|Year : 2014 | Volume
| Issue : 3 | Page : 197-199
Central venous catheter malposition into intrapleural space
Ovais Nazir1, Mushtaq Ahmad Wani2, Ashu Kumar Jain1, Rajesh Misra1
1 Departments of Anesthesiology, Artemis Health Institute, Gurgaon, Haryana, India
2 Departments of Anesthesiology, Government Medical College Jammu, Jammu and Kashmir, India
|Date of Web Publication||19-Sep-2014|
A-72, Gur Mandi, New Delhi - 110 007
Source of Support: Self funding, Conflict of Interest: All the
contributing authors done have any conflict of interest.
Placement of central venous catheter (CVC) can lead to complications such as, malposition of catheter and perforation and/or injury of nearby blood vessels and structures. We present a case about malposition of central venous catheter (CVC) from right internal jugular vein (IJV) into right intrapleural space. It is advisable to check free venous outflow in all the ports of CVC and following placement of CVC, chest radiograph should be taken to confirm the position.
Keywords: Central venous catheter, internal jugular vein, subclavian vein
|How to cite this article:|
Nazir O, Wani MA, Jain AK, Misra R. Central venous catheter malposition into intrapleural space. J Sci Soc 2014;41:197-9
| Introduction|| |
Central venous catheters (CVC) are an essential component of modern critical care. However, it can contribute in the overall morbidity in a critically ill patient. Despite their utility, placement of CVCs is often associated with complications such as malposition of the catheter, perforation and injury of nearby blood vessels and structures. , Our case report is about malposition of right internal jugular vein (IJV) CVC into right intrapleural space.
| Case report|| |
A 65-year-old female with upper airway tumor was admitted to the intensive care unit (ICU) with 5 days history of progressive stridor. An emergency tracheostomy was scheduled in the safe environment of the operating theatre. She had an internal jugular triple lumen central venous access placed on the 2 nd day of her ICU stay.
In the operating theater, it was noticed that out of three ports of CVC only through the proximal port, fluid was going freely and from other two ports, it was somewhat intermittent. We made an attempt to check all the ports by aspirating blood. We could be aspirate blood freely from the proximal port, whereas rest of two failed to yield blood on aspiration as shown in [Figure 1]. Upon flushing all ports with 5 ml normal saline, we could administer saline freely from all ports but blood could be aspirated only from proximal port of CVC. Upon repeated attempts, same result was obtained. Hence, it was a situation where proximal port of CVC was intravascular while status of rest of the two ports was unclear.
|Figure 1: The central venous catheters which failed to yield blood on aspiration from middle and distal port|
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We then decided to withdraw the CVC 4-5 cm proximally while continuously aspirating from ports to rule out any possibility of adherence of catheter to vessel wall or catheter kinking. To our surprise, it was noticed that upon withdrawing catheter 4-5 cm, we could now aspirate blood from middle port also but as soon the CVC was pushed back it again yielded same situation We then decided to do check chest X-ray to look for catheter position, which showed that catheter instead of going into the superior vena cava (SVC) was curving towards right chest wall as in the [Figure 2]. Since in our case, because middle and distal ports were not used for infusion of fluids after placement occurrence of hydrothorax was prevented. However, failure to aspirate blood from middle and distil ports lead to the suspicion of situation that was later confirmed by radiography. The chest X-ray [in [Figure 2] gave us a clue to explain the status of CVC that half of the catheter was inside the vessel and half outside in the right pleural cavity. The probability of catheter going into the right subclavian/axillary vein was ruled out by the path of CVC line on X-ray (compare the path of left subclavian CVC that was put later as shown in [Figure 3]) and failure to aspirate blood from distal and middle ports. The possibility of CVC going into the tributary of external jugular vein was also refuted by the direction of proximal and distal half of catheter (with proximal part going in the triangle formed by two heads of sternocleidomastoid muscle as shown in [Figure 1]). Furthermore, the aspiration of blood from middle port while withdrawing the CVC showed that CVC was partially intravascular. Then removal of the catheter was done from the right side and another CVC later on put through left subclavian approach and blood was be aspirated in from all the ports and CVC position was confirmed by check X-ray. After this patient was shifted to ICU and closely monitored and followed for 1 week stay there. Later she had an uneventful course in ICU and didn't develop any hemothorax or pneumothorax.
|Figure 2: Chest X-ray on the left of the patient showing malposition of central venous catheters (path highlighted by black arrows) from right internal jugular vein|
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|Figure 3: Chest X-ray on the right shows central venous catheters that we later on put through le subclavian vein (path highlighted by black arrows), tracheostomy tube can also be seen|
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| Discussion|| |
Malposition of the catheter into the interpleural space is a known complication of CVC. In a systematic review performed by Ruesch et al., it was reported that catheter malposition rates was 5.3% and 9.3% for IJV and subclavian vein catheterization, respectively.  Paw  have reported that the incidence of malposition following catheterization via the left IJV was more than the right IJV. Cannulation by the right subclavian vein is associated with the highest risk of malposition of approximately 9.1%. 
Partial placement of catheter (half of the catheter inside the vessel and half outside) with distal part going up to lateral part of intrapleural space is seen very rarely, and till now, such a case has not been reported in the literature. Schummer et al.  reported a case similar to our patient, with unrecognized stenosis of the SVC. Perforation occurred in the SVC after catheterization of the left IJV with a hemodialysis catheter. Extra-vascular positioning of the catheter was unrecognized and the patient subsequently died of complications.
Iwakura et al. have reported a case of malposition of CVC in a 2-year-old boy who was scheduled for patch closures of ASD and VSD. Chest X-ray examination in ICU revealed the misplacement of the catheter into his right intrapleural space which later on developed severe hemothorax of the right side, where catheter had been inserted. 
In our case, the catheter up to the proximal port was partially inside the vessel, through which we could aspirate blood, but rest of the catheter was outside the vessel and pierced the vessel wall, leading to malposition into the right pleural cavity. Catheter placement is a blind procedure and misplacement of CVC remains a known, but uncommon complication. A post-procedural chest radiograph is generally considered essential in identifying malposition of the catheter.
| Conclusion|| |
We recommend from this experience that free venous outflow must be carefully checked in all the ports of CVP catheter, and following placement of CVC catheter, chest radiograph should be completed to confirm the position.
| References|| |
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|2.||Tong MK, Siu YP, Ng YY, Kwan TH, Au TC. Misplacement of a right internal jugular vein haemodialysis catheter into the mediastinum. Hong Kong Med J 2004;10:135-8. |
|3.||Ruesch S, Walder B, Tramèr MR. Complications of central venous catheters: Internal jugular versus subclavian access - A systematic review. Crit Care Med 2002;30:454-60. |
|4.||Paw HG. Bilateral pleural effusions: Unexpected complication after left internal jugular venous catheterization for total parenteral nutrition. Br J Anaesth 2002;89:647-50. |
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[Figure 1], [Figure 2], [Figure 3]