Anaesthesia, 1992, Volume 47, pages 30-3 1 CASE R E P O R T
Internal jugular catheterisation Blood reflux is not a reliable sign in patients with thoracic trauma J. PINA, N. MORUJAO
AND
J. CASTRO-TAVARES
Summary An internal jugular catheter. which was inserted into a patient with a traumatic haemopneumothorax, accidentally entered the pleural cavity. This was initially undetected because the two signs most frequently used to conjirm correct placement. those of blood reflux and fluctuation of central venous pressure with respiration, were positive. A number of precautions are suggested which should be taken when central venous catheters are inserted in patients with thoracic trauma.
Key words Veins,jugular; cannulation, complications. Complications; haemopneumothorax.
There are a number of ways in which the correct position of catheters in central veins can be verified, but the two which are most frequently used are those of reflux of blood back up the catheter and fluctuation of the central venous pressure (CVP) with respiration. In cases of thoracic trauma, a basic rule is to attempt venous puncture on the same side as the damaged lung first of all, so that in the event of a mishap such as puncture of an emphysematous bulla, the function of the healthy lung is preserved. In this report we describe a complication of internal jugular vein cannulation in a patient with an ipsilateral haemothorax. Since reflux of blood and respiratory fluctuations led us to believe that the cannula was correctly sited, we suggest further precautions which should be taken during central venous cannulation in patients with thoracic trauma, even when the high anterior approach to the internal jugular vein is used. Case history A 30-year-old, 75-kg Caucasian man with a traumatic haemoperitoneum and a right haemopneumothorax was admitted for emergency laparotomy. A chest drain was inserted and 450 ml of blood drained into the bottle over 30 min, after which the drainage stopped. The patient was fully conscious and his blood pressure and pulse rate just before induction were 120/80 mmHg and 130 beat.min-' respectively. Anaesthesia was induced with fentanylo. 1 mg, thiopentone 375 mg and vecuronium 8 mg and the trachea was intubated. Maintenance was with nitrous oxide in
oxygen and the lungs were mechanically ventilated. At laparotomy, extensive lacerations of the right lobe of the liver and the right kidney were found. The right internal jugular vein was punctured at the first attempt via a high anterior approach and a 16-G catheter was inserted using a Seldinger technique (Vygon Leadercath 14-G; code 124.20). The procedure was uneventful and there was reflux of blood and fluctuation of central venous pressure with respiration. The lacerations in the liver and kidney were repaired and two units of packed red cells were transfused through the catheter. Although the patient was haemodynamically stable, the CVP measurement was zero. Soon after transfusion with the first unit of blood, drainage from the chest suddenly increased. The blood transfusion was followed by Ringer lactate and saline, after which the blood from the chest drain appeared to be more dilute. However, blood could still be aspirated back up the catheter and respiratory fluctuation of the CVP was still present. Over a period of about 30 min, 1500 ml had drained into the bottle, therefore the decision was made to perform a thoracotomy. After the patient was turned into the left lateral position, the CVP was found to have increased to 10 cmH,O. At thoracotomy, the catheter was seen to have perforated the wall of the superior vena cava and was lying in the pleural cavity, pointing upwards and to the right, with the tip well above the right atrium. The catheter was withdrawn, two pulmonary lacerations were sutured and the chest closed with a thoracic drain in place. No more bleeding occurred and the patient was discharged from the intensive care unit a few days later.
J.P.A. Pina, MD, N.L. da Silva Morujiio, MD, J.M.M. Castro-Tavares, MD, PhD, Professor, Medical School of Porto, Serviqo de Anestesia e Reanimaqgo, Hospital de S. Joiio, 4200 Porto, Portugal. Accepted 5 May 1991. 0003-2409/92/0 10030+ 02 $03.00/0
@ 1992 The Association of Anaesthetists of G t Britain and Ireland
30
Internal jugular catheterisation
31
Discussion A central venous catheter is useful for assessing fluid replacement and administering large volumes of fluid rapidly. The internal jugular vein is considered to be the safest route for catheterisation [ 11. However, many complications have been reported, even with this route [2]. Although some textbooks mention that blood reflux and respiratory fluctuations are not reliable signs of correct placement [3], we have been unable to find any case reports in which these signs were present when the catheter was not in a central vein. The position of the catheter within the pleural space explains all the signs observed: the flow of blood into the infusion set, the movement of the fluid column synchronously with respiration and the apparent sudden increase in central venous pressure when the patient was turned on his side (Fig. I). The use of the Seldinger technique is considered to be the safest method of vascular cannulation [4], although the equipment is more expensive. In this case, since the high approach to the internal jugular vein was used, it is probable that the guide wire itself was responsible for the false passage; a possible explanation is that it had been inserted the wrong way round, with the rigid end rather than the flexible end first. We conclude, therefore, that in patients with chest trauma, if a central venous catheter is inserted on the same side as a haemothorax, or if blood has already been transfused through the catheter, reflux of blood and fluctuation of venous pressure with respiration may not always be reliable signs with which to confirm central venous catheterisation. Thus, there are a number of basic rules which should be observed in a patient with a haemothorax, in order to minimise the risks of accidental placement of the catheter within the pleural cavity. Before the guide wire is introduced, care should be taken to identify and insert the end with the flexible tip. The first blood aspirated from the catheter should be put in a test tube and observed for clot formation. If clots do not form in 15-30 min, it suggests that the catheter is sited in the pleural space. The chest drainage should be observed, in particular to look for a correlation between changes in the rate of drainage and the
I Supine position
20 15
10
-
RA LA Left lateral position
Fig. 1. Transverse section at heart level. Supine position: Left and right atria (LA and RA), superior vena cava (SVC) and the tip of the catheter (Tip), out of the vessel and pointing to the right side, are all at the same level (central venous pressure zero cmH,O). Left
lateral position: the tip of the catheter became much higher than the RA, and produced central venous pressure readings of about 10 cmH,O.
