Complications of Central Line Placement: Pneumothorax, Arrhythmia, Hematoma

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.


Anatomical landmarks for central line placement in the internal jugular (IJ) vein, anterior approach. This patient was 101 years old and was DNR-CCA, she did not need any central lines.

Pneumothorax (PTX)

Case 1

A patient needed a TLC (triple lumen catheter) which was placed in the left subclavian vein by the surgical house officer. The CXR after the procedure did not show any evidence of PTX. Next morning on physical exam the patiend did not have air entry on the left side of the chest and a stat CXR was ordered.

CXR showed a left sided sided PTX with a deep sulcus.


Left PTX due to left subclavian line placement

A chest tube was placed with a resolution of the PTX. Subcutaneous emphysema developed around the chest tube insertion place.


Post-PTX Subcutaneous Emphysema

Case 2

This is another case of a PTX after a line placement:

82 yo AAF needed a central line for IVF because she was dehydrated. During an attempt to place an external jugular line, she started to comlpain of SOB. CXR showed a right-sided PTX.


PTX after an external jugular line. You can also see bullet fragments from previous GSW. There is a HD catheter.


PTX after an external jugular line - close-up view


Right lung not expanded after a chest tube placement


Right lung expanded, the chest tube is still in place. HD catheter and a left central line in place.

Arrhythmia

AFib with RVR after a TLC placement

39 yo AAF was admitted to the hospital with a diabetic foot ulcer. She needed IV access for Unasyn IV and labs, and failed several peripheral line attempts.

Right IJ TLC catheter was placed. Immediately after catheter was placed, she complained of SOB and palpitations. Her SpO2 was 100%, breath sounds were equal and clear bilaterally.

Is it PTX?
HR was 140 and irregular - PVCs?

What would you do?
EKG showed AFib with RVR, CXR showed the TLC at the level of right AV junction.


TLC at the right AV junction on CXR


AFib due to a TLC at AV junction

What happened?
TLC was withdrawn 5 cm with conversion to sinus rhythm and no further complaints.


TLC in SVC - correct position on CXR


Conversion to NSR after TLC was repositioned

Massive Hematoma

During an attempt to place a central line in the subclavian vein, physicians inadvertently punctured the subclavian artery. The patient expired due to massive bleeding despite the surgical intervention to close the puncture site.


Massive hematoma after subclavian artery puncture. Case and image courtesy of UnboundedMedicine.com, used under CreativeCommons license.

References

A Complication of Central Venous Catheterization. Loss of the guide wire. NEJM, 2007.
A Complication of Central Venous Catheterization. A Pulled IVC Filter. NEJM, 2007.
Central Venous Catheterization: Concise Definitive Review. Medscape, Critical Care Medicine, 05/16/2007 (free registration required).
NEJM Videos in Clinical Medicine. These are high-quality professional videos but they require a subscription to NEJM:
Central Venous Catheterization - IJ vein
Central Venous Catheterization - Subclavian Vein
Central Line
Improper placement of the central venous catheter - case one and case two from the Annals of Emergency Medicine

Published: 07/20/2005
Updated: 12/12/2009

23 comments:

  1. Amazing examples of complications of central lines placement.
    Nice job.

    ReplyDelete
  2. i have personally seen two cases of delayed pneumothorax from subclavian central line placement. Even though CDC recommends subclavian as the site of choice, I find that with the new ultrasound equipment, sonosite and such... its much easier to go to IJ and avoid complications.

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  3. Last month I unfortunetely experienced a left pnemohemothorax after an ER physician was placing a subclavian central line and the guidewire accidently punctured my left mammary artery. I immediately knew something was wrong with severe chest pain and shortness of breath. I was on anticoagulants at the time and bled profusely into my mediastinum and then into my left pleural cavity. My systolic pressure was down into the 60's and I was life flighted to the closest trauma center 200 miles away. I ended up losing 4 liters of blood through the chest tube and was very lucky to survive. I was doing research on the internet about this complication and was surprised to see it does happen quite often. The ER physician was doing a blind approach instead of using ultrasound. I think it would of been prevented if he was using ultrasound or fluoro. But nothing I can do know. I guess just lucky to be alive. Thanks.

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  4. what do we do for a hematoma in femoral central line, do we have to remove the line and start another one , though this line was patent.patient's pt was 3 min and inr 15 .when do we remove the faulty line.

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  5. My sister had a central line inserted last week and they punctured her lung (they went in blind), her lung collapsed and now they have a tube to inflate it. The first time they put it in, it collapsed again, when they did any xray, they found the tube had fallen out, so they reinserted the tube and inflated the lung again. It's been 3 days now and they say the puncture is not healing and she may have gotten pneumonia now. She originally went in for a blocked intestine, which ended up clearing with the liquid they gave her during the cat scan. They put the central line in, because they were going to do surgery.

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  6. Anyone know of damage to the ulnar and radial nerves in addition to pnemohemothorax.

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  7. "Damage to the ulnar and radial nerves" are unlikely to happen due to placement of a central line because the anatomical location is totally different. A damage to the brachial plexus (which contains the roots for the ulnar and radial nerves) can occur but it is very rare. I hope this answers your question.

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  8. what's the best & inital step to do if during central line placement, there is a obvious subcutneous emphysema.How about if subcutaneous emphysema occurs post placement?

