Anesth Analg 2006;102:1293-1294
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000199216.28502.1D
LETTER TO THE EDITOR
Central Venous Access in Obese Patients: A Potential Complication
E. Ottestad, MD,
C. Schmiessing, MD,
John G. Brock-Utne, MD, PhD,
V. Kulkarni, MD,
D. Parris, MD, and
J. B. Brodsky, MD
Department of Anesthesia, Stanford University Medical Center, Stanford, CA, brockutn{at}stanford.edu
To the Editor:
Because peripheral IV access may be limited in obese patients (1), cannulation of a central vein (subclavian, internal jugular) is often recommended (2). We report a previously unrecognized complication of central line placement in an obese patient.
A 54-yr-old, 160 kg, 183 cm tall (body mass index = 47.8 kg/m2) man with cerebral vasospasm was scheduled for cerebral angiography under general anesthesia. He had been admitted to the intensive care unit after an emergency craniotomy and clipping of an aneurysm after a subarachnoid hemorrhage 3 days earlier. At the time of the surgical procedure, a triple-lumen right subclavian venous catheter (Arrowgard® Blue Plus Multi-Lumen CVC, Arrow International, Inc., Reading, PA) had been percutaneously inserted without difficulty.
On admission to the radiology suite propofol 100 µg · kg–1 · min–1 was infusing through the proximal lumen of the subclavian catheter and neosynephrine 200 µg · kg–1 · min–1 was infusing through the medial lumen. As is our routine, the patency of each lumen was checked before induction of general anesthesia. Blood could only be aspirated from the distal lumen. Under direct fluoroscopy using contrast medium it was noted that only the distal lumen was intravascular, and the propofol (proximal lumen) and neosynephrine (medial lumen) were extravasating into the subcutaneous tissue of the neck.
A long guidewire was inserted under fluoroscopic guidance into the right atrium through the patent distal lumen. The triple-lumen catheter was removed and a double-lumen catheter (Blue FlexTip Catheter®, Arrow International) was passed over the guidewire. Fluoroscopy with dye injection confirmed that both catheter lumens were intravascular.
The initial triple-lumen catheter was 16 cm long and had been inserted to the hub. The patient had an extremely large neck (>70 cm in circumference). Because of the distance between his skin and the vein, only the distal lumen was intraluminal. A chest radiograph after placement demonstrated that the catheter was intrathoracic, and because blood could be aspirated from the distal lumen its position was considered acceptable (Fig. 1). The replacement catheter was 20 cm long. The additional length was needed to allow both catheter lumens IV access (Fig. 2). A similar complication was recently reported with a much shorter 10.8 cm pulmonary artery catheter introducer in an obese patient (3).
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Figure 1. A chest radiograph obtained after placement of the 16-cm triple-lumen subclavian catheter. Arrow points to the distal tip of the catheter.
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Figure 2. A chest radiograph obtained after placement of the 20-cm double-lumen subclavian catheter. Arrow points to the distal tip of the catheter.
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Standard central venous access catheters placed in subclavian veins may not be long enough in some obese patients. Longer length catheters should be considered for these patients. When using any multilumen catheter, all lumens should be checked to confirm intravascular position after placement. In morbidly obese patients catheter position can change with movement (3), so position should be reconfirmed periodically.
References
- Juvin P, Blarel A, Bruno F, Desmonts J-M. Is peripheral line placement more difficult in obese than lean patients? Anesth Analg 2003;96:1218.[Abstract/Free Full Text]
- Johnson G, Tobias JD. Central venous access in morbidly obese patients. Anesth Analg 2001;93:1363.[Free Full Text]
- Thompson EC, Wilkins HE III, Fox VJ, Fernandez LG. Insufficient length of pulmonary artery introducer in an obese patient. Arch Surg 2004;139:794–6[Abstract/Free Full Text]
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