rate at which the fluid is infused through the catheter. Likewise, the composition of both should be compared for similarities in dilution or colour, particularly if substances such as fat emulsions, methylene blue or multivitamin preparations are being transfused. The catheter should not be used for blood transfusion, if that is possible, to avoid confusion and wastage of blood. Finally, the medical and nursing staff should be aware of this complication, and of the clinical signs which should lead to its diagnosis.
References [I] ROSENM, LATTO IP, NG WS. Handbook of percutaneous
central venous catheterisation. Philadelphia: W.B. Saunders, 1981. [2] KAE CG, SMITHDR. Complications of central venous cannulation. Trauma, infection and thrombosis. British Medical Journal 1988; 297: 572-3. [3] PARSE MH, TAEORA F, AL-SAWWAF M. Monitoring: Vascular access techniques. In: SHOEMAKER WC, eds. Textbook of critical care. Philadelphia: W.B. Saunders, 1989: 13941. [4] SITZMANN JV, TOWNSEND TR, SILER MC, BARTLETT JG. Septic and technical complications of central venous catheterization. Annals of Surgery 1985; 202: 766-70.
Internal jugular catheterisation Blood reflux is not a reliable sign in patients with thoracic trauma J. PINA, N. MORUJAO
AND
J. CASTRO-TAVARES
Summary An internal jugular catheter. which was inserted into a patient with a traumatic haemopneumothorax, accidentally entered the pleural cavity. This was initially undetected because the two signs most frequently used to conjirm correct placement. those of blood reflux and fluctuation of central venous pressure with respiration, were positive. A number of precautions are suggested which should be taken when central venous catheters are inserted in patients with thoracic trauma.
Key words Veins,jugular; cannulation, complications. Complications; haemopneumothorax.
There are a number of ways in which the correct position of catheters in central veins can be verified, but the two which are most frequently used are those of reflux of blood back up the catheter and fluctuation of the central venous pressure (CVP) with respiration. In cases of thoracic trauma, a basic rule is to attempt venous puncture on the same side as the damaged lung first of all, so that in the event of a mishap such as puncture of an emphysematous bulla, the function of the healthy lung is preserved. In this report we describe a complication of internal jugular vein cannulation in a patient with an ipsilateral haemothorax. Since reflux of blood and respiratory fluctuations led us to believe that the cannula was correctly sited, we suggest further precautions which should be taken during central venous cannulation in patients with thoracic trauma, even when the high anterior approach to the internal jugular vein is used. Case history A 30-year-old, 75-kg Caucasian man with a traumatic haemoperitoneum and a right haemopneumothorax was admitted for emergency laparotomy. A chest drain was inserted and 450 ml of blood drained into the bottle over 30 min, after which the drainage stopped. The patient was fully conscious and his blood pressure and pulse rate just before induction were 120/80 mmHg and 130 beat.min-' respectively. Anaesthesia was induced with fentanylo. 1 mg, thiopentone 375 mg and vecuronium 8 mg and the trachea was intubated. Maintenance was with nitrous oxide in
oxygen and the lungs were mechanically ventilated. At laparotomy, extensive lacerations of the right lobe of the liver and the right kidney were found. The right internal jugular vein was punctured at the first attempt via a high anterior approach and a 16-G catheter was inserted using a Seldinger technique (Vygon Leadercath 14-G; code 124.20). The procedure was uneventful and there was reflux of blood and fluctuation of central venous pressure with respiration. The lacerations in the liver and kidney were repaired and two units of packed red cells were transfused through the catheter. Although the patient was haemodynamically stable, the CVP measurement was zero. Soon after transfusion with the first unit of blood, drainage from the chest suddenly increased. The blood transfusion was followed by Ringer lactate and saline, after which the blood from the chest drain appeared to be more dilute. However, blood could still be aspirated back up the catheter and respiratory fluctuation of the CVP was still present. Over a period of about 30 min, 1500 ml had drained into the bottle, therefore the decision was made to perform a thoracotomy. After the patient was turned into the left lateral position, the CVP was found to have increased to 10 cmH,O. At thoracotomy, the catheter was seen to have perforated the wall of the superior vena cava and was lying in the pleural cavity, pointing upwards and to the right, with the tip well above the right atrium. The catheter was withdrawn, two pulmonary lacerations were sutured and the chest closed with a thoracic drain in place. No more bleeding occurred and the patient was discharged from the intensive care unit a few days later.
