Complications of Central Line Placement: Pneumothorax, Arrhythmia, Hematoma
Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.
Anatomical landmarks for central line placement in the internal jugular (IJ) vein, anterior approach. This patient was 101 years old and was DNR-CCA, she did not need any central lines.
Pneumothorax (PTX)
Case 1
A patient needed a TLC (triple lumen catheter) which was placed in the left subclavian vein by the surgical house officer. The CXR after the procedure did not show any evidence of PTX. Next morning on physical exam the patiend did not have air entry on the left side of the chest and a stat CXR was ordered.
CXR showed a left sided sided PTX with a deep sulcus.
Left PTX due to left subclavian line placement
A chest tube was placed with a resolution of the PTX. Subcutaneous emphysema developed around the chest tube insertion place.
Post-PTX Subcutaneous Emphysema
Dr. Erfan presents the case. Click on the link to listen.
Case 2
This is another case of a PTX after a line placement:
82 yo AAF needed a central line for IVF because she was dehydrated. During an attempt to place an external jugular line, she started to comlpain of SOB. CXR showed a right-sided PTX.
PTX after an external jugular line. You can also see bullet fragments from previous GSW. There is a HD catheter.
PTX after an external jugular line - close-up view
Right lung not expanded after a chest tube placement
Right lung expanded, the chest tube is still in place. HD catheter and a left central line in place.
Arrhythmia
AFib with RVR after a TLC placement
39 yo AAF was admitted to the hospital with a diabetic foot ulcer. She needed IV access for Unasyn IV and labs, and failed several peripheral line attempts.
Right IJ TLC catheter was placed. Immediately after catheter was placed, she complained of SOB and palpitations. Her SpO2 was 100%, breath sounds were equal and clear bilaterally.
Is it PTX?
HR was 140 and irregular - PVCs?
What would you do?
EKG showed AFib with RVR, CXR showed the TLC at the level of right AV junction.
TLC at the right AV junction on CXR
AFib due to a TLC at AV junction
What happened?
TLC was withdrawn 5 cm with conversion to sinus rhythm and no further complaints.
TLC in SVC - correct position on CXR
Conversion to NSR after TLC was repositioned
Massive Hematoma
During an attempt to place a central line in the subclavian vein, physicians inadvertently punctured the subclavian artery. The patient expired due to massive bleeding despite the surgical intervention to close the puncture site.
Massive hematoma after subclavian artery puncture. Case and image courtesy of UnboundedMedicine.com, used under CreativeCommons license.
References:
A Complication of Central Venous Catheterization. Loss of the guide wire. NEJM, 2007.
A Complication of Central Venous Catheterization. A Pulled IVC Filter. NEJM, 2007.
Central Venous Catheterization: Concise Definitive Review. Medscape, Critical Care Medicine, 05/16/2007 (free registration required).
NEJM Videos in Clinical Medicine. These are high-quality professional videos but they require a subscription to NEJM:
Central Venous Catheterization - IJ vein
Central Venous Catheterization - Subclavian Vein
Central Line
Published: 07/20/2005
Updated: 12/12/2007
Anatomical landmarks for central line placement in the internal jugular (IJ) vein, anterior approach. This patient was 101 years old and was DNR-CCA, she did not need any central lines.
Pneumothorax (PTX)
Case 1
A patient needed a TLC (triple lumen catheter) which was placed in the left subclavian vein by the surgical house officer. The CXR after the procedure did not show any evidence of PTX. Next morning on physical exam the patiend did not have air entry on the left side of the chest and a stat CXR was ordered.
CXR showed a left sided sided PTX with a deep sulcus.
Left PTX due to left subclavian line placement
A chest tube was placed with a resolution of the PTX. Subcutaneous emphysema developed around the chest tube insertion place.
Post-PTX Subcutaneous Emphysema
Dr. Erfan presents the case. Click on the link to listen.
Case 2
This is another case of a PTX after a line placement:
82 yo AAF needed a central line for IVF because she was dehydrated. During an attempt to place an external jugular line, she started to comlpain of SOB. CXR showed a right-sided PTX.
PTX after an external jugular line. You can also see bullet fragments from previous GSW. There is a HD catheter.
PTX after an external jugular line - close-up view
Right lung not expanded after a chest tube placement
Right lung expanded, the chest tube is still in place. HD catheter and a left central line in place.
AFib with RVR after a TLC placement
39 yo AAF was admitted to the hospital with a diabetic foot ulcer. She needed IV access for Unasyn IV and labs, and failed several peripheral line attempts.
Right IJ TLC catheter was placed. Immediately after catheter was placed, she complained of SOB and palpitations. Her SpO2 was 100%, breath sounds were equal and clear bilaterally.
