ACA App
Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
Home | About us | Editorial Board | Search | Ahead of print | Current Issue | Archives | Submission | Subscribe | Advertise | Contact | Login 
Users online: 852 Small font size Default font size Increase font size Print this article Email this article Bookmark this page
 


 

 
     
    Advanced search
 

 
 
     
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    Introduction
    Case Report
    Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed7503    
    Printed148    
    Emailed2    
    PDF Downloaded155    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents
CASE REPORT  
Year : 2011  |  Volume : 14  |  Issue : 2  |  Page : 119-121
An unknown complication of peripherally inserted central venous catheter in a patient with ventricular assist device


1 Consultant Cardiac Anaesthetist, Goyal Hospital and Escorts Heart Institute, Jodhpur, India
2 Department of Anaesthesia and Intensive Care, Royal Brompton and Harefield Hospital NHS Trust, Harefield, United Kingdom

Click here for correspondence address and email

Date of Submission20-Nov-2010
Date of Acceptance27-Jan-2011
Date of Web Publication25-May-2011
 

   Abstract 

We report an unknown complication of peripherally inserted central venous catheter in a patient with Ventricular Assist Device. This rare complication led to the failure of the right ventricular assist device, which could be detrimental in patients with dilated cardiomyopathy.

Keywords: Ventricular assist device, peripheral central venous catheter

How to cite this article:
Parikh M, Wong M, Farrimond J. An unknown complication of peripherally inserted central venous catheter in a patient with ventricular assist device. Ann Card Anaesth 2011;14:119-21

How to cite this URL:
Parikh M, Wong M, Farrimond J. An unknown complication of peripherally inserted central venous catheter in a patient with ventricular assist device. Ann Card Anaesth [serial online] 2011 [cited 2019 Oct 21];14:119-21. Available from: http://www.annals.in/text.asp?2011/14/2/119/81567



   Introduction Top


A peripherally inserted central venous catheter is inserted for long-term administration of antibiotics, chemotherapy, total parenteral nutrition. It has a lesser rate of infection compared to the subclavian, internal jugular or the femoral lines. A peripherally inserted central venous catheter (PICC) is inserted in the peripheral veins, such as, the cephalic vein, basilic vein or brachial vein and then advanced through increasingly larger veins, toward the heart until the tip rests in the distal superior vena cava or the cavoatrial junction. PICC lines generally remain in place no longer than 30 days, although the duration of use varies from just a few days in patients requiring short courses of chemotherapy or biotherapy to a year in patients requiring longer treatment. [1] Commonly, other forms of intravenous access are considered if the treatment course is protracted. Although replacement is generally considered a year post insertion, patients have survived with the same PICC in situ for several years without complication. The portion of PICC line to be inserted varies from 35 - 55 cms in length, and this is adequate for the desired tip position in most of the patients. We report a case of a PICC being stuck in the impella of the ventricular assist device, thus leading to a malfunction of the device.


   Case Report Top


A 34-year-old male previously fit and well presented with a history of increased shortness of breath and palpitations to the local hospital. On investigation, he was found to have dilated cardiomyopathy with biventricular enlargement. He was diagnosed with heart failure and was medically managed.

