SESSION TITLE: ICU Complications
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Sunday, October 27, 2013 at 07:30 AM - 08:30 AM
INTRODUCTION: There is a tremendous increase in the number of central venous catheters (CVCs) inserted by the house staff due to the ease of insertion using the ultrasound guidance. Increasing number of cases with right atrium/ventricle perforation has been reported. There is a strong need for the recommendations on safe length of the guide-wire to be inserted. Studies have shown that the cavo-atrial junction averages about 18 cm from internal Jugular/ Subclavian sites and positioning guide-wire and catheters any deeper is rarely needed .
CASE PRESENTATION: 22 year old male with sickle cell disease was admitted for sickle cell painful crisis. Vital signs and physical examination was unremarkable. Laboratory results revealed chronic anemia. Chest X-ray and electrocardiogram(EKG) were normal. Right internal jugular central venous catheter (CVC) was placed under ultrasound guidance due to poor peripheral access. Patient tolerated the procedure well. Chest X-ray confirmed the position of the catheter in the superior venacava without any evidence of pneumothorax. After 24 hours of line placement, patient complained of chest tightness with palpitations, required higher oxygen concentration and Chest X-ray revealed enlarged cardiac silhouette with right pleural effusion. CT chest showed bilateral pleural and pericardial effusion. CVC tip is in superior vena cava. Patient condition worsened rapidly with distended neck veins, marked respiratory distress requiring intubation. Cardiac Tamponade was suspected and confirmed by Echocardiogram. Emergent pericardiocentesis was performed and transferred to OR. Intra-operative findings showed enlarged heart with right atrial laceration/ perforation with possible clot formation. Patient developed cardiac arrest with pulseless electrical activity.
DISCUSSION: Andrews et al. published an article “How much guidewire is too much” measuring the distance from various insertion sites to cavo-atrial junction (1). There is no clear cut consensus or guidelines on the length of the guidewire to be inserted, although most agree with no more than 18 cms for right sided approach and 20 cms for left sided approach or until the appearance of ectopic rhythms (2). Recent trend in increased CVC insertion by trainees requires an urgent need for guidewire length recommendations and its importance in order to minimize this dangerous complication.
CONCLUSIONS: Cardiac Tamponade caused by a central venous catheter can be disastrous. Simple precautions and technique can minimize this complication.
Reference #1: Andrews RT, Bova DA, Venbrux A, “How much guidewire is too much? Direct measurement of the distance from subclavian and internal jugular vein access sites to the superior vena cava-atrial junction during central venous catheter placement”. Crit Care Med. 2000;28(1):138. PMID10667513
Reference #2: Missing the guidewire: an avoidable complication Hesham R Omar, Ahmed Fathy, Devanand Mangar, Enrico Camporesi International Archives of Medicine 2010, 3:21
DISCLOSURE: The following authors have nothing to disclose: Rakesh Vadde, Meenakshi Ghosh, Saurav Pokharel, Setu Patolia, Dharani Narendra, Danilo Enriquez, Frances Schmidt, Joseph Quist
No Product/Research Disclosure Information