An unusual complication of central venous catheterization

Vignesh Kumar Chandiraseharan; AR Malathy

doi:10.4103/2348-3334.158715

CASE REPORT

Year : 2015 | Volume : 2 | Issue : 3 | Page : 276-278

An unusual complication of central venous catheterization

Vignesh Kumar Chandiraseharan, AR Malathy
Department of Internal Medicine, ESIC Medical College, PGIMSR and Model Hospital, KK Nagar, Chennai 78, Tamil Nadu, India

Date of Web Publication

12-Jun-2015

Correspondence Address:
Dr. Vignesh Kumar Chandiraseharan
Senior Resident, Department of Internal Medicine, ESIC Medical College, PGIMSR and Model Hospital, KK Nagar, Chennai 78, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2348-3334.158715

Abstract

An 87-year-old female, a known case of diabetes mellitus was admitted with acute febrile illness with altered sensorium and uncontrolled hyperglycemia. She was evaluated and diagnosed to have urosepsis, septic shock and lactic acidosis. In view of the difficulty in securing a peripheral intravenous line, a central venous catheterization was performed. Though nonpulsatile venous blood was aspirated from the needle initially, blood stained serous fluid was aspirated after insertion of the catheter. The fluid was analyzed and found to have high triglyceride concentration suggesting that it was lymph. A chest X-ray was taken which too confirmed malposition of the catheter. This case represents a rare complication of right thoracic duct cannulation during central venous catheterization of the right internal jugular vein (IJV), when anecdotal reports advice preferring right IJV to left in view of possible thoracic duct cannulation.

Keywords: Central venous catheterization, right lymphatic duct, internal Jugular vein

How to cite this article:
Chandiraseharan VK, Malathy A R. An unusual complication of central venous catheterization. CHRISMED J Health Res 2015;2:276-8

How to cite this URL:
Chandiraseharan VK, Malathy A R. An unusual complication of central venous catheterization. CHRISMED J Health Res [serial online] 2015 [cited 2022 May 18];2:276-8. Available from: https://www.cjhr.org/text.asp?2015/2/3/276/158715

Introduction

Central venous catheterization is an essential procedure in the intensive care unit. Though it is a safe procedure in trained hands, complications are not uncommon. One such rare complication has been described in this case report where right internal jugular vein catheterization resulted in inadvertent right thoracic duct cannulation. This case report also emphasizes the need for routine use of ultrasonographic guidance for such procedures to minimize the incidences of such complications.

Case Report

An 87-year-old female, a known case of diabetes mellitus on irregular treatment was brought to our institution with fever of 3 days duration and altered sensorium for the past 2 days. She was febrile, dehydrated, had tachycardia and tachypnea. Her renal parameters were elevated, leukocytosis was present and arterial blood gas analysis revealed high anion gap metabolic acidosis. Serum lactate levels were elevated. Urine and blood cultures revealed the presence of urosepsis. She was treated with intravenous fluids, culture appropriate antibiotics and insulin. She developed an extensive ecchymosis around the sites of intravenous cannulation as a consequence of severe sepsis following which she went in for septic shock. As a secure intravenous line was required, central venous catheterization was planned.

The right internal jugular vein (IJV) was cannulated using modified Seldinger's technique. Nonpulsatile blood was aspirated from the needle, and the guide wire was passed with minimal resistance. The central venous catheter was inserted over the guidewire and secured. The three ports were flushed with heparin saline. Reaspiration from the ports was done to confirm the position of the catheter. The aspirate obtained was serosanguinous rather than venous blood [Figure 1]. Though about 5-10 ml of heparinized saline only was used, the aspirate was repeatedly serosanguinous confirming malposition of the catheter [Figure 2]. The fluid was analyzed biochemically which revealed a high triglyceride concentration suggesting that it was lymph. A chest X-ray was performed which also confirmed malposition of the catheter. Hence, the catheter was removed, and the left external jugular vein cannulated for resuscitation. A repeat check X-ray after 12 h showed no evidence of any complications such as a pleural effusion or a pneumothorax. In spite of treatment, her general condition worsened and she succumbed to her illness 5 days later.

