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Hemodialysis catheter insertion: is increased PO2 a sign of arterial cannulation? A case report
© Chirinos et al.; licensee BioMed Central Ltd. 2014
Received: 15 March 2014
Accepted: 22 July 2014
Published: 29 July 2014
Ultrasound-guided Central Venous Catheterization (CVC) for temporary vascular access, preferably using the right internal jugular vein, is widely accepted by nephrologists. However CVC is associated with numerous potential complications, including death. We describe the finding of a rare left-sided partial anomalous pulmonary vein connection during central venous catheterization for continuous renal replacement therapy (CRRT).
Ultrasound-guided cannulation of a large bore temporary dual-lumen Quinton-Mahurkar catheter into the left internal jugular vein was performed for CRRT initiation in a 66 year old African-American with sepsis-related oliguric acute kidney injury. The post-procedure chest X-ray suggested inadvertent left carotid artery cannulation. Blood gases obtained from the catheter showed high partial pressure of oxygen (PO2) of 140 mmHg and low partial pressure of carbon dioxide (PCO2) of 22 mmHg, suggestive of arterial cannulation. However, the pressure-transduced wave forms appeared venous and Computed Tomography Angiography located the catheter in the left internal jugular vein, but demonstrated that the tip of the catheter was lying over a left pulmonary vein which was abnormally draining into the left brachiocephalic (innominate) vein rather than into the left atrium.
Although several mechanical complications of dialysis catheters have been described, ours is one of the few cases of malposition into an anomalous pulmonary vein, and highlights a sequential approach to properly identify the catheter location in this uncommon clinical scenario.
Central venous catheterization (CVC) using a large bore catheter (>7 French) is widely used in renal patients for hemodynamic monitoring, rapid infusion of fluids and blood products, antibiotic administration, parenteral nutrition, and vascular access for hemodialysis and continuous renal replacement therapy (CRRT). Ultrasound (US)-guided CVC for temporary vascular access, preferably using the right internal jugular vein (IJV), is widely accepted by nephrologists . Compared to the subclavian approach, right IJV is the preferred site because of easier catheterization, high rate of success when using only anatomical landmarks of the sternocleidomastoid muscle, and straighter path to the superior vena cava . However CVC is associated with numerous potential complications, including death. Most mechanical complications occur early, during the puncture of the target vessel or catheter advancement, with subsequent development of hemorrhage, pseudoaneurysms, arteriovenous fistula, arterial dissection, neurological injury and severe or lethal airway obstruction [3, 4]. Therefore, nephrologists and nephrology trainees should not only be trained in temporary vascular access placement, but also be informed about techniques to identify or differentiate successful venous punctures from arterial punctures, as well as how to prevent and manage procedure-related complications [1, 2].
Over 5 million catheters are placed annually in the United States, most of the time for hemodialysis procedures . In comparison to traditional blind CVC insertion techniques using superficial anatomical landmarks, CVC under US guidance achieves higher success rates, including fewer needle attempts, rapid vein localization and fewer complications [7, 8]. However, inadvertent arterial trauma or cannulation under US guidance still occurs. Among the various mechanical complications of CVC, unintended arterial puncture has been reported to occur in up to 8% of cases . Because this complication is often recognized by getting pulsatile, bright red blood before the catheter is introduced into the blood vessel, inadvertent arterial catheterization is much less common, <0.1% [2, 4]. In most cases of misplacement, the catheter follows an unpredicted pathway into the vena cava tributaries, a complication observed in 40 cases of a series of 2,580 patients. In three of these patients, the aberrant location resulted from a persistent left superior vena cava . The risk factors associated with CVC complications include obesity, short neck and urgent catheterization .In patients with hypotension, low hemoglobin and hypoxemia, the visual signs of pulsatile, bright red blood suggestive of arterial puncture might be missed [2, 4, 10].
Stepwise approach to differentiate true venous placement from inadvertent arterial cannulation following dialysis catheter insertion
Do not remove the catheter
Attach a pressure transducer to the catheter and discriminate between venous and arterial waveforms*
Perform blood gas analysis (high PO2 is suggestive of arterial blood)**
Obtain Chest X-ray (frontal and lateral)
If still in doubt, obtain Computed Tomography Angiography***
Surgical or endovascular intervention if arterial cannulation is confirmed
If arterial trauma with a large caliber catheter occurs, prompt surgical or endovascular intervention is likely the safest approach. The pull and pressure technique (removal of the catheter followed by external compression) is associated with significant risk of hematoma, airway obstruction, stroke and pseudoaneurysm, especially when the site of the arterial trauma cannot be effectively compressed. Endovascular treatment appears to be safe for the management of arterial injuries that are difficult to expose surgically, such as those below or behind the clavicle .
Our patient had a partial anomalous pulmonary venous connection (PAPVC). PAPVC is a congenital anomaly present in 0.4 to 0.7% of postmortem examinations. About 90% of all PAPVCs originate from the right lung, 7% from the left lung and 3% from both lungs. The common drainage sites are the superior vena cava, the inferior vena cava, right atrium and brachiocephalic (innominate) vein [12, 17, 18]. Most of these anomalies are discovered incidentally during routine radiographic evaluation of the lungs done for other reasons. In isolated PAPVC, the patient is usually asymptomatic if anomalous venous return is less than 50% of total pulmonary venous blood. Some patients could develop cardio-respiratory symptoms if there is significant left-to-right shunt, which is associated with other cardiac anomalies (10 to 15% of those with atrial septal defects have PAPVC). The majority of patients with a left PAPVC, as in the case of our patient, have a good long term prognosis .
In summary, the placement of a dialysis catheter in a vein draining pulmonary venous blood due to anomalous pulmonary venous connection may lead to apparent arterial cannulation (high PO2 in blood gas analysis). Our case highlights the available methods to properly identify the catheter location in a patient with a rare congenital pulmonary vascular malformation and the importance of prompt Computed Tomography Angiography for definitive diagnosis before surgical or invasive interventions.
The patient was deceased at the time of preparation of this manuscript. Written informed consent was obtained from his next-of-kin for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.
The authors express their gratitude to Monique Clark for expert graphic assistance. ARR is supported by the NIDDK (DK091316) and the American Society of Nephrology Gottschalk Award.
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