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Canadian Journal of Anesthesia 51:89-90 (2004)
© Canadian Anesthesiologists' Society, 2004

Correspondence

Successful aspiration of blood does not exclude malposition of a large-bore central venous catheter

Matthias Hohlrieder, MD, Heinrich M. Schubert, MD, Matthias Biebl, MD, Christian Kolbitsch, MD, Patrizia L. Moser, MD and Ingo H. Lorenz, MD

Innsbruck, Austria

To the Editor:

We report the occurence of a primarily unnoticed mal-positioned central venous catheter (CVC), in which aspiration of blood failed to indicate CVC tip position in the pleural cavity.

A 44-yr-old man was anesthetized for thoracoscopy-assisted thoracic spinal fusion surgery. After orotracheal intubation the left subclavian vein was punctured, confirmed by the aspiration of abundant dark venous blood. The guide wire and the dilatator passed without resistance and a large-bore multi-lumen catheter (12 Fr x 8", 3-lumen; Arrow InternationalTM, Reading, PA, USA) was subsequently inserted.1 Aspiration of blood into the transparent part of both large-bore lumina and easy flushing indicated correct intravascular catheter placement. Intraoperatively, when rechecking the catheter, aspiration of blood failed, whereas flushing was easy. Thoracoscopic view revealed a left-side, minimally bloody hydrothorax with the catheter tip freely visible in the intrapleural space (FigureGo). At the end of surgery the hydrothorax was drained and the misplaced catheter was removed uneventfully.



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  		FIGURE Thoracoscopic view of the tip of the central venous catheter misplaced in the left pleural cavity.

 
In the present case, infusion into the pleural cavity was caused by perforation of the subclavian vein. A secondary perforation would explain the successful initial aspiration of blood through both large-bore lines. Yet, most secondary perforations are late complications2 and, in addition, erosion is rendered unlikely because practically no blood was detectable in the pleural cavity on thoracoscopy.

Therefore, primary malposition with initial intrapleural placement seems to be more likely.3 Perforation of the subclavian vein with the needle is hardly conceivable, because initial aspiration of blood was abundant. Perforation with the J-shaped guide wire must be considered, as the wire tip can be very stiff and sharp when the tip of the needle is located close to the intima. The clamps on the 12 Gauge (GA) lines do not provide an absolutely tight seal, so blood can fill the distal part of the 12 GA lumina when passing the catheter through the vein lumen. Approximately 0.1 mL blood is enough to produce a continuous 1 cm blood column on aspiration in the proximal transparent part of the catheter. Therefore, it is likely that aspiration of an insufficient blood volume, as evidenced by a blood column in the transparent part of the 12 GA lumina, led to erroneously conclude the catheter was correctly placed. Consequently, the volume of blood aspirated must exceed the volume of the CVC lumina, and an additional control aspiration is recommended immediately before starting the infusion.

References

1 Conahan TJ 3rd, Schwartz AJ, Geer RT. Percutaneous catheter introduction: the Seldinger technique (Letter). JAMA 1977; 237: 446–7.

2 Molinari PS, Belani KG, Buckley JJ. Delayed hydrothorax following percutaneous central venous cannulation. Acta Anaesthesiol Scand 1984; 28: 493–6.[Medline]

3 Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med 1994; 331: 1735–8.[Abstract/Free Full Text]




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