-term fluid therapy. In recent years, however, there have been a number of reports of complications following insertion of the catheter. Many reports of series of subclavian vein catheterization have been published (Christensen, Nerstr0m and Baden, 1967; Smith et al., 1965) with complication rates varying from negligible (Wilson et al., 1962), to 7.5% (Yarom, 1964). The commonest complication is pneumothorax but the morbidity from this alone may be lessened by routine radiography. Injection of radiopaque dye through the catheter at the time of radiography will make it possible to verify correct positioning of the catheter tip within the lumen of lie vein. Haemothorax and hydrothorax have been described (Refetoff, 1965) and transfixion of the trachea has also occurred (S. Hilding, 1971, personal communication), resulting in perforation and deflation of the cuff of an endotracheal tube of a patient undergoing IPPR. In this case no other subsequent complications followed. We report here the case of a patient who developed a left-sided pneumothorax and a right-sided hydrothorax following left infraclavicular subclavian vein catheterization. CASE REPORT The patient, a 71-year-old woman, developed a faecal fistula and ileus one week after hemicolectomy. By this
time repeated venepuncture precluded further peripheral cannulation and a central vein catheter was inserted to treat her hypovolaemic state. A subclavian catheter (subclavian vein cannula size 170x1.75 mm, manufactured by Stilles) was inserted into the left subclavian vein using the infraclavicular route with the patient lying in a slight Trendelenburg position. 14.9.71. The catheter was advanced easily into the left subclavian vein and retrograde blood flow observed. The patient did not complain of respiratory difficulty or chest pain either before or after the procedure. Routine control chest X-ray about 30 min later showed a small left apical pneumothorax, which could not be detected clinically. The catheter was not radiopaque but retrograde blood flow was observed and as the catheter was being inserted for parenteral fluid therapy rather than cv.p. manometry, a contrast injection was not carried out. Approximately 6 hrs later the patient complained of central chest pain and dyspnoea. At this time there was no hyper-resonance over the left upper zone and breath sounds were not easily detected. Chest X-ray showed an increase in size of the pneumothorax without mediastinal shift. The patient was transferred to the Intensive Care Unit; her systolic blood pressure was 90 mm Hg and her pulse rate was 120 beats/ min, and regular. A size 16 needle was inserted below the 7th rib in the postaxillary line and air was aspirated with clinical improvement; the needle was then withdrawn. Two hours later the condition of the patient had deteriorated. She was now markedly dyspnoeic, with tachypnoea (56 b.p.m.) and her systolic blood pressure was 70 mm Hg. Clinically the left chest was more resonant than the right, but there was no obvious tracheal deviation (fig. 1). A 28 f.g. Argyle chest drain was inserted through the 7th intercostal space in the postaxillary line and suction applied. Measurement of cv.p. via the previously inserted subclavian catheter showed cv.p. to be — 1 cm HiO. Chest X-ray showed considerably less air in the pleural space (fig. 2). In spite of treatment for the pneumothorax the patient's condition continued to deteriorate. Forty-five minutes after MICHAEL E. WARD,* M.B.3-S.(LOND.), MJLCS^ I_KX.S.(ENG.); PETER F. S. LEE, M.B.,B.S.(LOND.); from the Department of
Anaesthetics, Centrallasarretett, Vasterfls, Sweden. •Present address: Department of Anaesthetics, King's College Hospital, Denmark Hill, London SE5 9RS. Requests for reprints to M.E.W.
Downloaded from http://bja.oxfordjournals.org/ at University of Michigan on April 18, 2015
The case history of a patient who developed a unilateral pneumothorax with contralateral hydrothorax following percutaneous subclavian vein catheterization is outlined, and suggestions are made to explain how this unusual double complication may have been produced. Recommendations for greater safety when using this technique are: routine post-procedure radiography with contrast injection, at least at weekly intervals, and withdrawal of the catheter by a few millimetres prior to fixation and daily thereafter. Constant awareness of the risk of serious complications is necessary.
BRITISH JOURNAL OF ANAESTHESIA
128
DISCUSSION
FIG.
