GA2-56
Vascular injury during central venous access insertion under general anesthesia
Levey T, Coalson D
University of Chicago, Chicago, IL, USA
Introduction: Central line placement in children under general anesthesia carries a low rate of serious complications (1). However, complications during placement can require extensive intervention.
Case: A two-year-old with a new renal mass undergoing right internal jugular (IJ) port placement for chemotherapy. No prior anesthetics. Starting hemoglobin was 10.2 g/dL and platelets and coagulation labs were within normal limits. Mask induction with sevoflurane (sevo) was followed by insertion of a 22 g IV and tracheal intubation. The patient was unreactive during incision and creation of the subcutaneous tunnel with an end-tidal sevo of 3.5%. While the dilator and split sheath were being inserted, the patient coughed and desaturated. There was normalization of saturation and no further movement after a bolus of propofol. Fluoroscopy showed the wire still within the superior vena cava (SVC). The wire was removed and the catheter was placed through the sheath. Blood was unable to be aspirated, so the wire was replaced and found to be outside the SVC. The catheter and wire were removed in preparation for another attempt, however x-ray showed a hemothorax. A chest tube was placed with 300 mL of blood return. Blood pressure (BP) initially fell but responded to administration of fluid and PRBCs. A new right IJ catheter was placed. TTE was performed to rule out cardiac tamponade. After a period of stable BP and minimal chest tube drainage the decision was made to extubate the patient. After extubation the patient became hypotensive and again had significant chest tube output. After re-intubation, additional IVs and an arterial catheter were placed and a thoracotomy performed. During thoracotomy, the patient became profoundly hypotensive and bradycardic requiring extensive fluids, blood products, ACLS medications, multiple defibrillations, and cardiac massage. Spontaneous circulation returned, but without recovery of a normal oxygen saturation, leading to the decision to go on VA ECMO. After cannulation, the patient had return of saturations to baseline, adequate BP, and a final hemoglobin of 8.3 (from a nadir of 3.8). Care was later withdrawn in light of severe neurologic injury.
Discussion: Vascular injury with line placement is rare, but associated with a high rate of mortality (2). Alternate approaches may have resulted in a different outcome, but there is not much evidence to guide management in pediatric patients. Presumably, the catheter could have been left in place pending vascular surgery consult for removal. The extubation of the patient and resulting negative pleural pressure and increased patient movement could conceivably have contributed to the second round of bleeding from the vascular injury. Even with the advantage of being in the operating room and the ability to intervene extensively, this case demonstrates the potentially catastrophic nature of vascular injuries during central line placement.
1 Malbezin S, Gauss T, Smith I, et al. A review of 5434 percutaneous pediatric central venous catheters inserted by anesthesiologists. Pediatric Anesthesia. 2013;23(11):974-979.
2 Askegard-Giesmann JR, Caniano DA, Kenney BD. Rare but serious complications of central line insertion. Seminars in Pediatric Surgery. 2009;18(2):73-83.
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