| Abstract|| |
A patient for double valve replacement developed an unusual complication consequent to extra-vascular displacement of a port of a central venous catheter, placed through the right subclavian vein. The patient had an uneventful surgical course and the trachea extubated after routine mechanical ventilation. Patient developed excessive mediastinal drainage later, which was noticed to be watery in nature. The source of the drainage was found to be a port of the central venous catheter, draining extra-vascular into the subclavian vascular sheath and thereafter through the pericardium into the mediastinal drains.
Keywords: Complication, extravascular, subclavian vein cannulation
|How to cite this article:|
Kapoor MC, Kumar S, Gourishanker R. Fluid infusion into the pericardium resulting from accidental displacement of a subclavian venous cannula. Ann Card Anaesth 2011;14:41-4
|How to cite this URL:|
Kapoor MC, Kumar S, Gourishanker R. Fluid infusion into the pericardium resulting from accidental displacement of a subclavian venous cannula. Ann Card Anaesth [serial online] 2011 [cited 2021 Jan 26];14:41-4. Available from: https://www.annals.in/text.asp?2011/14/1/41/74398
| Introduction|| |
Right subclavian vein catheterization was first reported by Aubaniac in 1952.  Its use remained limited clinically, to some extent, as it was considered fraught with complications. Complications reported include pneumothorax, hemothorax, subcutaneous emphysema, subclavian/internal mammary artery trauma, pleural effusion, hydromediastinum, brachial plexus injury, air embolism, cardiac perforation, subclavian vein thrombosis, perivascular insertion, bleeding requiring blood transfusion, arrhythmias requiring intervention, thoracic duct injury, and pericardial tamponade. ,, Incidence of complications, resulting from central venous cannulation, range from 5% to 11% depending on operator experience. 
| Case Report|| |
A 32-year-old (152 cm/55 kg) woman with severe aortic and mitral regurgitation of rheumatic origin, in New York Heart Association functional class 3, was taken up for double valve replacement surgery under cardiopulmonary bypass (CPB). After peripheral venous and arterial cannulation under local anesthesia, general anesthesia was induced and trachea intubated in a routine manner. The right subclavian vein was cannulated with a 7 Fr 20 cm long, triple lumen central venous cannula (CVC) uneventfully, on first attempt, using the lateral infraclavicular approach (Certofix Trio V 720; B Braun Melsungen AG, Germany). The placement was confirmed by withdrawal of blood from all ports and the ports were irrigated with saline. The CVC cannula was inserted up to the 13 cm mark and hub sutured after looping the balance 7 cm of catheter. The distal port of the CVC was connected to the central venous pressure transducer, one proximal port was connected to a measured intravenous infusion set and the second proximal port left free for potential vasoactive drug delivery. Heparin was administered for anticoagulation, after re-confirming placement of the CVC by withdrawal of blood. Patient placed on CPB after bicaval venous and aortic arterial cannulation.
Anesthesia was maintained following a fast track protocol. On completion of the valve replacements, an infusion dobutamine 5 μg/kg/min was initiated via the free proximal port of the CVC. Patient was weaned off CPB and heparinization reversed with protamine. Pleura remained intact during the surgery. During the post-CPB period, the intravenous infusion attached to the CVC port was found to be flowing slowly. The CVC was moved out a bit under the surgical drapes, as the out-dwelling part of the CVC was seen to be kinked, and blood withdrawn to confirm intravascular placement. On closure of chest, the patient was transferred to the ICU and electively ventilated. Routine postoperative chest X-ray was normal, and the CVC was seen lying in the right subclavian vein [Figure 1], but the tip was reaching only up to the level of medial end of the clavicle. It was not repositioned inside to avoid breach of sterility. Six hours after surgery, the endotracheal tube was removed after the patient had met the standard criteria for extubation, the patient was hemodynamically stable and with minimal mediastinal drainage. Post-extubation, patient was comfortable, hemodynamically stable and had adequate blood gases.
|Figure 1 :Routine postoperative chest X-ray taken before tracheal extubation showing the inadequate depth of insertion of the CVC|
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Eight hours after extubation, excessive mediastinal drainage was noticed. The patient had drained about 1500 ml from the mediastinum in the past 6 h. The drainage was, however, noted to be very watery. The patient was, however, sitting up comfortably, not dyspneic and just complaining of mild pain on the right side of chest. Patient exhibited stable hemodynamics, apart from a CVP of −2 mmHg, despite a volume intake of nearly 2000 ml in the postoperative period. Eighteen hundred milliliters of the above fluid had been infused through the proximal CVC port. The CVP trace was normal in configuration. An emergent chest X-ray revealed a homogenous soft opacity over the right hemithorax [Figure 2]. Palpation of the right infraclavicular region revealed fullness at the site of insertion of the CVC and on removal of CVC dressing, the 10 cm mark of the CVC was visible at the point of insertion.
