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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2016  |  Volume : 27  |  Issue : 5  |  Page : 1052-1054
An unusual complication of malposition of left internal jugular catheter in a patient with chronic kidney disease


1 Department of Nephrology, Indo-US Hospital, Hyderabad, Telangana, India
2 Department of Anesthesia, Indo-US Hospital, Hyderabad, Telangana, India
3 Department of Cardiothoracic Surgery, Indo-US Hospital, Hyderabad, Telangana, India

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Date of Web Publication22-Sep-2016
 

How to cite this article:
Yadla M, Jalli M, Rao DP. An unusual complication of malposition of left internal jugular catheter in a patient with chronic kidney disease. Saudi J Kidney Dis Transpl 2016;27:1052-4

How to cite this URL:
Yadla M, Jalli M, Rao DP. An unusual complication of malposition of left internal jugular catheter in a patient with chronic kidney disease. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2019 Jul 17];27:1052-4. Available from: http://www.sjkdt.org/text.asp?2016/27/5/1052/190887
To the Editor,

Malposition is one of the complications of the central venous catheter insertion. Malposition with left internal jugular catheter is rarely reported in literature, probably due to lesser number of cannulations and underreporting of complications. Few case reports exist regarding straight descent of left internal jugular catheter in patients with chronic kidney disease.

Massive hemothorax is one of the fatal complications of the central venous cannulation, which is more common during the procedure. However, massive hemothorax following the removal of catheter is rare.

Here in, we report one such case hemothorax following the removal of the left internal jugular catheter.

A 56-year-old aged woman was admitted with complaints of altered sensorium. Evaluation revealed serum creatinine of 6 mg/dL and bilateral contracted kidneys. Computed tomography scan brain was within normal limits. Three sessions of hemodialysis were given through femoral access. After stabilization of her general condition, right internal jugular catheterization was unsuccessful due to hematoma after the arterial puncture. Subsequently, left internal jugular catheterization was done through the standard approach. After cannulation, there was flow from the arterial port but no flow from the venous port though blood could be easily pushed. A check X-ray of chest was taken [Figure 1]. This showed straight descent of the left catheter. The left lateral Xray showed the catheter to be in anterior mediastinum [Figure 2]. In view of malposition and malfunction, the catheter was removed. After 1 h, she developed altered sensorium, profuse sweating, and breathlessness. Blood sugars were 124 mg/dL and blood pressure (BP) was 60 mm Hg. Blood gas analysis showed hypoxia; electrocardiography was within normal limits. Chest X-ray showed haziness of the left hemothorax with mediastinal shift suggestive of massive pleural effusion vs. hemothorax [Figure 3]. Intercostal drainage was placed. One liter of blood was drained. Meanwhile, she was stabilized with inotropes, packed cell transfusion, and oxygen support. Within an hour of placement of intercostal drainage, there was slow improvement in BP and general condition, slowly, inotropes were weaned off. Next day, 200 mL of blood was drained. On the 3 rd day, drain was removed. A repeat X-ray chest was normal [Figure 4]. At discharge, she was stable and her serum creatinine was 4.2 mg/dL.
Figure 1: X-ray chest - PA view showing the straight descent of left internal jugular catheter.

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Figure 2: X-ray lateral view showing catheter location anterior to tracheal shadow.

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Figure 3: X-ray chest - PA view showing the left-sided massive hemothorax after removal of the jugular catheter.

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Figure 4: X-ray - posterior-anterior view showing expanded lung on the left side after intercostal drainage.

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Complications of internal jugular catheterization include arterial puncture. Ruesch et al reported more arterial punctures, less malpositions with internal jugular compared to subclavian cannulations. [1] The incidence of hemothorax was reported to be 1.3%. [1] The incidence of malposition and vascular perforations is more with left internal jugular catheter than with right internal jugular vein due to acute angulations of left internal jugular vein at two points, i.e., where it meets the subclavian vein and where it enters left brachio-cephalic vein, longer course, and smaller tributaries compared to the right vein.

Straight descent of the left internal jugular catheter on PA view of chest X-ray should be followed by lateral chest radiograph. On a PA view or AP view, if the catheter is located laterally, it may be in internal thoracic vein, if it is along, the aortic knob, then it may be in superior intercostal vein, and if it is along the cardiac border, then it is in the pericardiophrenic vein, whereas on lateral X-ray, if the catheter is in the anterior third of the mediastinum, it suggests the location to be in internal mammary vein. If it is in the middle third, the probable location may be pericardiophrenic vein, and if it is in the posterior third, the catheter may be in the superior intercostal vein. Placement in internal mammary vein may be associated with pleural effusion, chest wall abscess, and if in the pericardiophrenic vein may be present with cardiac tamponade. The presence of catheter in superior intercostal vein may be associated with back pain. If the catheter is in paramedian location on posterioranterior (PA) view and in middle mediastinum in lateral view, then it may be in the left-sided superior vena cava.

In our patient, the lateral film showed the catheter in anterior third suggesting the location to be internal mammary vein. Although she was asymptomatic after the placement of catheter, she developed hemothorax after its removal. This probably can be explained on the inadvertent creation of rent in pleural space which was completely sealed off by the catheter traversing across. Immediately after the removal, there was development of hemothorax through the rent in the pleural space.

Muhm et al reported the incidence of malpositions with left internal jugular access to be 4.12%, with right to be 1.1% and 2.53% with soft silicone catheters, and 0.79% with semirigid catheters. [2] Rather than the physician expertise, the type of catheter, anatomical approach is reported to be associated with malposition. Malposition of internal jugular catheter into subclavian vein, contralateral jugular vein, superior intercostal vein, reverse direction in subclavian vein, and accessory hemiazygos vein have all been reported.

Massive hemothorax is an unusual complication of malposition. Two cases were reported following the left internal jugular catheter in dialysis patients, one occurred 10 days after the removal of the catheter and in another case two days after placement of the catheter. [3],[4] In our case, massive hemothorax occurred immediately after the removal of the catheter. Early recognition and the appropriate management with chest drainage were lifesaving.

The points of interest in this case are threefold:

  1. Need for check X-ray after the central venous catheter placements
  2. Lateral chest X-ray to be done if straight descent of catheter is seen on PA view
  3. Early recognition and apt management of massive hemothorax are lifesaving.


Conflict of interest: None declared.

 
   References Top

1.
Ruesch S, Walder B, Tramèr MR. Complications of central venous catheters: Internal jugular versus subclavian access - A systematic review. Crit Care Med 2002;30:454-60.  Back to cited text no. 1
    
2.
Muhm M, Sunder-Plassmann G, Apsner R, et al. Malposition of central venous catheters. Incidence, management and preventive practices. Wien Klin Wochenschr 1997;109:400-5.  Back to cited text no. 2
[PUBMED]    
3.
Fraile P, Cosmes PG, García-Bernalt V, Tabernero JM. Late-onset hemothorax after left jugular vein catheterization for hemodialysis. Nefrologia 2008;28:115-6.  Back to cited text no. 3
    
4.
Ying-Chih L, Tung-Min Y. Delayed greatvessel perforation related to an indwelling haemodialysis catheter over the left internal jugular vein. Nephrology (Carlton) 2010;15: 780.  Back to cited text no. 4
[PUBMED]    

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Correspondence Address:
Dr. Manjusha Yadla
Department of Nephrology, Indo-US Hospital, Hyderabad, Telangana
India
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DOI: 10.4103/1319-2442.190887

PMID: 27752021

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