1.
Chest radiograph prior to insertion of chest drain. Note large left pneumothorax.
i
FIG. 2. Chest radiograph some time after insertion of chest drain. Note re-expansion of left lung, but marked opacity of right lung field.
The most likely explanation for the rapid development of the large hydrothorax was penetration of the superior vena cava by the tip of the introducing stilette of the catheter, and subsequent passage of fluid from it into the pleural space. Baden (1964) described a patient who developed a right hydrothorax after a right subclavian catheter had been used for fluid therapy for 20 hours. Radiology then showed that the catheter had so curled up upon itself that it could not be within the vein and was removed. In the case being presented, microscopy of the tear in the vein wall at the junction of the right innominate vein with the superior vena cava showed the vessel wall to be damaged, but there was no evidence of oedema or fluid in the space between the pleura and vessel. It is suggested that the sequence of events was as follows. The stilette pierced the left pleura and lung, producing a slowly increasing pneumothorax. Immediately following this the stilette, when being redirected into the vessel was advanced too far so that it pierced the vein wall on the right side. However, as the stilette was withdrawn the catheter came to lie partially in the vessel wall and initially the fluid passed into the vein as planned. Later the pneumothorax on the left side became too large to remain untreated and a large chest drain was inserted. The rapid aspiration of air from the left chest then drew the mediastinum across toward
Downloaded from http://bja.oxfordjournals.org/ at University of Michigan on April 18, 2015
insertion of the chest drain there was no clinical evidence of pneumothorax, and auscultation showed equal ventilation of right and left lungs. Nevertheless, the blood pressure was unrecordable and the heart rate was 140 beats/min, and regular. Cv.p. was low, between 0 and + 1 cm HiO and she was given lanatoside C0.4 mg slowly i.v., 15% Mannitol 150 ml, and 6% Macrodex in glucose rapidly, but a bradycardia developed and the patient died 30 min later. At all times retrograde blood flow could be elicited through the subclavian catheter. Postmortem examination revealed normal parietal pleurae apart from a small puncture mark in the left pleura! dome. There was no air in the left pleural space but there was 400 ml of pale yellow serous fluid. There was 1100 ml of similar fluid in the right pleural space. The fluid was not bloodstained on either side. The left subclavian vein showed no thrombus formation or endothelial changes, but at the upper end of the superior vena cava at the entrance of the right innominate vein there was a tear 1 cm in length, adjacent to the right pleura. With a fine probe it appeared that this tear passed directly to the right pleural cavity. In spite of the large volume of fluid in the right pleural cavity, the lung was only mildly atelectatic There was no sign of excess fluid in the mediastinum. The anastomosis between the transverse colon and distal ileum had completely broken down and there was a considerable quantity of faecal matter in the peritoneal cavity.
PNEUMOTHORAX AND CONTRALATERAL HYDROTHORAX the left, thus letting the catheter pass through the vessel wall into the pleural space on the right side and allowing fluid to pass from the cannula into the right pleural space. Samples of fluid from both pleural spaces were sent to Uppsala Academiska Sjukhus laboratory for fructose analysis, but the presence of interfering substances prevented the obtaining of accurate results. Samples were also sent to Pharmacia Laboratories (Sweden) for dextran analysis. Comparison of the results with the known concentration and volume of infused fluids (table I)
Contents Time 20.20 23.20 04.00 05.10 05.15 died 05.50
Fluid
Vol (ml)
Fructose Glucose (g) Other (g) 112.5 37.5 electrolytes — amino-acids 100 — amino-acids 100 — mannitol 22.5 g —
Normodex Vamin Vamin Mannitol
1000 1000 1000 150
Macrodex 6%
250
—
3400
312.5
12.5 15 g dextran 70 50
Normodex is a physiological balanced salt+sugar solution produced by Pharmacia (Sweden). Vamin is a solution of 18 amino acids produced by Vitrum (Sweden). Macrodex is a 6% solution of dextran 70 in 5% glucose produced by Pharmacia (Sweden).