Is it PTX?
HR was 140 and irregular - PVCs?
What would you do?
EKG showed AFib with RVR, CXR showed the TLC at the level of right AV junction.
TLC at the right AV junction on CXR
AFib due to a TLC at AV junction
What happened?
TLC was withdrawn 5 cm with conversion to sinus rhythm and no further complaints.
TLC in SVC - correct position on CXR
Conversion to NSR after TLC was repositioned
Massive Hematoma
During an attempt to place a central line in the subclavian vein, physicians inadvertently punctured the subclavian artery. The patient expired due to massive bleeding despite the surgical intervention to close the puncture site.
Massive hematoma after subclavian artery puncture. Case and image courtesy of UnboundedMedicine.com, used under CreativeCommons license.
References:
A Complication of Central Venous Catheterization. Loss of the guide wire. NEJM, 2007.
A Complication of Central Venous Catheterization. A Pulled IVC Filter. NEJM, 2007.
Central Venous Catheterization: Concise Definitive Review. Medscape, Critical Care Medicine, 05/16/2007 (free registration required).
NEJM Videos in Clinical Medicine. These are high-quality professional videos but they require a subscription to NEJM:
Central Venous Catheterization - IJ vein
Central Venous Catheterization - Subclavian Vein
Central Line
Published: 07/20/2005
Updated: 12/12/2007
Labels: Cardiology, Pulmonology
12 Comments:
Amazing examples of complications of central lines placement.
Nice job.
i have personally seen two cases of delayed pneumothorax from subclavian central line placement. Even though CDC recommends subclavian as the site of choice, I find that with the new ultrasound equipment, sonosite and such... its much easier to go to IJ and avoid complications.
Last month I unfortunetely experienced a left pnemohemothorax after an ER physician was placing a subclavian central line and the guidewire accidently punctured my left mammary artery. I immediately knew something was wrong with severe chest pain and shortness of breath. I was on anticoagulants at the time and bled profusely into my mediastinum and then into my left pleural cavity. My systolic pressure was down into the 60's and I was life flighted to the closest trauma center 200 miles away. I ended up losing 4 liters of blood through the chest tube and was very lucky to survive. I was doing research on the internet about this complication and was surprised to see it does happen quite often. The ER physician was doing a blind approach instead of using ultrasound. I think it would of been prevented if he was using ultrasound or fluoro. But nothing I can do know. I guess just lucky to be alive. Thanks.
what do we do for a hematoma in femoral central line, do we have to remove the line and start another one , though this line was patent.patient's pt was 3 min and inr 15 .when do we remove the faulty line.
My sister had a central line inserted last week and they punctured her lung (they went in blind), her lung collapsed and now they have a tube to inflate it. The first time they put it in, it collapsed again, when they did any xray, they found the tube had fallen out, so they reinserted the tube and inflated the lung again. It's been 3 days now and they say the puncture is not healing and she may have gotten pneumonia now. She originally went in for a blocked intestine, which ended up clearing with the liquid they gave her during the cat scan. They put the central line in, because they were going to do surgery.
Anyone know of damage to the ulnar and radial nerves in addition to pnemohemothorax.
"Damage to the ulnar and radial nerves" are unlikely to happen due to placement of a central line because the anatomical location is totally different. A damage to the brachial plexus (which contains the roots for the ulnar and radial nerves) can occur but it is very rare. I hope this answers your question.
what's the best & inital step to do if during central line placement, there is a obvious subcutneous emphysema.How about if subcutaneous emphysema occurs post placement?
"what's the best & inital step to do if during central line placement, there is a obvious subcutneous emphysema"
A: Remove the line.
"How about if subcutaneous emphysema occurs post placement?"
A: Examine the line on CXR, physically, and flush it. If operating properly, you can leave it in place. Monitor the size of the subcut. emphysema several times a day until resolution.
There was an interesting paper published in Critical Care just month or two ago about central lines. Apparently, the complications happen more often than we think.
I have a blog post dedicated to this issue, if you are interested:
http://realicu.com/content/complications-central-venous-line-placement-%E2%80%93-happens-more-often-we-think
Ralph,
Complications with central line placement are not uncommon. Placement with U/S guidance is one approach to decrease them:
http://clinicalcases.org/2009/03/central-line-placement-with-ultrasound.html
Thank you.
I agree that significant complications (PTX) of the central line placement are quite rare. I am using US guidance in my practice. Interesting paper in the August issue of Critical Care Medicine - "An unseen danger: Frequency of posterior wall penetration by needles during attempts to place internal jugular vein central catheters using ultrasound guidance." indicates that even using US you are still not "immune" from complications.
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