Axillary artery occlusion following central venous catheterisation

Dear Editor, Insertion of a central venous catheter is now common in critically ill patients, especially those admitted to the ICU for haemodynamic monitoring, poor peripheral access, administration of medications, and continuous renal replacement therapy. The immediate complications of central venous cannulation include bleeding (following arterial puncture), thoracic duct injury (after left subclavian or internal jugular approach), pneumothorax, haemothorax, air embolism, cardiac arrhythmias and catheter malposition. The subclavian vein (SCV) approach to central venous cannulation is associated with the lowest risk of infection and is therefore a preferred method for many clinicians. A 38-year-old man was referred to us in a coma because of ingestion several hours earlier of large amounts of phenobarbital and benzodiazepines. His Glasgow Coma Scale score was 5/15, and his blood pressure was 65/50 mmHg, a very low urine output and cold clammy skin. Several large skin bullae were detected in the calcanean regions of his feet suggestive of prolonged immobility and coma. An arterial blood gas showed a severe mixed metabolic and respiratory acidosis. The patient underwent orotracheal intubation then gastric lavage via a nasogastric tube followed by a single dose of activated charcoal. In spite of large amounts of crystalloid fluids intravenously, the patient remained shocked. As the patient’s haemodynamic was too unstable to measure central vein pressure, and because of the likely need for future haemodialysis, blind left SCV catheterisation was performed by a general surgeon. Shortly after catheter insertion, the left hand became cyanotic, which was cold, with significantly diminished capillary refill, and a weak radial pulse. Emergent colour Doppler ultrasound showed no arterial blood flow in the left axillary artery (LAA) and a chest radiograph showed malposition of the catheter in the lumen of the LAA (Fig. 1). The end of the central venous catheter had resulted in complete obstruction of the artery orifice. The cannula was promptly withdrawn and direct non-occlusive pressure was applied to the site of subclavian region for 10 min. Immediately after this, the colour of the hand returned to normal and the blood flow normalised. Arterial puncture is an immediate complication of central venous access procedures occurring in 3–15% of cases. A study by Eisen and colleagues showed that mechanical complications occurred in up to 33% of attempts. Fortunately, mechanical complications tend to be detected at the time of catheterisation or shortly after that. Greater experience of the operators, fewer insertion attempts, and ultrasound guidance are associated with less mechanical complications. The benefits of ultrasound guidance for catheterisation of the internal jugular vein have been described, and this has become recognised as a standard of care in many countries. Alternatively, measuring intra-luminal pressure with a transducer before vessel dilation will also help to avoid arterial puncture. In our case, the pressure in the manometer measurement tube was very high such that the surface of water came up to the end of the tube, and we could not administer any fluid via the catheter as it had occluded the lumen of the LAA. This was the probable mechanism of abrupt cyanosis of the left upper extremity. Recirculation in the left hand after catheter withdrawal confirmed this. In conclusion, close monitoring and X-ray of any patient after insertion of a central venous catheter are important in the diagnosis of any complications of catheterisation. Chest radiograph allows recognition of catheter malposition or other mechanical complications. Finally, this case shows that although the beneficial effects of ultrasound for SCV approach are still debated, catheter malposition is more likely to happen after blind catheterisation and therefore we strongly recommend this procedure be performed under ultrasonographic guidance. Figure 1. Orifice of left axillary artery occluded by the tip of the catheter. doi: 10.1111/1742-6723.12006 Emergency Medicine Australasia (2012) 24, 684–685 bs_bs_banner