On worsening of his symptoms he was referred for heart transplant or ventricular assist device insertion assessment. His cardiac output on right heart catheterization was 1.5 L/minute and ejection fraction on echocardiography was 8%. It was decided to insert a biventricular assist device. He had a Jarvik ventricular assist device on the right side and Heartware on the left side. He was transferred to the intensive care unit (ICU). His stay in the ICU was complicated by renal failure, chest infection, and coagulopathy, which were treated accordingly. He was transferred to the transplant ward. In the Transplant ward he developed  Stenotrophomonas maltophilia Scientific Name Search ion, for which he needed antibiotics for a long period. It was decided that a PICC line be inserted, in view of his coagulopathy and high chance of infection. The PICC line insertion site was the right cephalic vein. A rough estimation of the length was calculated by measuring from the antecubital fossa up to the right second intercostal space. All aseptic precautions were taken. Lignocaine 1% was given as a local anesthetic at the insertion site. The Seldinger technique was used. The peripheral central venous catheter was inserted without any problem. After insertion there was problem with the flows on the right-sided ventricular assist device (VAD) and it was alarming. Lateral and anteroposterior chest X-ray was performed, which showed that the peripheral central venous catheter was stuck in the impella of the Jarvik right ventricular assist device [Figure 1] and [Figure 2]. A catheter was stuck as it was inserted too far and due to the suction effect of the device it was sucked in. This caused the right ventricular assist device (RVAD) to stop functioning. He had an episode of ventricular tachycardia, but that settled without any treatment. These patients are normally on Anticoagulation, and Unfractionated Heparin was started to prevent a thromboembolic phenomenon. The international normalized ratio (INR) is kept between 2 and 3. The surgical team discussed the merits of the various treatment options extensively with the team looking after him and it was thought that the best course of action would be for the right ventricular assist device to be stopped. The patient was transferred to the Intensive Care Unit for observation. Transthoracic echocardiography was performed. The right side of the heart was functioning well with tricuspid annular plane systolic excursion of 1.0 cm. He remained stable for the next 24 hours. The patient was transferred to the catheterization laboratory for the removal of the PICC line. This was performed under radiographic guidance. The portion of the line stuck in the impella was left behind and the rest of the PICC line was removed without any complication. He was transferred to the Intensive Care Unit, where he remained for the next two days and was stable. Later he was transferred to the ward. Regarding the catheter left behind in the impella of the right ventricular assist device, it would be less of a problem for the thromboembolic phenomenon, as the device had been stopped. The patient was continued on heparin infusion for the next three days and was then continued on warfarin to maintain an INR between 2 and 3. If the INR fell below 2 then additional low molecular weight Heparin was started, to prevent a thromboembolic phenomenon.
Figure 1: Chest X-ray showing the PICC line entangled in the RVAD

Click here to view
Figure 2: Lateral chest X-ray showing PICC line in RVAD

Click here to view



   Discussion Top


Infectious complications following VAD implantation are common, with most studies documenting a 30 to 50% occurrence. [2] Left ventricular assist device-related infections range in severity from the local driveline exit-site involvement to mediastinal and pocket infections, and most seriously, to LVAD-related bloodstream involvement. Evidence also suggests that patients with infection are more likely to develop thromboembolic complications. Pathogens include coagulase-negative staphylococcus, Staphylococcus aureus,  Escherichia More Details coli, corynebacterium, and Candida. These infections require antibiotics ranging from six to eight weeks.

Peripherally inserted central venous catheter line insertion was conducted due to long-term administration of antibiotics. Due precautions should be taken in patients with right ventricular assist device. These devices have a suction effect. If using the Seldinger technique and the guide wire is inserted too far in then it may get sucked into the impella of the device and stop the device from functioning. First and foremost, while treating these patients, one should determine where the inflow tract to the device has been made, whether it is in the right atrium or the right ventricle. More caution must be taken if the device is in the right atrium, as there will be increased chances of either the catheter or the guide wire getting embedded into the device. There may be increased chances of the patient having a thromboembolic event from the wire or the catheter once it gets into the device. Anticoagulation is routine, with the INR kept between 2 and 3, with Warfarin. If the INR is below 2 then the patient is started on low molecular weight heparin in our institution, to prevent thromboembolism.

Insertion of central venous catheters or for that matter PICC line insertion in these patients should be radiologically guided or performed with the help of transesophageal echocardiography. [3] The insertion of the guide wire as well as the catheter should be seen in its entire length and placed in the correct position. Failure of the device in critical patients dependent on the ventricular assist device may destabilize them and this can be disastrous.

 
   References Top

1.Souhami R, Tannock I, Hohenberger P, Horiot JC (eds). Oxford Textbook of Oncology. Oxford: Oxford University Press; 2002.  Back to cited text no. 1
    
2.Piccione W Jr. Left ventricular assist device implantation: Short and long-term surgical complications. J Heart Lung Transplant 2000;19:S89-94.  Back to cited text no. 2
[PUBMED]    
3.Chaney MA, Minhaj MM, Patel K, Muzic D. Transoesophageal echocardiography and central line insertion. Ann Card Anaesth 2007;10:127-31.  Back to cited text no. 3
[PUBMED]  Medknow Journal  

Top
Correspondence Address:
M Parikh
Escorts Goyal Heart Center, Jodhpur - 342 003
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.81567

Rights and Permissions


    Figures

  [Figure 1], [Figure 2]



 

Top