Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
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Table of Contents
Year : 2013  |  Volume : 16  |  Issue : 3  |  Page : 231-232
Asystole during pulmonary artery catheter sheath removal: A rare occurance

1 Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Anesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
3 Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India

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Date of Web Publication29-Jun-2013

How to cite this article:
Samanta S, Haldar R, Samanta S. Asystole during pulmonary artery catheter sheath removal: A rare occurance. Ann Card Anaesth 2013;16:231-2

How to cite this URL:
Samanta S, Haldar R, Samanta S. Asystole during pulmonary artery catheter sheath removal: A rare occurance. Ann Card Anaesth [serial online] 2013 [cited 2022 Oct 4];16:231-2. Available from:

The Editor,

Despite controversies, pulmonary artery catheter (PAC) is still extensively used invasive monitoring equipment in cardiac patients. Insertion of PAC is preceded by the placement of a sheath for stabilizing and guiding the PAC. Ventricular arrhythmias with near cardiac arrest have been previously attributed to insertions as well as removal of PAC. [1] We report a case where the removal of PAC sheath lead to asystole.

A 39-year-old female patient (diabetic) with end stage renal disease was posted for kidney transplantation. Chest X-ray showed cardiomegaly and electrocardiography showed incomplete left bundle branch block. Evaluation by a cardiologist revealed a hypertensive patient with severe mitral regurgitation, moderate mitral stenosis and moderate pulmonary arterial hypertension with a left ventricular ejection fraction (EF) of 40%. She was treated with digoxin and carvedilol. Digoxin was stopped 24 h before induction. Hemodialysis was carried out the day before surgery. In the operation theater, under monitoring and sedation, a 9 Fr PAC sheath (Edwards Lifescience, Irvine, USA,) and a central venous catheter (CVC) were inserted at a distance of 1 cm from each other via the right internal jugular vein. After an uneventful surgery, the patient was extubated and shifted to intensive care unit (ICU). During ICU stay, the patient was monitored for hemodynamic variables, cardiac indices, and electrolytes. On the third post-operative day, the PAC was removed by the anesthetist but the PAC sheath was left in situ for central venous access. Next day, the urologist encountered resistance while removing the sheath, which prompted multiple attempts. Following this, the patient suddenly developed cardiac arrest [Figure 1]. Immediately, cardiopulmonary resuscitation (CPR) was commenced with call for intensivist's assistance. The patient was intubated and injected adrenaline (1 mg) and with CPR, return of spontaneous circulation was obtained within 6 min. Cardiological evaluation revealed an EF 25% and normal plasma digoxin and cardiac biomarker levels. She was electively ventilated and mild hypothermia was initiated. Magnetic resonance imaging brain ruled out hypoxic damage. After stabilization of the patient, the sheath was removed carefully by enlarging its entry point under local anesthesia and ultrasound guidance keeping the resuscitation kit ready. Once the patient became conscious and oriented, the ventilatory support was gradually tapered off and the patient was extubated. The echocardiography examination showed an EF 40-45%. Subsequently the patient was discharged from ICU.
Figure 1: Electrocardiography, arterial line and monitoring trends showing asystole

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The following differential diagnosis were considered for this event: Mechanical stimulation of the carotid sinus; Carotid sinus hypersensitivity; Pulmonary hypertensive crisis; Acute left ventricular failure; Vasovagal syncope; Venous air embolism (VAE); Thrombus dislodgement; [2] Dysautonomia; Dyselectrolytemia; Digoxin toxicity; Indirect mechanical stimulation by CVC; Pneumothorax; and Cardiac tamponade. Mechanical stimulation of carotid sinus activates baroreceptors leading to adverse hemodynamic consequences. The sudden onset bradycardia followed by asystole without ventricular arrhythmia is suggestive of reflex event. Stimulation and compression of the carotid sinus during the manipulation of the sheath by an untrained person can lead to vasovagal response including hypotension and bradycardia and cardiac arrest. [3] In severe autonomic imbalance (diabetes) reversible asystole may develop in the absence of sinus node disease or carotid hypersensitivity. [4] Ultrasound and echocardiography ruled out thrombus dislodgement, pulmonary embolism, tension pneumothorax, VAE, and cardiac tamponade in our case. Proximal migration of PAC in cardiac chambers by PAC sheath manipulation causing fatal arrhythmia was not considered as the PAC was already removed. [5] Important preventive aspects for this catastrophic event include: Avoidance of neck stimulation (carotid sinus region) especially in the presence of low baseline heart rate; Insertion as well as removal of invasive lines (CVC, PAC, sheath, dialysis catheter) to be carried out by trained persons under adequate monitoring and keeping resuscitation drugs and equipment ready; Removal of central venous lines in Trendelenburg position and during expiration; Avoidance of human and technical error whenever possible; Use of ultrasonography in difficult cases.

To summarize, removal of invasive lines should not be taken lightly and it should be performed with the same precautions as exercised during their placement.

   References Top

1.Damen J. Ventricular arrhythmias during insertion and removal of pulmonary artery catheters. Chest 1985;88:190-3.  Back to cited text no. 1
2.Chastre J, Cornud F, Bouchama A, Viau F, Benacerraf R, Gibert C. Thrombosis as a complication of pulmonary-artery catheterization via the internal jugular vein: Prospective evaluation by phlebography. N Engl J Med 1982;306:278-81.  Back to cited text no. 2
3.van Lieshout JJ, Wieling W, Karemaker JM, Eckberg DL. The vasovagal response. Clin Sci (Lond) 1991;81:575-86.  Back to cited text no. 3
4.Milstein S, Buetikofer J, Lesser J, Goldenberg IF, Benditt DG, Gornick C, et al. Cardiac asystole: A manifestation of neurally mediated hypotension-bradycardia. J Am Coll Cardiol 1989;14:1626-32.  Back to cited text no. 4
5.Unnikrishnan D, Idris N, Varshneya N. Complete heart block during central venous catheter placement in a patient with pre-existing left bundle branch block. Br J Anaesth 2003;91:747-9.  Back to cited text no. 5

Correspondence Address:
Sukhen Samanta
New PG Hostel, Room No. 218, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9784.114255

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  [Figure 1]