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Home , Central venous catheter, Cubital fossa

Occurring as a 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 From the and Department of , during intravenous feeding with a central venous University College Hospital and Medical School, are reported. The connection between intravenous adminis- Gower Street, London, United Kingdom tration sets and such is shown to be a danger area which requires further technological improvement. The world literature concerning this hazard is reviewed. (Sherwood Medical Intramedicut; Fig. 2).' This defect had ap- peared after a period of ten days. T HE EARLIEST OBSERVATION of the fatal potential of The catheter was immediately removed. The following day he was intravenous air was described in 1667 by Redi, the subsequently noted to have a monoplegia affecting the left leg. A Italian naturalist.'2 Beauchesne reported the first fatal myelogram was normal. This neurological problem is now resolving case of air embolism following surgery on the in and it is thought that this must have been caused by air embolism. 1818.4 Since then, this complication has been recorded following a variety of procedures.9'19 The use of central Discussion venous catheters directly exposes patients to this Air accidents occurring during transfusion have potentially fatal hazard. been well documented. 19 The exact dose ofintravenous 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 . 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 , (Bardic Intra- cath). 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 ofthe 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 re- quired laparotomy. During his postoperative course he developed a period of acute pulmonary insufficiency which subsequently re- solved. As he was being weaned from intermittent positive pres- sure ventilation, it was noted that his clinical condition suddenly deteriorated. He developed an unexpected tachypnoea and tachy- cardia. 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 375 376 PETERS AND ARMSTRONG Ann. Surg. o April 1978 is a theoretical risk of air embolism should this intro- ducing cannula be left in the 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 subse- quently died in the attempted proce- dure. Obviously, a secure occlusive 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 administra- tion 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 FIG. 2. Fracture in catheter hub. 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- rate at which air enters the circulation appears to be more important. A bolus of 100cc of air has been known to cause death.21 Tunnicliffe and Stebbing in 1916 TABLE 1. Accidental Air Embolism with Central Venous Catheter administered intravenous oxygen to three patients as a treatment for cyanosis.20 Their "'therapeutic" dose was Author Circumstance Comment 10 cc/min and "'toxic'" effects were noted at 20 cc/min. Levinsky'° 1969 Insertion Fatal They noted gurgling heart sounds and produced tran- Lucas" 1969 Disconnected CVP Fatal sient quadriplegia in one case. Needless to say, this catheter hub treatment has now ceased at Kings College Hospital. Hoshal'2 1969 Disconnected CVP Resuscitation Aubaniac2 and Yoffa22 both recognized the possi- catheter hub successful bility of air embolism when describing their tech- Hoshal'2 1969 Disconnected CVP Resuscitation niques of inserting central venous catheters. The catheter hub successful complication was noted by Baden, who reported three Flanagan'3 1969 Insertion Fatal cases in 1964.3 Air was heard to rush into the circula- tion, although no untoward reaction was noted. The Johnson'4 1970 Insertion Resuscitation first fatal air embolism occurring during the insertion of successful a central venous catheter was described in 1969 by Mattox'5 1970 Lacerated pleura Fatal bulla Levinsky.'3 A search of the literature revealed a total of 12 cases with four deaths (Table 1). Green"'6 1971 Disconnected CVP Transient CNS signs catheter hub Air embolism can occur with such catheters in a variety of ways. If a catheter is inserted into a vein Parsa'7 1974 Disconnected CVP Resuscitation exposed at the antecubital , and the retaining catheter hub successful ligature accidentally transfixes the vein; air can enter Ordway"8 1974 Disconnected CVP Resuscitation the circulation19 (Fig. 3). Also, during insertion of catheter hub successful catheters into neck , air embolism can easily Grace7 1977 Disconnected CVP Left hemiplegia and occur;3"13 and to avoid this the patient must be placed catheter hub subsequent death in a Trendelenburg position and turned slightly towards Grace7 1977 Disconnected CVP , transient left the selected site of catheterization.'3 In patients with catheter hub hemiplegia severe and tachypnea, it would be safer Armstrong' 1977 Fracture of CVP Nonfatal, transient catheter hub left lower limb to introduce a long catheter through a vein in the ante- monoplegia cubital fossa. Furthermore, with apparatus where the Peters 1977 Disconnected CVP Fatal catheter is placed through an introducing plastic catheter hub cannula, e.g., Sherwood Medical Intramedicut, there Vol. 187 * No. 4 AIR EMBOLISM FROM CATHETERIZATION 377

