Air Embolism Occurring as a Complication of Central Venous Catheterization J. L. PETERS, B.Sc., F.R.C.S.,* R. ARMSTRONG, F.F.A.R.C.S.t

Two patients with air embolism (one fatal) which occurred during intravenous feeding with a central venous catheter are reported. The connection between intravenous administration sets and such catheters is shown to be a danger area which requires further technological improvement. The world literature concerning this hazard is reviewed.

of the fatal potential of intravenous air was described in 1667 by Redi, the Italian naturalist.'2 Beauchesne reported the first fatal case of air embolism following surgery on the neck in 1818.4 Since then, this complication has been recorded following a variety of procedures.9'19 The use of central venous catheters directly exposes patients to this potentially fatal hazard. T HE EARLIEST OBSERVATION

From the Intensive Care Unit and Department of Surgery, University College Hospital and Medical School, Gower Street, London, United Kingdom (Sherwood Medical Intramedicut; Fig. 2).' This defect had appeared after a period of ten days. The catheter was immediately removed. The following day he was subsequently noted to have a monoplegia affecting the left leg. A myelogram was normal. This neurological problem is now resolving and it is thought that this must have been caused by air embolism.

Discussion

Air accidents occurring during transfusion have been well documented. 19 The exact dose of intravenous air which can cause death in man is not known. The

Case Reports Case 1. H.C., a 62-year-old woman, was admitted to St. George's Hospital, for the investigation of weight loss and pain in the left hypochondrium. Subsequent investigations suggested the presence of a left subphrenic abscess. This was drained using a Nather Ochsner posterior extraserous approach on July 10, 1973. An intravenous feeding regime was commenced via a right infraclavicular subclavian central venous catheter, (Bardic Intracath). This was securely fixed to the patient with adhesive dressings. At 6:30 a.m. on July 18, the patient was noted to be well. However, at 7:15 a.m. her condition deteriorated; she became unresponsive and died. It was then noted that the intravenous administration set had become detached from the hub of the central venous catheter (Fig. 1). The patient had been sleeping in the semirecumbent position. A postmortem examination confirmed that the cause of death was due to pulmonary and cerebral air embolism. Case 2. G.P., a 60-year-old man, was admitted to University College Hospital after being the victim of a road traffic accident. He sustained multiple fractures and a ruptured spleen which required laparotomy. During his postoperative course he developed a period of acute pulmonary insufficiency which subsequently resolved. As he was being weaned from intermittent positive pressure ventilation, it was noted that his clinical condition suddenly deteriorated. He developed an unexpected tachypnoea and tachycardia. Closer clinical examination revealed air entering the circulation via a fracture in the hub of the central venous catheter * Senior Surgical Registrar. t Consultant Anesthetist. Submitted for publication: August 4, 1977.

FIG. 1. Detachment of CVP catheter connection.

0003-4932-78-0400-0375-0060 X J. B. Lippincott Company

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FIG. 2. Fracture in catheter hub.

rate at which air enters the circulation appears to be more

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is a theoretical risk of air embolism should this introducing cannula be left in the vein after insertion, (Fig. 4), i.e. the cannula should be withdrawn clear of the skin. Air embolism has also been described after a central venous catheter has been removed.18 The air entered along the catheter track and the patient subsequently died in the attempted resuscitation procedure. Obviously, a secure occlusive dressing should be placed over the catheter site, e.g. collodion or paraffin gauze, in the immediate postremoval period. However, the disconcerting feature of the accidents reviewed has been the ease with which the administration set can become detached from the venous catheter and allow air into the circulation. The use of multiple point taps, adaption or extension tubes, increases the risk. The true incidence of this complication is difficult to assess. The patient, especially if confused, may tamper with the dressings and apparatus. The drip tubing may get caught up with bedside equipment when the patient is moved or walks about the ward. Several cases occurred during the changing of ad-

important. A bolus of 100cc of air has been known

to cause death.21 Tunnicliffe and Stebbing in 1916 administered intravenous oxygen to three patients as a treatment for cyanosis.20 Their "'therapeutic" dose was 10 cc/min and "'toxic'" effects were noted at 20 cc/min. They noted gurgling heart sounds and produced transient quadriplegia in one case. Needless to say, this treatment has now ceased at Kings College Hospital.

Aubaniac2 and Yoffa22 both recognized the possibility of air embolism when describing their techniques of inserting central venous catheters. The complication was noted by Baden, who reported three cases in 1964.3 Air was heard to rush into the circulation, although no untoward reaction was noted. The first fatal air embolism occurring during the insertion of a central venous catheter was described in 1969 by Levinsky.'3 A search of the literature revealed a total of 12 cases with four deaths (Table 1). Air embolism can occur with such catheters in a variety of ways. If a catheter is inserted into a vein exposed at the antecubital fossa, and the retaining ligature accidentally transfixes the vein; air can enter the circulation19 (Fig. 3). Also, during insertion of catheters into neck veins, air embolism can easily occur;3"13 and to avoid this the patient must be placed in a Trendelenburg position and turned slightly towards the selected site of catheterization.'3 In patients with severe hypovolemia and tachypnea, it would be safer to introduce a long catheter through a vein in the antecubital fossa. Furthermore, with apparatus where the catheter is placed through an introducing plastic cannula, e.g., Sherwood Medical Intramedicut, there