J.P.A. Pina, MD, N.L. da Silva Morujiio, MD, J.M.M. Castro-Tavares, MD, PhD, Professor, Medical School of Porto, Serviqo de Anestesia e Reanimaqgo, Hospital de S. Joiio, 4200 Porto, Portugal. Accepted 5 May 1991. 0003-2409/92/0 10030+ 02 $03.00/0
@ 1992 The Association of Anaesthetists of G t Britain and Ireland
30
Internal jugular catheterisation
31
Discussion A central venous catheter is useful for assessing fluid replacement and administering large volumes of fluid rapidly. The internal jugular vein is considered to be the safest route for catheterisation [ 11. However, many complications have been reported, even with this route [2]. Although some textbooks mention that blood reflux and respiratory fluctuations are not reliable signs of correct placement [3], we have been unable to find any case reports in which these signs were present when the catheter was not in a central vein. The position of the catheter within the pleural space explains all the signs observed: the flow of blood into the infusion set, the movement of the fluid column synchronously with respiration and the apparent sudden increase in central venous pressure when the patient was turned on his side (Fig. I). The use of the Seldinger technique is considered to be the safest method of vascular cannulation [4], although the equipment is more expensive. In this case, since the high approach to the internal jugular vein was used, it is probable that the guide wire itself was responsible for the false passage; a possible explanation is that it had been inserted the wrong way round, with the rigid end rather than the flexible end first. We conclude, therefore, that in patients with chest trauma, if a central venous catheter is inserted on the same side as a haemothorax, or if blood has already been transfused through the catheter, reflux of blood and fluctuation of venous pressure with respiration may not always be reliable signs with which to confirm central venous catheterisation. Thus, there are a number of basic rules which should be observed in a patient with a haemothorax, in order to minimise the risks of accidental placement of the catheter within the pleural cavity. Before the guide wire is introduced, care should be taken to identify and insert the end with the flexible tip. The first blood aspirated from the catheter should be put in a test tube and observed for clot formation. If clots do not form in 15-30 min, it suggests that the catheter is sited in the pleural space. The chest drainage should be observed, in particular to look for a correlation between changes in the rate of drainage and the
I Supine position
20 15
10
-
RA LA Left lateral position
Fig. 1. Transverse section at heart level. Supine position: Left and right atria (LA and RA), superior vena cava (SVC) and the tip of the catheter (Tip), out of the vessel and pointing to the right side, are all at the same level (central venous pressure zero cmH,O). Left
lateral position: the tip of the catheter became much higher than the RA, and produced central venous pressure readings of about 10 cmH,O.
rate at which the fluid is infused through the catheter. Likewise, the composition of both should be compared for similarities in dilution or colour, particularly if substances such as fat emulsions, methylene blue or multivitamin preparations are being transfused. The catheter should not be used for blood transfusion, if that is possible, to avoid confusion and wastage of blood. Finally, the medical and nursing staff should be aware of this complication, and of the clinical signs which should lead to its diagnosis.
References [I] ROSENM, LATTO IP, NG WS. Handbook of percutaneous
central venous catheterisation. Philadelphia: W.B. Saunders, 1981. [2] KAE CG, SMITHDR. Complications of central venous cannulation. Trauma, infection and thrombosis. British Medical Journal 1988; 297: 572-3. [3] PARSE MH, TAEORA F, AL-SAWWAF M. Monitoring: Vascular access techniques. In: SHOEMAKER WC, eds. Textbook of critical care. Philadelphia: W.B. Saunders, 1989: 13941. [4] SITZMANN JV, TOWNSEND TR, SILER MC, BARTLETT JG. Septic and technical complications of central venous catheterization. Annals of Surgery 1985; 202: 766-70.