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 on the tap is unprotected in case this is inadvertently left in FIG.l5l~~.Taleti opnpoto. the "open" position (Fig. 5). If no tap is used, when the patient must lie supine during changes of the infu- sion 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 ofdh sivefstraping doe lite to imrv sft. 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 gad..at Tapareftic taedy". ideTh deh are usually discovered by the staff as a ""leak." In our cases, because of the patient's respiratory efforts, air embolism occurred. If the technique de- scribed by Benotti and Blackburn5 is used, then ex- treme 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 scribedangreothe resut ofl falt thechnology. Thus,o catheter hub with a hemostat. There is obviously a thereiosWes omthakM.cturKrs.qalneed for sthisnforwlkinesnfof equispmentitoaConstSeureon.beui- danger of inducing a minute fracture in the plastic poveandeiv perhapsinstnadoeizted. mpoesaey material which could subsequently appear following a period of hyperalimentation. Theprvisonofackinowlethedgm uents c ecans The deaths among the cases described provide ample evidence that this vital junction between central Colgeu osialrono,doallowingiusticlatoaeyrhepr deataisofteir scasbes; Proeso K.e Simsuton forurovdin tehisnostortem report andFigre 3;aned Motiss SarahoH qipensatoher sertaial VFIN assist ance. hpssadadzd C' r

c~~~~~~~~~~C St. Peters,JL and Cohen S.L.: Airon Emboivesmt C Aermestrong,tR., L ' L CadFiused by Factureds Cenral Venoshl Cathetr. Lancretara SKIN

PLASTIC INTRODUCING CANNULA 1:954, 1977. 2. Aubaniac, R.: L'Injection Intreveneuse Sous Claviculaire, Advantages and Technique. La Presse Medicale, 60:1456, 1952. FIG. 4. Theoretical hazard of air entering via introducing cannula 3. Baden, H.: Perkutan Kateterisation of V. Subclavia. Nord. left in situ. Med., 71:590-593, 1964. 378 PETERS AND ARMSTRONG Ann. Surg. * April 1978 4. Beauchesne: Physiological Researches into Life and Death by Suggested Method of Treatment. Am. J. Clin. Pathol., F.M.X. Bichat with notes by F. Magendie, Boston, 188, 21:247, 1951. 1827. 13. Levinsky, W. J.: Fatal Air Embolism During Insertion of CVP 5. Benotti, P. N., Blackburn, G. L. et al.: Safe Cannulation of Apparatus. JAMA, 209:966, 1969. The Internal For Long Term Hyperalimenta- 14. Lucas, C. E. and Irani, F.: Air Embolus via Subclavian tion. Surgery, Gynaecology and Obstetrics. Vol 144, 574, Catheter. N. Engl. J. Med., 281:966, 1969. 1977. 15. Mattox, K. L. and Bricker, D. L.: Air Embolism Following 6. Flanagan, J. P. and Kelly, T. R.: Letter to the Editor. N. EngI. Catheterization. Tex. Med., 66:74, 1970. J. Med, 281:1426, 1969. 16. Ordway, C. B.: Air Embolus via CVP Catheter Without 7. Grace, D. M.: Air Embolism With Neurological Complications. Positive Pressure-Presentation of Case and Review. Ann. A Potential Hazard ofCentral Venous Catheters. Can. J. Surg. Surg. 179:149, 1974. 20:51, 1977. 17. Parsa, M. H.: Safe Central Venous Nutrition. Springfield, 8. Green, H. L. et al.: Air Embolism as a Complication During Charles C Thomas, 1974. p. 68. Parenteral Alimentation. Am. J. Surg., 121:614, 1971. 18. Paskin, D. L., Hoffran. W. S. and Tuddenham, W. J.: A New 9. Hazard Health Notice; HN (76) 74. Department of Health and Complication of Subclavian Vein Catheterisation. Ann. Social Security. Warning against the use of non-vented semi- Surg., 179:266, 1974. rigid containers when using a positive displacement pump 19. Simpson, K.: Air Accidents during Transfusion. Lancet, 1: to administer intravenous fluids. 697, 1942. 10. Hoshal, V. L. Jr. and Fink, G. G.: The Subclavian Catheter. 20. Tunnicliffe, F. W. and Stebbing, G. F.: Intravenous Injection of N. EngI. J. Med., 281:1425, 1969. Oxygen Gas as Therapeutic Measure. Lancet, 2:321, 1916. 11. Johnson, C. L. et al.: Subclavian : Preventable 21. Yeakel, A. E.: Lethal Air Embolism from Plastic Blood Complications; Report of Two Cases. Mayo Clin. Proc., 45: Storage Container. JAMA, 2(04:267, 1969. 712, 1970. 22. Yoffa, D.: Supraclavicular Subclavian Venepuncture and 12. Larsen, C. P.: Venous Air Embolism. Report of Four Cases. Catheterisation. Lancet, 2:614, 1965.