If you wish to respond to a paper or other item already published in the BJA, please go to the abstract/full text version of that item and click on the link "E-Letters: Submit a response to the article".
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Entrapped central venous catheter
- prakash k. dubey (16 February 2007)
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Reply to the questions
- Jayesh Dhanani, Siva Senthuran, R. Boots, Jeffrey Lipman (19 January 2007)
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Won the battle but lost the war ?
- Dr V Paul, UK (4 January 2007)
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prakash k. dubey
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While describing an interesting complication, the authors,J. Dhanani et al (1), have proposed a useful algorithm. I agree to their conclusion that clinicians should be aware of this possibility during such an insertion. I wish to add a few preventive aspects of this procedure to the algorithm; If possible avoid multiple cannulation of a single vein. Use imaging guidance, if available. Attempt second insertion at a more peripheral site (2). Suspect this complication if unusual resistance is encountered followed by a feeling of giving way during the isertion of introducer needle. Awareness and caution are necessary to avoid serious sequelae. Ref. 1.J. Dhanani et al. The entrapped central venous catheter. Br J Anaesth 2007; 98:89-92 2. Dubey PK. Venous double cannulation: avoiding complications. Anesth Analg 2001;93(4):1080 Conflict of Interest:None declared |
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Jayesh Dhanani, Intensive care fellow Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital Brisbane, Australia, Siva Senthuran, R. Boots, Jeffrey Lipman
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We thank Dr Paul for the concerns raised and the Editor for the opportunity to respond. In reply: 1. 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, following 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. 2. 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. 3. Lastly, we would like to point out that though this battle was with venous access, the war is always for a good patient outcome and fortunately both were won. Conflict of Interest:None declared |
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Dr V Paul York Hospital, UK
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Editor - The case presented formed an interesting and informative read. I commend the authors on the careful way in which they handled the situation. However there are a couple of points that struck me :- 1) 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 ? Doesn't this defeat the very purpose for which the whole exercise was started ? 2) In the management algorithm, the method of continuous gentle traction seems like one that could go either way ; couldn't this also gradually increase the tear and end up with what you wanted to avoid in the first place - a complete fracture ? Conflict of Interest:None declared |
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