Indian Journal of Anaesthesia

LETTER TO EDITOR
Year
: 2012  |  Volume : 56  |  Issue : 4  |  Page : 425--427

Should ultrasonography check be routinely done following removal of femoral vascular catheter in patients with end-stage renal disease?


Tanmoy Ghatak, Afzal Azim, Arvind K Baronia, Banani Poddar, Mohan Gurjar 
 Department of Critical Care Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India

Correspondence Address:
Tanmoy Ghatak
Rammohan Pally, Arambagh, Hooghly, West Bengal - 712 601
India




How to cite this article:
Ghatak T, Azim A, Baronia AK, Poddar B, Gurjar M. Should ultrasonography check be routinely done following removal of femoral vascular catheter in patients with end-stage renal disease?.Indian J Anaesth 2012;56:425-427


How to cite this URL:
Ghatak T, Azim A, Baronia AK, Poddar B, Gurjar M. Should ultrasonography check be routinely done following removal of femoral vascular catheter in patients with end-stage renal disease?. Indian J Anaesth [serial online] 2012 [cited 2020 May 28 ];56:425-427
Available from: http://www.ijaweb.org/text.asp?2012/56/4/425/100845


Full Text

Sir,

With the increasing use of femoral vascular catheter in intensive care unit (ICU), the insertion related complications of them are dealt seriously. [1],[2] But, scarcity of reports about complications following removal of femoral vascular catheter encourage us to report two interesting, potentially fatal complications of femoral vascular catheter removal in end-stage renal disease (ESRD) patients. The importance of bedside ultrasonography (USG) after femoral vascular catheter removal has been stressed in this communication.

 Case 1



A 22-year-old student was transferred to our ICU with hospital-acquired pneumonia with ESRD due to obstructive uropathy. On admission, he was conscious, haemodynamically stable, tracheostomised on mechanical ventilation and pale (haemoglobin 8 gm/dl). He had mildly deranged prothrombin time (3 seconds prolonged) and normal platelet count. He had left femoral dialysis catheter (DC) (12 Fr, 18 cm, Mahurkar) in situ. Since, the insertion site was erythematous, we removed DC. No oozing was visible. A new DC was placed in right femoral vein uneventfully under USG guidance. Two days later, patient complained of left thigh pain. His left thigh and groin area was found warm, tender and slightly swollen. Urgent bedside USG and Doppler of that region showed large haematoma (12×10 cm) just posterior to the femoral vessels with intact vascular flow [Figure 1]. The patient developed septic shock with haemoglobin drop (6 gm/dl) on next day. In view of increasing groin swelling and impending compartment syndrome, surgical drainage was arranged. A large haematoma and pus was removed. Microbiology revealed growth of Staphylococcus aureus-sensitive to vancomycin from the pus and contemporary blood cultures. He showed clinical improvement within 48 hrs of intravenous vancomycin therapy.{Figure 1}

 Case 2



A 72-year-old obese retired nurse, with hypertensive heart disease and ESRD was referred to our ICU for extensive cellulitis of the left leg leading to septic shock. For invasive blood pressure monitoring, we put a right femoral arterial catheter (7 Fr, Certofix mono, B Braun) uneventfully under USG guidance. However, the patient recovered from septic shock within 3 days. Her haemoglobin, prothrombin time and platelet counts came to normal limits. Decision was made to remove the femoral catheter. After 2 days of removal of catheter, patient complained of right thigh pain. On palpation, some indurations were felt. A bedside lower limb USG showed a large haematoma anterior to common femoral artery, approximately 120-ml volume. A lower limb computed tomography angiogram [Figure 2] showed a pseudoaneurysm from right femoral artery via catheter tract with haematoma. It was treated conservatively by USG-guided compression repair under follow-up of vascular surgeons. With treatment, the pseudoaneurysm reduced in size and no communication with femoral artery was detected.{Figure 2}

 Comments



In our 1 st case, the onset of septic shock and haemoglobin drop drew our attention that the apparently benign looking concealed haematoma might be the source of sepsis. ESRD patients, due to impaired host immunity are predisposed to hospital-acquired infections. [3],[4] The dialysis procedure also might increase the risk of bacteremia via contamination of dialysate or equipment/ dialyzer reuse, and water treatment. [3],[4] This case highlights that a haematoma may be a source of sepsis and septic shock in addition to other pathways described by Jaber. [4]

Regarding our 2 nd case, iatrogenic femoral pseudoaneurysm via the catheter track following femoral arterial catheter removal is very rare in reporting. Heparinization during haemodialysis, obesity, advanced age, and concurrent anticoagulant treatment for deep vein thrombosis prophylaxis may be important risk factors in our case. It is seen that ESRD patients are prone to bleed even with normal coagulation profile and platelets. [5]

Probably the haematomas were precipitated due to femoral venous wall breach by wide bore (12 Fr) dialysis catheter or force of blood flow of femoral artery in presence of narrow (7 Fr) breach in arterial wall. Dysfunctional Von Willebrand factor leading to unrecognised vascular shear, uremic toxins and Prostacyclin I2 leading to platelet aggregation dysfunction in ESRD can be the possible mechanisms. [5]

Both our cases are unique in the sense that we should be aware that catheter related complications can also occur at the time of removal in susceptible patients like patients with ESRD. Clinical examination of the site is essential and if required bedside USG and Doppler should be performed for early detection and management of life-threatening complications.

References

1Prabhu MV, Juneja D, Gopal PB, Sathyanarayanan M, Subhramanyam S, Gandhe S, et al. Ultrasound-guided femoral dialysis access placement: A single-center randomized trial. Clin J Am Soc Nephrol 2010;5:235-9.
2Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C, et al. Ultrasonic locating devices for central venous cannulation: Meta-analysis. BMJ 2003;327:361.
3Katneni R, Hedayati SS. Central venous catheter-related bacteremia in chronic hemodialysis patients: Epidemiology and evidence based management. Nat Clin Pract Nephrol 2007;3:256-66.
4Jaber BL. Bacterial infections in hemodialysis patients: Pathogenesis and prevention. Kidney Int 2005;67:2508-19.
5Hedges SJ, Dehoney SB, Hooper JS, Amanzadeh J, Busti AJ. Evidence-based treatment recommendations for uremic bleeding. Nat Clin Pract Nephrol 2007;3:138-53.