Entrapped central venous catheter
York, UK
E-mail: drvarghesepaul{at}yahoo.com
Editor—The case presented by Dhanani and colleagues1 formed an interesting and informative read. I commend the authors on the careful way in which they handled the situation. However, a couple of points struck me:
- The main reason for putting in a new catheter was the suspicion that the old one could have been infected. So if the new catheter had passed through the old (‘supposedly infected’) catheter, was it wise to leave the new one in situ? Surely this defeats the very purpose for which the whole exercise was started?
- In the management algorithm, the method of continuous gentle traction seems like one that could go either way, in that this could also gradually increase the tear and end up with what you wanted to avoid in the first place—a complete fracture?
Brisbane, Australia
* E-mail: j.lipman{at}uq.edu.au
Editor—We thank Dr Paul for the concerns raised and the Editor for the opportunity to respond. In reply, there is concern regarding the new catheter becoming contaminated by the old. Though there are different ways for line-related infection to develop (contaminated hub, insertion site infection, blood stream infection, etc.), we cannot find any evidence for catheter entrapment increasing the risk of infection. We do not believe our approach posed any greater risk than the common practice of inserting a new line prior to removal of the older one even when they may brush against each other in vivo. Furthermore, after one major procedural complication, we felt it prudent to leave the new line in situ and consider a line change only if there were ongoing concerns of catheter-related sepsis. Fortunately, the patient improved clinically and was discharged without further complications.
With regard to the management algorithm, the approach was formulated after considering the extent of the fracture, the degree of entrapment, and the available institutional resources. There were also concerns regarding the volume of contrast media needed as more would be required if catheter manoeuvring was attempted. We believe gentle traction would be appropriate as a first line intervention in cases with minimal entrapment (<25% of circumference) and fracture.
Reference
1 Dhanani J, Senthuran S, Olivotto R, Boots RJ, Lipman J. The entrapped central venous catheter. Br J Anaesth (2007) 98:89–92.
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