indicates the origin of the hydrothorax. The dextran on the left side (12.5 mg/ml) was approximately the calculated plasma concentration of infused dextran, whereas the fluid in the right pleural space (dextran concentration 2.5 mg/ml) was largely from the infusion, the dextran having been diluted by the other infused fluids. Correct positioning of the catheter tip in a vein was checked by applying a negative pressure to the tip, produced by sinking the drip bottle to floor level well below the patient Application of such a negative pressure (calculated as between 25-40 cm H,O) to a catheter tip lying just inside the pleural space may have sucked a little blood through the puncture site around the catheter, thus giving a false positive result. It is suggested that only a minimum negative pressure is used to test positioning of a catheter. Refetoff (1965) described a patient who developed intermittent dyspnoea after insertion of a polyethylene catheter, via a cut-down into the left
brachial vein, and who had repeated aspirations of a right pleural effusion over a 12-day period, with an average of 1,800 ml obtained each day. Analysis of the fluid gave varying results; glucose concentration on day 12 as 1,388 mg/100 ml, compared with 1.0 mg/100 ml on day 11. Injection of radiopaque dye along the catheter showed it to be lying in the pleural space, and the patient recovered after withdrawal of the catheter. The aspirated fluid is reported to have been "pink tinged and slightly cloudy". Perforation of a vein by an indwelling catheter has been described by Ashraf (1963). In his patient a polyethylene catheter was passed up from the left brachial vein, and after 7 days of satisfactory fluid therapy, retrosternal pain developed with swelling over the manubrium sterni up into the root of the neck. A small pleural effusion was detected on chest X-ray. Radiography after injection of a radiopaque dye along the catheter revealed the tip to be lying in the innominate vein with contrast leaking into the surrounding tissues. Ashraf (1963) theorized that this resulted from pressure necrosis at the tip, and recommended withdrawal of the catheter a short way prior to fixation. Galbert and Kay (1971) similarly described venous perforation by a central vein catheter producing hydrothorax, and in their patient also the aspirated pleural fluid was clear. Mahaffey and Witherspoon (1966) describe yet another example of misplacement of central vein catheters. Here the misplacement was detected when ventilation became difficult during operation, and only after aspiration of 350 ml of a bloodstained fluid, did the ventilation and colour return to normal. From our experience and from the world literature the following recommendations are made when percutaneous subclavian vein catheterization is carried out. Successful and unsuccessful catheterization must be followed by chest radiography to exclude pneumothorax. The use of radiopaque catheters should not exclude a dye injection radiograph to demonstrate the presence of the catheter tip within the vessel. Furthermore, an injection radiograph should follow the insertion of any central vein catheter even from the periphery, and this procedure should be periodically repeated if the catheter is to be used for longterm therapy. Lastly, supporting AshraPs (1963) recommendation, the catheter must be withdrawn a few milimetres both prior to fixation and then daily to guard against pressure necrosis, ulceration and perforation at the catheter tip.
Downloaded from http://bja.oxfordjournals.org/ at University of Michigan on April 18, 2015
TABLE I. Details of the infused fluids and contents.
229
BRITISH JOURNAL OF ANAESTHESIA
230 ACKNOWLEDGEMENTS
Our grateful thanks are due to Dr L. EngevOc, Department of Surgery, Centrallasarettet, Vasteris, for permission to describe his case; to Dr Alsen, Department of Pathology, for carrying out the postmortem and microscopy; and to Docent J. Kilknder, Head of the Department of Clinical Chemistry, for his advice and help with chemical analysis.
suggerent comment cette double complication inhabituelle pourrait £tre produite. Les recommandations pour atteindre une plus grande seairite en utilisant cette technique sont: radiographie de routine avec injection de substance opaque apres la procedure, au moins a intervalle hebdomadaire, et retrait du cathiter de quelques centimetres avant de le fixer et ensuite joumellement. II est necessaire d'fitre constamment aleni au risque des complications severes.
