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Migration of feeding line
- Harshal D Wagh, Dr.Valerie Page (8 January 2007)
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Migration of central venous catheter
- Nigel A White (15 September 2006)
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Tension hydrothorax induced by migration of central venous catheter
- N SAXENA (11 September 2006)
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Re Tension Hydrothorax induced by central venous catheter migration in a patient with burns.
- Andrew R Bodenham (11 September 2006)
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Harshal D Wagh, SHO Anaesthetics , Dr.Valerie Page
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I read with interest the article in BJA sept 2006;97:423-424. We would like to report a similar incident where there was migration of a feeding line to the mediastinum. A 48 year old lady ASA 2 underwent D2 total gastrectomy and splenectomy for tumour at the Gastroesophageal Junction .It was a difficult prolonged surgery with a large blood loss and deranged clotting towards the end of the surgery As a result she was admitted to ITU with the Double lumen tube(DLT) in situ. A pharyngostomy and tube change was deferred till the clotting was corrected.The next day after clotting was corrected the DLT was changed to an endotracheal tube and a feeding line (nutricath) was inserted in the right Subclavian vein after two attempts. The procedure was uneventful with a good backflow of blood through the port and was flushing well. It was primed with hepsaline and post procedure xray chest was normal. So feeding was commenced through the line-nutriflex 2500ml. over 24hrs. Overnight the patient started to have decrease in tidal volume and increased oxygen requirement. On auscultation there were coarse crepts with reduced air entry on the right side.Xray revealed a white-out of the right lung field. Aspiration through the nutricath showed nutriflex .A ultrasound of the chest revealed large right.pleural effusion and small left pleural effusion.A right sided chest drain inserted drained 3.5 lts of fluid. The hemodynamics and airway pressures rapidly improved after the drain.Xray post drain insertion was almost normal with near complete expansion of the affected lung.The patient improved and was weaned off the ventilator over the next few of days and extubated without any further problems. Thus inspite of an uneventful procedure, evidence of correct placement and adequate fixation there was migration of the catheter to the mediastinum Dr.Harshal Wagh SHO- Anaesthetics Dr.V. Page Consultant- Anaesthetics/ITU Watford General Hospital Email-drhdw@yahoo.com Conflict of Interest:None declared |
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Nigel A White, Anaesthetist
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I read with interest the letter of Maisniemi and Koljonen in the September issue of the BJA 1. The problem of migration of central venous lines is not new. Experience in our institution has taught us that merely fixing the catheter to the skin with the detatchable fixation device provided is not adequate. It is relatively easy to remove the line and leave the fixation device still attached to the skin. For this reason we always advocate 4 point fixation, i.e. fixation at the puncture site with the detatchable fixation device and also at the hub at the fixed suture point. We have found that if this is done catheters do not migrate. I appreciate that in the case described by Maisniemi and Koljonen with burns a second set of sutures may be viewed as an additional infection risk. In this case I would suggest suturing the detachable fixation device to the skin and then suturing this to the fixed suture point on the hub of the line. If this is done loosely so as not to kink the catheter it anchors a fixed point on the line, namely the suture point at the hub, to the skin and makes displacement much less likely. References 1. Maisniemi KJ, Koljonen VS Tension hydrothorax induced by central venous catheter migration in a patient with burns. Br J Anaesth 2006;97:423-424 Conflict of Interest:None declared |
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N SAXENA Cardiff, UK
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Editor-I read with interest the article by Maisniemi and Koljonenin-1 about the development of a tension hydrothorax following a central venous catheter migration. Catheter migration, both primary and secondary may occur and their reported incidence varies from 1.7 % to 26%- 2. We recently encountered a scenario where a patient receiving an infusion of noradrenaline, through a right internal jugular central venous catheter (CVC), previously stable, developed hypotension following a ‘wash and change of sheets’. This was refractory to even higher doses of the same infusion running through the proximal infusion port of our CVC. Inability to aspirate blood through the proximal lumen suggested that the catheter had migrated proximally. Attaching the infusion to the distal lumen, which was still aspirating freely, corrected the hypotension. This highlights that the only definitive