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LETTER TO EDITOR
Year : 2019  |  Volume : 63  |  Issue : 2  |  Page : 157-159  

Displaced paediatric central venous catheter causing extravasation of intravenous fluid due to relatively longer gap between the distal and proximal lumens


1 Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Paediatric Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Web Publication11-Feb-2019

Correspondence Address:
Dr. Mridul Dhar
Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_674_18

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How to cite this article:
Govil N, Dhar M, Masaipeta K, Ahmed I. Displaced paediatric central venous catheter causing extravasation of intravenous fluid due to relatively longer gap between the distal and proximal lumens. Indian J Anaesth 2019;63:157-9

How to cite this URL:
Govil N, Dhar M, Masaipeta K, Ahmed I. Displaced paediatric central venous catheter causing extravasation of intravenous fluid due to relatively longer gap between the distal and proximal lumens. Indian J Anaesth [serial online] 2019 [cited 2019 Feb 17];63:157-9. Available from: http://www.ijaweb.org/text.asp?2019/63/2/157/251981



Sir,

A 4-month-old female child weighing 6 kg was posted for surgical excision of a sacrococcygeal teratoma. Pre-anaesthetic evaluation revealed no other significant history or findings on examination. On the day of surgery, the child was taken into the operation theatre and general anaesthesia was induced uneventfully. After discussion with surgical team, decision was taken to place a central venous catheter (CVC) as the patient had difficult peripheral venous access and was also going to require a relatively longer duration of IV antibiotics.

A 4.5-French, 6-cm double-lumen CVC (Vygon®) was inserted into the right internal jugular vein (IJV) under ultrasound guidance (USG). The catheter was introduced using over the wire Seldinger technique and position was confirmed by smooth aspiration of blood from both ports and visualization of catheter tip in the IJV lumen on USG. The catheter was fixed at 5 cm at the skin using the secondary fixation wing, as the blood flow was achieved at ~ 1.5 cm during initial puncture with the introducer needle. After securing the catheter with sutures and flushing the catheter with heparinised saline, the patient was turned prone for the surgery with the head turned sideways. IV fluid was not given through the central line intraoperatively. The surgery and eventual recovery were uneventful. Backflow of blood from the catheter during aspiration was confirmed once more at the end of the surgery.

Two hours post-operatively, IV fluids were initiated via the central line (proximal port). Soon after starting the fluid, the child developed a swelling in the submandibular region, which was soft, gradually increasing in size and tender to touch [Figure 1]. The IV fluid was stopped immediately, and a chest X-ray and USG examination of the swelling was ordered. The chest X-ray revealed a neck swelling which was more on the right side. The CVC appeared to be in place but seemed to have curved slightly in the subcutaneous tissue [Figure 2]. USG of the neck was suggestive of fluid collection in the subcutaneous plane and the catheter tip was still visible in the IJV lumen. The catheter was removed and a gentle compression was given on the swelling. The swelling subsided to near normal after 7–8 h. On examination of the catheter, it was observed that the proximal lumen was almost 2 cm from the tip of the catheter [Figure 3].
Figure 1: Submandibular swelling following fluid infusion

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Figure 2: Curving of catheter in the subcutaneous tissue

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Figure 3: Relatively longer distance of proximal lumen from distal tip

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Central venous access is often required in younger paediatric patients during elective surgeries.[1] Although technically challenging, it offers a smooth intra- and post-operative course and avoidance of multiple pricks. Sizes of CVCs ranging from 3 to 5.5 french are available commercially. Cases of displaced and migrated CVC's have been reported and are quite common especially in the paediatric population.[2]

In the current case, it was hypothesised that the even though the initial placement of the CVC was correct, it could have migrated and curved during prone positioning due to sideways turning of the head; or subsequently during the post-operative period when the child was actively moving her neck. As the distance of the proximal lumen was nearly 2 cm from the tip, it could have led to slipping of the proximal lumen in and out of the IJV into the subcutaneous tissue; even though the rest of the catheter was still inside the vein.

Paediatric CVC's of different makers have varied specifications and different arrangement of lumens. In the present case, the CVC had a relatively longer gap between the proximal lumen and the distal tip, which increased the chances of the proximal lumen slipping out of the vein. When deciding the depth of insertion of CVC's in paediatric patients, in addition to the age- and height-based formulas,[3] one should also consider the arrangement and distance of the various lumens from the tip to minimise chances of CVC mal-positioning and prevent inadvertent extravasation of IV fluid or drugs into subcutaneous tissue.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Scott-Warren VL, Morley RB. Paediatric vascular access. BJA Educ 2015;15:199-206.  Back to cited text no. 1
    
2.
Roldan CJ, Paniagua L. Central venous catheter intravascular malpositioning: Causes, prevention, diagnosis, and correction. West J Emerg Med 2015;16:658-64.  Back to cited text no. 2
    
3.
Andropoulos DB, Bent ST, Skjonsby B, Stayer SA. The optimal length of insertion of central venous catheters for pediatric patients. Anesth Analg 2001;93:883-6.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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