Anesth Analg 2004;99:31-35
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000117148.40842.CA
CARDIOVASCULAR ANESTHESIA
Life-Threatening Mediastinal Hematoma Caused by Extravascular Infusion Through a Triple-Lumen Central Venous Catheter
Matthias Hohlrieder, MD,
Rosmarie Oberhammer, MD,
Ingo H. Lorenz, MD,
Josef Margreiter, MD,
Gabriele Kühbacher, MD, and
Christian Keller, MD
Department of Anesthesiology and Critical Care Medicine, University of Innsbruck, Austria
Address correspondence and reprint requests to Matthias Hohlrieder, MD, Department of Anesthesiology and Critical Care Medicine, University of Innsbruck, Anichstrasse 35, A-6020 Innsbruck, Austria. Address e-mail to matthias.hohlrieder{at}uibk.ac.at
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Abstract
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We report a case of life-threatening mediastinal hematoma in a 6-mo-old girl during surgical correction of scaphocephaly. The hematoma was caused by extravascular infusion via the proximal lumen of a dislocated triple-lumen central venous catheter (CVC). Worsening symptoms of hypovolemia and ventilation problems prompted performance of transesophageal echocardiography, which reliably and quickly allowed us to exclude pericardial tamponade and detect a mediastinal hematoma. The anesthesiologist should be alert when a patient with a CVC develops acute cardiopulmonary or respiratory symptoms. Repeated aspirations of blood, especially after major positional changes and before giving large quantities of fluid or blood, should be performed to detect secondary malposition of the CVC.
IMPLICATIONS: This pediatric case report demonstrates a life-threatening intraoperative mediastinal hematoma caused by infusion of packed erythrocytes through the extravascular proximal lumen of a partially dislocated central venous catheter. Transesophageal echocardiography facilitated rapid intraoperative diagnosis.
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Introduction
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Central venous catheters (CVC) may be associated with serious complications. Intracardiac malpositioning with a risk of cardiac perforation and pericardial tamponade, as well as insufficient intravascular advancement of the catheter, can be a dangerous pitfall with this routine technique. We report a pediatric case of life-threatening intraoperative hypovolemia with a massive mediastinal hematoma caused by extravascular infusion via the proximal lumen of a triple-lumen CVC.
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Case Report
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A 6-mo-old girl (8100g, 65 cm) was anesthetized for surgical correction of scaphocephaly. Preoperative evaluation revealed no pertinent medical history. Standard monitoring (electrocardiogram, pulse oximetry, and arterial blood pressure) was applied, a 22-gauge IV catheter inserted, and anesthesia induced with midazolam, fentanyl, propofol, and rocuronium. After orotracheal intubation the lungs were ventilated pressure controlled (peak pressure = 15, positive end-expiratory pressure = 3, f = 20, and minute ventilation 1.2 L/min) and anesthesia was maintained with fentanyl and midazolam. The left subclavian vein was successfully punctured on the first attempt, and a 13-cm triple-lumen 5.5F catheter (Arrow InternationalTM, Reading, PA) was inserted using the Seldinger technique. The catheter was easily advanced 7 cm from the skin entry site and secured with two sutures. Aspiration of abundant blood through all three lumens and easy flushing with saline indicated correct intravascular catheter placement. Central venous pressure (CVP) was measured via the distal lumen, whereas the middle lumen was used for infusion of dopamine, fentanyl, and midazolam. The proximal lumen was used for drug and volume administration. Ringer’s lactate solution 80 mL/h with glucose 5% (3:2) was infused via the peripheral IV catheter. The vital signs remained within normal ranges (arterial blood pressure, 80/40 mm Hg; heart rate, 120 bpm; CVP, 10; oxygen saturation, 99%) for 4 h.
Toward the end of surgery, the cumulative blood loss, estimated from the suction unit, increased from 150 to 250 mL within a 30-min interval. Despite adequate administration of volume via the proximal lumen of the CVC, the patient exhibited worsening clinical signs of hypovolemia. The patient’s arterial blood pressure decreased to 40/10 mm Hg, whereas the heart rate increased to 160 bpm. CVP values decreased to 3 mm Hg, whereas the pressure waveform remained unchanged. To maintain an adequate minute ventilation, the peak pressure and the frequency had to be increased to 24 mbar and 22 min–1, respectively. A few minutes later, the arterial oxygen saturation gradually decreased to 94% despite an inspired oxygen concentration of 100%. Volume resuscitation included 140 mL of human albumin and 300 mL of packed erythrocytes. Dopamine-infusion was increased from 2.5 µg · kg–1 · min–1 to 9 µg · kg–1 · min–1, whereas ephedrine, phenylephrine, and epinephrine were administered as bolus doses. Surgery was completed after approximately 30 min of increasing hemodynamic instability and ventilation problems. Emergency transesophageal echocardiography (TEE) was performed (Fig. 1 and 2(1)), revealing a large mediastinal hematoma compressing the right atrium as well as the superior vena cava (SVC). A very small left ventricular end-diastolic area along with coapting papillary muscles during systole indicated severe hypovolemia. TEE also showed bilateral pleural fluid collections. After removal of the sterile cover, a doughy edema of the left subclavian and shoulder area was observed. A chest radiograph demonstrated a left upper lobe atelectasis and the catheter tip next to the SVC-subclavian junction (Fig. 3).
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Figure 1. Mediastinal hematoma in midesophageal bicaval view (1). SVC = superior vena cava; H = hematoma; RA = right atrium.