Figure 1: Photograph showing serosanguinous fluid aspirated from central venous catheter port

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Figure 2: Chest X-ray posterioranterior view showing central venous catheter misplaced and positioned away from the cardiac shadow

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Discussion

The right lymphatic duct is about 1.25 cm in length, courses along the medial border of the scalenus anterior at the root of the neck and ends in the right subclavian vein, at the angle of its junction with the right IJV [Figure 3]. Its orifice is guarded by two semilunar valves, which prevent the passage of venous blood into the duct. The right lymphatic duct receives the lymph from the right jugular trunk, the right subclavian trunk and the right bronchomediastinal trunk. These three collecting trunks frequently open separately in the angle of union of the two veins.

Figure 3: The relationship between the right lymphatic and thoracic duct and venous system. Courtesy: 2011 Pearson Education, Inc.

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The thoracic duct conveys the greater part of the lymph and chyle into the blood. It is the common trunk for all the lymphatic vessels of the body, excepting those on the right side of the head, neck, and thorax, and right upper extremity, the right lung, right side of the heart, and the convex surface of the liver. It extends from the second lumbar vertebra to the root of the neck. It begins in the abdomen as the cisterna chyli, and enters the thorax through the aortic hiatus of the diaphragm, and ascends through the posterior mediastinal cavity. Opposite the fifth thoracic vertebra, it inclines towards the left side, enters the superior mediastinal cavity, and ascends passing into the neck about 3 or 4 cm above the clavicle and ends by opening into the angle of junction of the left subclavian vein with the left IJV. The thoracic duct has several valves with two at its termination. ^[1]

The possible mechanisms of misplacement are an atypical insertion site of the thoracic duct at the dorsocaudal wall of the left innominate vein and a possible incompetent closing valve. The incidence of misplacement is determined by the number of needle passes, difficulty in establishing access, operator experience, poor anatomical landmarks and the number of previous catheter placements. Migration of central venous catheter is different from malposition and it occurs due to fracture and embolization of fragments of catheter. It can be precipitated by increased intrathoracic pressure due to coughing, sneezing or weight lifting, changing the body position or by physical movements such as abduction or adduction of the arms. Accidental thoracic duct cannulation has been a rare but documented complication during IJV cannulation predominantly on the left side ^{[2],[3],[4],[5],[6],[7]} though it has been reported even on right IJV catherization. ^[8] Ultrasound guided placement of central venous catheter is presently the standard of care for difficult central venous catheterization and it markedly reduces the incidence of catheter malpositioning, though there are few incidences of malposition reported in spite of it being used. ^[9] There are reports of incidences of thoracic duct injury occurring with catheterization of subclavian vein too. ^{[10],[11],[12]} Some authors advocate preferring right IJV to the left due to higher incidence of thoracic duct injury with left IJV catheterization. ^[13],[14] Thoracic duct injury or cannulation with infusion of fluids have resulted in various deleterious consequences such as chylothorax, hemothorax, cardiac tamponade and constrictive pericarditis. ^[15] Right lymphatic duct cannulation is a much rarer complication, but has been reported during the insertion of Swan-Ganz catheter ^{More Details}, though not with any deleterious consequence. ^[16] In our case too, no deleterious consequence occurred due to right thoracic duct injury but the patient succumbed to her illness.

Malposition of central venous catheter can be identified by the absence of bloody aspirate from the ports, chest radiograph and central venous pressure (CVP) tracing. In our case, a chest X-ray was taken which confirmed malposition and the serous fluid aspirate which was sent for analysis had a high triglyceride concentration suggesting it was lymph. CVP tracing was not necessary as blood was not aspirated at all. catheter tip malpositions can be identified by chest radiography. Some authors advocate routine chest radiography after jugular catheterization to detect catheter tip malposition and related complications. ^[17],[18]

Conclusion

Lymphatic duct injury though a rare complication, is to be expected during central venous catheterization. Chest radiography is mandatory after central venous catheter placement especially if malposition is suspected. Though lymphatic duct injury or cannulation commonly occurs during left IJV catheterization, it is not immune to injury during right IJV catheterization even in situs solitus. The advocation of preferring right IJV catheterization to left just to prevent lymphatic duct injury needs reconsideration. Ultrasound guided insertion should be preferred during central venous catheterization, especially when there is a difficulty in establishing access due to poor anatomical landmarks, previous catheter placements and inexperienced personnel to prevent such adverse incidences. In addition to that early identification of malposition and retrieval is necessary to prevent undue complications.

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