proof of a CVC being in a vessel (vein, hopefully) is the ability to aspirate blood freely through all its lumens. This fact lends itself to a recommendation of frequent checking of lumens for free backflow to confirm its intravascular position. The difficulty in checking the lumens frequently by aspirating would however involve stopping the infusions, aspirating and then waiting as the infusion fills up the dead space of the lumens. This may result in temporary instability in those patients where a precarious balance between vasopresors, inotropes and sedation has been achieved. However the risk of this approach should be considered against the potential risk of infusing potentially necrotic drugs or large fluid volumes in the extravascular/ intra-pleural space. So i would recommend adoption of a practice of check- aspirating all the lumens of a CVC, where possible, on at least a once daily basis and using the distal lumen preferentially for the more vital infusions. References 1. K. J. Maisniemi, V. S. Koljonen. Tension hydrothorax induced by central venous catheter migration in a patient with burns.Br J Anaesth 2006; 97: 423-24 2. Vazquez RM, Brodski EG. Primary and secondary malposition of silicone central venous catheters. Acta Anaesthesiol Scand Suppl 1985; 81: 22–6 Conflict of Interest:None declared |
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Andrew R Bodenham Dept Anaesthesia, leeds General Infirmary
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Editor. I read with interest the case report (1). It is relevant to try to understand how the exit hole of the proximal lumen of the multilumen catheter came to lie in the pleural space whilst the exits of the two distal lumens lay within the vein, as described by the authors. In my opinion this could only occur if the sharp introducing needle entered the pleural space first and then left this space to enter the vein. Thereafter the guidewire, dilators and multilumen catheter would follow the same course. It is possible that the jugular vein was traversed prior to pleural puncture. Presumably the proximal lumen was initially intravascular and then connected with the pleural space as the catheter migrated outwards. It is unlikely that this misplacement could have been caused by guidewire, dilator, or catheter misplacement after initial correct needle placement. An alternative hypothesis is that the proximal lumen exit lay outside the vein and the pleural space, and fluid was infused under pressure into the tissues adjacent to the pleura, and this fluid collection then subsequently tracked into the pleural space. It is then pertinent to question how a needle enters the pleural space during attempted internal jugular cannulation and how it can be avoided. In the average adult neck the internal jugular vein is superficial within 2cm of the skin. Study of anatomical cross sectional images or thoracic CT or MRI shows how the dome of the pleura extends higher into the neck than often appreciated, but its apex is relatively posterior in relation to the jugular vein (2). Puncture of the pleura is more likely with low puncture sites, deep penetration with the needle and multiple needle passes. A puncture site that penetrated first the pleura and then the vein close by, as reported in this case, suggests the needle tip must have been deep within the thoracic inlet. It is only on descending to the level of the 1st to 2nd thoracic vertebra, behind the clavicle and below the first rib, that the right internal jugular vein/right brachiocephalic vein lie in close proximity to the pleura. The greater part of the length of a standard 6-7cm introducing needle will have been needed to be inserted, for the tip to reach this position, from the cited skin puncture site 3cm above the clavicle. The number of needle passes was not specified, and I presume ultrasound guidance was not used. Such problems related to needle puncture are nearly always avoidable with the routine use of ultrasound guidance by an operator competent in its use. Ultrasound allows first pass needle puncture into the centre of a suitable patent vein, utilising the shortest possible route to the vein, and choosing a puncture site which does not overlie any vital structures like the carotid artery and pleura. Ultrasound guidance is now recommended for this purpose in the UK (www.nice.org.uk) (3,4). Are other countries following this course? Dr AR Bodenham. Consultant in Anaesthesia and ICM Leeds General Infirmary Leeds LS1 3EX. UK 1. Maisniemi KJ Koljonen VS. Tension hydrothorax induced by central venous catheter migration in a patient with burns. Br JAnaesth 2006; 97: 423-424 2. Ellis H, Logan BM, Dixon A. Human cross-sectional anatomy. Atlas of body sections and CT images. Butterworth-Heinemann, Oxford, 1991, p76-79. 3. Hind D, Calvert N, McWilliams R et al. Ultrasonic locating devices for central venous cannulation: meta analysis. BMJ 2003, 327: 361. 4. National Institute for Clinical Excellence. Guidance on the use of ultrasound locating devices for central venous catheters (NICE technology appraisal, No. 49.) London: NICE, 2002. Conflict of Interest:None declared |
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