REFERENCES
Downloaded from http://bja.oxfordjournals.org/ at University of Michigan on April 18, 2015
Ashbaugh, D., and Thomson, J. W. W. (1963). Subdavian vein infusion. Lancet, 2, 1138. Ashraf, M. M. (1963). Venous perforation due to polyPNEUMOTHORAX UND KONTRALATERALER ethylene catheters. Ann. Surg., 157, 375. HYDROTHORAX NACH VENENKATHETER IN Aubaniac, R. (1952). L'injection intraveineuse sousDER V. SUBCLAVIA daviculaire. Prase mid., 60, 1456. Baden, H. (1964). Perkutan vena subclavia kateterization ZUSAMMEHFASSUNG kompliceret med infusion i cavum pleurae. Nord. Med., Es erfolgt die kasuistische Mitteilung fiber einen Patienten, 72, 1416. Christensen, K. H., Nerstrem, B., and Baden, H. (1967). bei dem sich unilateral ein Pneumothorax und kontralateral Complications of percutaneous catheterisatkm of the sub- ein Hydrothorax nach perkutaner Einlegung eines Venenkatheters in die Subclavia entwickelte. Es werden Betrachclflvian vein; 129 cases. Ada. chir. scand., 133, 615. Davidson, J. T., Ben-Hur, N., and Nathen, H. (1963). Sub- tungen angestellt, durch wekhe die Entstehung dieser ungewShnlichen doppelten Komplikation zu erkHren clavian venepuncture. Lancet, 2, 1139. Galben, M. W., and Kay, J. E. (1971). Perforation of the versucht wird. Empfehlungen zur grofieren Sicherheit bei right innominate vein by a polyethylene central venous Verwendung dieser Technik sind doppelt: RoutinemSflig durchgefuhrte Rdntgendarstellung mit Kontrastmittelincatheter. Brit. J. Anaesth., 43, 713. Mahaffey and Witherspoon, S. M. (1966). An unusual jektion, und zwar zumindest in wochentlichen Abstfinden, complication following venous cutdown. Anesthesiology, ferner Zuriickziehen des Katheters um wenige mm vor dem Fixieren »"d dann weiterhin taglich. Es ist notwendig, 27, 198. Niesel, H. C , and Lee, P. F. S. (1972). Punktion der vena sich immer zu vergegenwartigen, daO diese Methode das Risiko schwerer Komplikation beinhaltec subclavia unter Verwendung von Teflon Kathetera. Z. prakt. Aniisth. Wiederbeleb., 7, 170. Refetoff, S. (1965). Iatrogenic hydrothorax. Arm. intern Med., 63, 869. Smith, B. E., Modell, J. H., Gaub, M. L., and Moya, F. NEUMOTORAX E HIDROTORAX (1965). Complications of subclavian vein catheterisation. CONTRALATERAL DESPUES DE LA Arch. Surg., 90, 228. CATETERIZAaON DE LA VENA SUBCLAVIA Wilson, J. N., Grow, J. B., Demong, C. V., Prevedel, A. T., and Owens, J. C. (1962). Central vein pressure in optimal RESUMEN blood volume maintenance. Arch. Surg., 85, 563. Yarom, R. (1964). Subclavian venepuncture. (Letter.) Se resume la anamnesis de un paciente que desarroll6 Lancet, 1, 45. un neumot6rax unilateral con hidrot6rax contralateral despujs de la cateterizacion percutanea de la vena subclavia PNEUMOTHORAX ET HYDROTHORAX y se sugiere como pucde haber sido producida esta inCONTRALATERAL APRES CATHETERISATION habitual doble complicacion. Las recomendaciones para una DE LA VEINE SOUS-CLAVIERE mayor seguridad cuando se utiliza esta tecnica son: Radiograffa postoperatoria sistcmatica con inyeccion de contraste, SOMMAIRE por lo menos a intervalos semanales, y retirada del caterer Les auteurs decrivent un patient qui apres catheterisarion en unos cuantos milimetros antes de la fijaci6n y todos percutanee de la veine sous-daviere developpa un pneumo- los dfas siguientes. Es necesario estar constantemente alerta thorax unilateral avec hydrothorax contralatiral, et al riesgo de complicaciones graves.