TABLE 1. Accidental Air Embolism with Central Venous Catheter Author

Circumstance

Comment

1969 Insertion

Fatal

1969 Disconnected CVP catheter hub

Fatal

1969 Disconnected CVP catheter hub

Resuscitation

Hoshal'2

1969 Disconnected CVP catheter hub

Flanagan'3 Johnson'4

1969 Insertion

Mattox'5

1970 Lacerated pleura bulla

Resuscitation successful Fatal Resuscitation successful Fatal

Green"'6

1971 Disconnected CVP catheter hub

Transient CNS signs

Parsa'7

1974 Disconnected CVP catheter hub

Resuscitation

Levinsky'° Lucas"

Hoshal'2

1970 Insertion

Ordway"8

1974 Disconnected CVP catheter hub

Grace7

1977 Disconnected CVP catheter hub

Grace7

1977 Disconnected CVP catheter hub

Armstrong'

1977 Fracture of CVP catheter hub

Peters

1977 Disconnected CVP catheter hub

successful

successful Resuscitation successful Left hemiplegia and subsequent death Coma, transient left hemiplegia Nonfatal, transient left lower limb monoplegia Fatal

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FIG. 3. Transfixion ligature may allow air to pass around the cannula.

ministration sets. The provision of a tap which can close the catheter to the atmosphere is an advantage. Care must be taken to ensure that no port on the tap is unprotected in case this is inadvertently left in the "open" position (Fig. 5). If no tap is used, when the patient must lie supine during changes of the infusion apparatus. The second case highlights a new defect in this equipment. At the present moment it is difficult to determine whether or not the fault discovered is simply an aberration in the manufacturing process. However, the strength and quality of the materials used obviously requires improvement. Development of such fractures in catheters has also been noted by colleagues working in other hospitals. The faults are usually discovered by the nursing staff as a ""leak." In our cases, because of the patient's respiratory efforts, air embolism occurred. If the technique described by Benotti and Blackburn5 is used, then extreme care must be exercised. In this method, the catheter is rail-roaded to a distant site for the purpose of dressing procedures, etc., by grasping the plastic catheter hub with a hemostat. There is obviously a danger of inducing a minute fracture in the plastic material which could subsequently appear following a period of hyperalimentation. The deaths among the cases described provide ample evidence that this vital junction between central

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1:954, 1977. 2. Aubaniac, R.: L'Injection Intreveneuse Sous Claviculaire, Advantages and Technique. La Presse Medicale, 60:1456, 1952. 3. Baden, H.: Perkutan Kateterisation of V. Subclavia. Nord. Med., 71:590-593, 1964.

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4. Beauchesne: Physiological Researches into Life and Death by F.M.X. Bichat with notes by F. Magendie, Boston, 188, 1827. 5. Benotti, P. N., Blackburn, G. L. et al.: Safe Cannulation of The Internal Jugular Vein For Long Term Hyperalimentation. Surgery, Gynaecology and Obstetrics. Vol 144, 574, 1977. 6. Flanagan, J. P. and Kelly, T. R.: Letter to the Editor. N. EngI. J. Med, 281:1426, 1969. 7. Grace, D. M.: Air Embolism With Neurological Complications. A Potential Hazard of Central Venous Catheters. Can. J. Surg. 20:51, 1977. 8. Green, H. L. et al.: Air Embolism as a Complication During Parenteral Alimentation. Am. J. Surg., 121:614, 1971. 9. Hazard Health Notice; HN (76) 74. Department of Health and Social Security. Warning against the use of non-vented semirigid containers when using a positive displacement pump to administer intravenous fluids. 10. Hoshal, V. L. Jr. and Fink, G. G.: The Subclavian Catheter. N. EngI. J. Med., 281:1425, 1969. 11. Johnson, C. L. et al.: Subclavian Venipuncture: Preventable Complications; Report of Two Cases. Mayo Clin. Proc., 45: 712, 1970. 12. Larsen, C. P.: Venous Air Embolism. Report of Four Cases.

13. 14. 15. 16. 17.

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Suggested Method of Treatment. Am. J. Clin. Pathol., 21:247, 1951. Levinsky, W. J.: Fatal Air Embolism During Insertion of CVP Monitoring Apparatus. JAMA, 209:966, 1969. Lucas, C. E. and Irani, F.: Air Embolus via Subclavian Catheter. N. Engl. J. Med., 281:966, 1969. Mattox, K. L. and Bricker, D. L.: Air Embolism Following Subclavian Vein Catheterization. Tex. Med., 66:74, 1970. Ordway, C. B.: Air Embolus via CVP Catheter Without Positive Pressure-Presentation of Case and Review. Ann. Surg. 179:149, 1974. Parsa, M. H.: Safe Central Venous Nutrition. Springfield, Charles C Thomas, 1974. p. 68. Paskin, D. L., Hoffran. W. S. and Tuddenham, W. J.: A New Complication of Subclavian Vein Catheterisation. Ann. Surg., 179:266, 1974. Simpson, K.: Air Accidents during Transfusion. Lancet, 1: 697, 1942. Tunnicliffe, F. W. and Stebbing, G. F.: Intravenous Injection of Oxygen Gas as Therapeutic Measure. Lancet, 2:321, 1916. Yeakel, A. E.: Lethal Air Embolism from Plastic Blood Storage Container. JAMA, 2(04:267, 1969. Yoffa, D.: Supraclavicular Subclavian Venepuncture and Catheterisation. Lancet, 2:614, 1965.

Air embolism occurring as a complication of central venous catheterization.

Air Embolism Occurring as a Complication of Central Venous Catheterization J. L. PETERS, B.Sc., F.R.C.S.,* R. ARMSTRONG, F.F.A.R.C.S.t Two patients w...
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