|Figure 2 :Chest X-ray taken after excessive mediastinal drainage reported showing a homogenous soft opacity over the right hemithorax|
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The possibility of a hydrothorax was contemplated and a thoracic drain inserted under local anesthesia, but no fluid drained out. The individual ports of the CVC were checked for blood withdrawal. There was failure to draw blood from the proximal infusion port. The possibility of this port being extravascular was considered. Diluted propofol was injected through this port as an indicator. This led to an immediate appearance of a milky drainage in the pericardial drainage tubes. Left subclavian CVC cannulation was performed under local anesthesia and the right CVC cannula removed. The patient thereafter had an uneventful postoperative course.
| Discussion|| |
CVC is an essential tool in cardiac surgery for pressure measurement and drug/fluid therapy. Percutaneous placement of CVC, guided by surface anatomical landmarks, is an accepted practice in the operating room. The correct placement of the CVC is confirmed by aspiration of venous blood and visualization of a CVP waveform.  Though it is recommended that all right atrial catheters must be carefully positioned within the high right atrium to avoid damage to the tricuspid valve, arrhythmia, venous thrombosis, falsely elevated pressure measurements, and potentially lethal complication of vascular erosion/perforation,  CVC position is usually not assessed until the postoperative chest radiograph, potentially allowing malposition to persist undetected. 
The incidence of extravascular placement of the CVCs is approximately 2%,  while perforation of the central venous catheter into the mediastinum is a rare event.  Life-threatening mediastinal hematoma, after extravascular infusion, has been reported postvenous perforation by the CVC.  The inability to aspirate blood from the CVC should lead to the consideration of an extravascular placement of the central venous catheter.  In the case reported, a boggy swelling resulted from extravasation of fluid into the subcutaneous tissue of the chest wall which led to the homogenous opacification of the right chest in the chest X-ray. An extravascular collection/infusion around the subclavian vein is normally prevented from entering the pericardial sac by the reflection of the fibrous pericardium, which closes the pericardial sac by fusing with the external coats of the great vessels. In bicaval venous cannulation, the attachment of the fibrous pericardium to the superior vena cava is separated to cannulate the superior vena cava away from the heart. The fluid administered, in the postoperative period, was infused perivascular around the right subclavian vein and then drained into the pericardium. Thus, there was no rise in the CVP. Fortunately, it drained out through the mediastinal drains. In the absence of a mediastinal drain, it could have lead to cardiac tamponade.
Methods to predict the length required for placement of the tip of CVC at the right atrial-superior vena cava junction, using height/weight-based formulae, for children and adults, have been proposed. ,, A reliable formula reduces complications and saves time and expense.  In infraclavicular subclavian vein cannulation, considering the wide area of the clavicle and variation in puncture-site selection among individuals, there is a variability of insertion depth, despite application of a constant formula.  Using the right subclavian infraclavicular approach, Czepizak et al, found the formula [(patient's height in cm/10) - 2 cm] as the most accurate (96% success), to predict the necessary CVC length to achieve the desired superior vena cava placement.  Our patient was 152 cm tall and we placed the CVC with an indwelling length of 13 cm based on this formula. However, the out-dwelling loop of the CVC was pulled out blindly under the surgical drapes, resulting in an inadequate indwelling length of the CVC. All the ports of the CVC remained intravascular till the time of tracheal extubation, as no excessive mediastinal drainage was seen till then. The same was also evident in the routine postoperative chest X-ray taken [Figure 1].
A correctly placed right subclavian CVC catheter was withdrawn partially due to kinking of the out-dwelling portion of the CVC. Using the lateral approach, subclavian venous puncture occurs at a depth of 5−7 cm and considering that 10 cm length mark was seen postoperatively at the percutaneous entry site, the proximal port of the CVC would have been barely in the vein at that stage as the proximal port opening is 4.5 cm proximal to the CVC tip (in the CVC brand used).
The proximal port of the CVC possibly moved out further, after tracheal extubation, due to the patient's movement/posture changes. Subclavian catheters have been shown to move up to 3 cm toward the heart with movement of the head or neck. , Correctly placed CVC may intentionally or unintentionally be manipulated by patients, the "twiddler's syndrome." 
When infusion or withdrawal is unsatisfactory, pain is present on infusion, or the catheter has not been used for a considerable length of time, proper position of the catheter should be confirmed by the chest X-ray examination. It is recommended that repeated aspirations of blood, not only from the distal lumen, but also from the most proximal lumen, be performed to detect secondary malposition of CVC, especially after major positional changes and before giving large quantities of fluid or blood. 
We have described an unusual complication consequential to extravascular displacement of a port of a CVC placed through the right subclavian vein. The displacement resulted from pulling out of the CVC by the operator. It is recommended that CVCs be securely sutured and out-dwelling portion of long catheters be secured well to prevent displacement and accidental manipulation. The correctness of placement of the CVC must be verified, by radiography or ultrasound, and re-verified in case the CVC is manipulated later.
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Mukul C Kapoor
Cardiothoracic Anaesthesiology, Army Hospital Research and Referral, Delhi 110 010
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]