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Figure 2. Mediastinal hematoma in midesophageal ascendens aortic short axis view (1). SVC = superior vena cava; H = hematoma; A = aorta; MPA = main pulmonary artery; RPA = right pulmonary artery.
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Figure 3. Chest radiograph demonstrating a left upper lobe atelectasis and the catheter tip next to the superior vena cava (SVC)-subclavian junction.
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When rechecking the left subclavian catheter, aspiration of blood through the proximal lumen failed, whereas the middle and the distal lumen were correctly placed intravascularly. The two skin sutures were intact, but the insertion length was noticed to be 5.5 cm. Thereafter, the dislocated catheter was closed, and successful volume resuscitation used only the peripheral venous catheter. A right femoral arterial catheter and a left femoral venous catheter were inserted while percutaneous thoracostomy drained approximately 100 mL of bloody-serous fluid bilaterally. After the administration of 200 mL of blood and 200 mL of colloids, arterial blood pressure, heart rate, and CVP soon returned to normal (arterial blood pressure, 85/40 mm Hg; heart rate, 130 bpm; CVP, 7 mm Hg). The patient was transferred to the pediatric intensive care unit and tracheally extubated within 3 h. Two days later, she was discharged from the intensive care unit and made a full recovery.
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Discussion
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Percutaneous central venous catheterization providing pressure measurement, drug and fluid therapy, as well as the possibility of aspiration in case of air embolism is often used during anesthesia for major surgical procedures. In the operating room, it is generally accepted to place the catheter in a blind fashion (2) and to confirm intravascular catheter placement by aspiration of venous blood and visualization of a CVP waveform. Intravascular misplacement of subclavian catheters with the tip in the contralateral subclavian vein in either jugular vein or in the heart, is not typically assessed until the postoperative chest radiograph.
Compared with adults, CVC placement in children is technically more difficult and carries more risks (3,4). In children, the subclavian vein is one of the most preferred sites for CVC placements and is well tolerated (5). The risk of serious complications related to subclavian CVC insertion is 0.4%–9.9%, with pneumothorax being the most frequent (5,6). However, the most serious complication in infant CVC is cardiac perforation and tamponade caused by excessive length of insertion (7–9). Therefore, clinically useful guidelines for correct initial length of insertion primarily aim to avoid intracardiac placement (10).
Several authors have developed age-, height-, and weight-based formulas to predict the required intravascular catheter length to achieve SVC placement (10–13). A reliable formula would likely reduce complications and save time and expense (11). Andropoulos et al. (10) have published height- and weight-based formulas for children predicting right internal jugular and right subclavian CVCs to be positioned above the right atrium 97% and 98% of the time, respectively. Focusing on the left subclavian approach, Czepizak et al. (11) found the formula [patient’s height/10] + 2 to predict the catheter length most accurately (97%). However, this formula is not validated for children and does not account for the probable differences in catheter insertion length because of variations in approaches to the same site. In infraclavicular subclavian vein cannulation, considering the wide area of the clavicle, puncture-site selection in practice is left to the individual’s experience (14) and probably contributes to variability of insertion depth despite application of a constant formula.
Our left subclavian catheter was initially advanced 7 cm from the skin entry site and secured with two sutures. Easy aspiration of blood and flushing with saline through all three lumens indicated correct intravascular catheter placement. The 7-cm insertion is appropriate according to the formula of Czepizak et al. (11), calculating a maximum length of insertion of 8.5 cm for the left subclavian vein. However, this maximum length recommendation does not take into consideration the possible problems that could be encountered if the orifice one of the lumens is too far away from the catheter tip. In fact, there are no published recommendations about the distance between the skin insertion site and the proximal lumen orifice. In adults, subclavian catheters have been shown to move up to 3 cm towards the heart with movement of the head or neck (15,16). Our patient’s head and shoulders were repositioned two times during the operation. Considering the 32-mm distance of the proximal lumen orifice from the tip, a secondary extravascular malposition of the proximal lumen orifice is very likely.
Most of the fluid volume, including 300 mL of packed erythrocytes administered through the proximal lumen, was accumulated in the subclavian and mediastinal area. Ephedrine, phenylephrine, and epinephrine bolus doses were also administered via the proximal lumen. The mediastinal hematoma caused a compression of the right atrium and the SVC. The rapid diagnosis and exclusion of pericardial tamponade provided by TEE was lifesaving. On-line TEE-documentation of hemodynamic improvement facilitated management of the complication without sternotomy.
A review of literature indicates that mediastinal hematomas caused by CVC are rare (17–20). This is the first reported case of a life-threatening intraoperative mediastinal hematoma caused by an infusion via the orifice of an extravascular proximal lumen of a partially dislocated CVC. Repeated aspirations of blood, not only from the distal lumen, but also from the most proximal lumen, should be performed to detect secondary malposition of the CVC. This is especially required after major positional changes and before giving large quantities of fluid or blood. Because the distance between the proximal and the distal port is 32 mm in these triple-lumen catheters, one should consider alternatives in small infants. Manufacturers should be encouraged to produce the pediatric catheters with the proximal lumen orifice closer to the tip. We recommend using the proximal lumen for CVP measurement so that changes in the shape of the pressure curve can alert the anesthesiologist to suspect a partly dislocated catheter. TEE reliably and rapidly allowed us to exclude pericardial tamponade, to accurately localize a mediastinal hematoma, and provided additional information about left-ventricular preload during a life-threatening intraoperative condition.
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References
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Accepted for publication December 23, 2003.
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Abstract
Introduction