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  9. "what's the best & inital step to do if during central line placement, there is a obvious subcutneous emphysema"

    A: Remove the line.

    "How about if subcutaneous emphysema occurs post placement?"

    A: Examine the line on CXR, physically, and flush it. If operating properly, you can leave it in place. Monitor the size of the subcut. emphysema several times a day until resolution.

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  10. There was an interesting paper published in Critical Care just month or two ago about central lines. Apparently, the complications happen more often than we think.
    I have a blog post dedicated to this issue, if you are interested:
    http://realicu.com/content/complications-central-venous-line-placement-%E2%80%93-happens-more-often-we-think

    ReplyDelete
  11. Ralph,

    Complications with central line placement are not uncommon. Placement with U/S guidance is one approach to decrease them:

    http://clinicalcases.org/2009/03/central-line-placement-with-ultrasound.html

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  12. Thank you.
    I agree that significant complications (PTX) of the central line placement are quite rare. I am using US guidance in my practice. Interesting paper in the August issue of Critical Care Medicine - "An unseen danger: Frequency of posterior wall penetration by needles during attempts to place internal jugular vein central catheters using ultrasound guidance." indicates that even using US you are still not "immune" from complications.

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  13. If someone can answer this question for me. IF a patient is to receive a central line and they are on either LOvenox or blood thinners, and are at any risks of having bleeding problems, which would be the better optimal placement, subclavian, internal jugular or femoral?
    Especially with there being more infection risks with the IJ or femoral.
    Thanks

    ReplyDelete
  14. "IF a patient is to receive a central line and they are on either LOvenox or blood thinners, and are at any risks of having bleeding problems, which would be the better optimal placement, subclavian, internal jugular or femoral?"

    Femoral placement is preferred because one can compress the vein and stop the bleeding. You cannot compress the subclavian vein. Compression of the IJ is impractical and dangerous because of the juxtaposition to carotid artery.

    "Especially with there being more infection risks with the IJ or femoral."

    The IJ infection risk should not be much higher than subclavian.

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  15. We had a MD place a central line on my patient and it was arterial. The nurse had medications running for several hours until she realized it was arterial. Of course I understand this is the wrong placement, but what exactly is the damage that will happen placing this arterially and infusing meds?

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  16. Re: "what exactly is the damage that will happen placing this arterially and infusing meds?"

    It depends on the medications. See a few examples:

    http://www.ncbi.nlm.nih.gov/pubmed/10726331

    http://www.ncbi.nlm.nih.gov/pubmed/9350405

    http://www.mayoclinicproceedings.com/content/80/6/783.refs

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  17. "what exactly is the damage that will happen placing this arterially and infusing meds?"

    It depends on the medications. See a few examples:

    http://www.ncbi.nlm.nih.gov/pubmed/9350405

    http://www.ncbi.nlm.nih.gov/pubmed/10726331

    http://www.mayoclinicproceedings.com/content/80/6/783.refs

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  18. What are the long term adverse effects(real or potential) of a retained guide wire following the placement of a central IV line in the right internal jugular -- i.e., assume a fully intact guide wire (approx. 24 inches in length) was lost down the internal jugular vein such that today it resides fully intact inside the inferior venacava down into the right bifurcation of the femoral vein. Also, that the guide wire has been lodged inside the inferior vena cava (from heart to bifurcation level) for almost 9 years, and, presumed to be fibrosed along the intima of the vena cava.

    Is there a chance(s)(i.e., any risk or level of adversity)that after 9 years the retained guide wire can (nevertheless) still puncture the vena cava, breakdown and small physical parts migrate into the heart, or cause a stroke from pieces of fibrin surrounding the guide wire breaking free and migrating up into the vascular of the brain, etc., etc.

    Any comments or suggestions regarding potential and/or future complications or risks directly associated from a retained intravenous central line guide wire appreciated.

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  19. RN ICU...

    Is it safe to use a central line that was placed in the right subclavian vein and was passed into and ended up in the right internal jugular vein? Patient was on three vasopressors, two types of sedations, protonix drip, and sandostatin. The Dr. placing the line and the primary both approved of the lines being used, but fellow ICU nurses disputed their approvals. Any literature or studies I could read. Thank you for taking the time to read my question.

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  20. @ RN ICU asked

    "Is it safe to use a central line that was placed in the right subclavian vein and was passed into and ended up in the right internal jugular vein?"

    Sure. Though not ideal it is an acceptable line and would be safe. It's still venous and we place IJ lines after all. I would agree with the attendings and in the short term I would certainly use the original line for administering life sustaining medications even though it migrated into the IJ. In most cases the line would likely be changed over a wire and repositioned into SVC (a more appropriate location for a 'central line'), but sometimes you have to use what you have, particularly in the ICU setting.

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  21. Change the line. You don't need pressors going to the brain, they need to go to peripheral vessels. Use ultrasound when placing the next line to make sure it ends in the correct place - IJ or subclavian with the tip pointing down.

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  22. Have you seen any literature on placing a central line and hitting the aorta?

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  23. jeffery willis1/07/2013 11:18 AM

    I had a central line put in cause they could not find a vein for an iv drip.In the process the dr. hit a nerve and pain went down my left arm.Now I am not able to work because I now have neck and back pain.i also suffered from nausia an faint spells after the central line was put in place.have anyone ever had the same complaint

    ReplyDelete