Visual loss and central venous catheterization: cortical blindness and hemianopsia after inadvertent subclavian artery entry

Central line complications

Central venous access is a common procedure performed in many clinical settings for a variety of indications. Central lines are not without risk, and there are a multitude of complications that are associated with their placement. Complications can present in an immediate or delayed fashion and vary based on type of central venous access. Significant morbidity and mortality can result from complications related to central venous access. These complications can cause a significant healthcare burden in cost, hospital days, and patient quality of life. Advances in imaging, access technique, and medical devices have reduced and altered the types of complications encountered in clinical practice; but most complications still center around vascular injury, infection, and misplacement. Recognition and management of central line complications is important when caring for patients with vascular access, but prevention is the ultimate goal. This article discusses common and rare complications associated with central venous access, as well as techniques to recognize, manage, and prevent complications.

Sudden-Onset Bilateral Blindness in a Young Girl Receiving Parenteral Nutrition: Case Report and Review of Literature

BACKGROUND

Parenteral nutrition (PN) via a central venous catheter is routinely used for surgical patients without a functioning gastrointestinal tract. Complications of PN can be metabolic and thrombotic. Blindness is a rare and unexpected complication.

CASE

A young female patient with postcorrosive pyloric stenosis was started on PN through an indwelling central venous catheter. On the sixth day of PN, the patient reported sudden painless bilateral complete loss of vision. Examination revealed bilateral normal-sized pupils with normal pupillary reaction. There was complete bilateral absence of visual acuity with no perception of light. Fundus examination was normal. Magnetic resonance imaging revealed an acute infarct in the left occipital lobe, left corpus callosum, and posteromedial aspect of the left thalamus. No cardiac source of the thrombus could be identified. After supportive treatment, the vision started improving after 3 days; recovery was 95% after 10 days. A feeding jejunostomy was performed urgently under local anesthesia, and 1 month of enteral nutrition was administered. One month after the event, the patient's vision returned to normal. Definitive surgery in the form of antrectomy with Billroth II reconstruction was performed 8 weeks later.

CONCLUSION

Blindness secondary to central venous catheterization is very rare; possible mechanisms are venous thrombosis with paradoxical emboli, air emboli, or accidental arterial puncture. Clinicians must exercise caution while using PN. A high index of suspicion is required to diagnose and treat unexpected complications.

Management of inadvertent arterial catheterisation associated with central venous access procedures

OBJECTIVE

This study aims to describe the clinical management of inadvertent arterial catheterisation after attempted central venous catheterisation.

METHODS

Patients referred for surgical or endovascular management for inadvertent arterial catheterisation during a 5-year period were identified from an endovascular database, providing prospective information on techniques and outcome. The corresponding patient records and radiographic reports were analysed retrospectively.

RESULTS

Eleven inadvertent arterial (four common carotid, six subclavian and one femoral) catheterisations had been carried out in 10 patients. Risk factors were obesity (n=2), short neck (n=1) and emergency procedure (n=4). All central venous access procedures but one had been made using external landmark techniques. The techniques used were stent-graft placement (n=6), percutaneous suture device (n=2), external compression after angiography (n=1), balloon occlusion and open repair (n=1) and open repair after failure of percutaneous suture device (n=1). There were no procedure-related complications within a median follow-up period of 16 months.

CONCLUSIONS

Inadvertent arterial catheterisation during central venous cannulation is associated with obesity, emergency puncture and lack of ultrasonic guidance and should be suspected on retrograde/pulsatile catheter flow or local haematoma. If arterial catheterisation is recognised, the catheter should be left in place and the patient be referred for percutaneous/endovascular or surgical management.

Cerebrovascular events associated with infusion through arterially malpositioned triple-lumen catheter: report of three cases and review of literature

Analysis of 10 adult patients treated from January 1998 to November 2004 for arterial misplacement of triple-lumen catheter (TLC) during internal jugular vein cannulation was performed. Three cases that developed neurologic symptoms occurring in the context of infusion through a TLC that was arterially malpositioned are presented, along with the review of literature. In 7 patients, the diagnosis of arterial misplacement was suspected by the color or flow characteristics of blood and confirmed by a combination of blood gas analysis, connecting catheter to transducer, and/or chest film. In the remaining 3 patients, intraarterial misplacement was not suspected. In these patients, the initial review of chest films by qualified physicians prior to starting infusion failed to detect malposition of the catheter. Retrospectively, subtle clues suggestive of arterially placed TLCs were found. All 3 patients developed neurologic symptoms. Initiation of neurologic workup delayed a correct diagnosis by 6 to >48 hours. A volumetric pump was used for infusion in all patients. Of the 3 patients with neurologic symptoms, 1 recovered completely, 1 became comatose, and 1 partially improved. Based on our observations and review of literature, we conclude that cursory examination of chest films to verify proper positioning of central venous catheter attempted through the internal jugular vein may fail to detect arterial malposition. Infusion by volumetric pump precludes backflow of blood in the intravenous tubing as an indicator. Neurologic symptoms concurrent with the infusion of fluids and medication should raise suspicion of accidental arterial infusion.

In-hospital stroke

Between 6.5% and 15.0% of all strokes occur in patients already in hospital, many of whom are there for surgical procedures or cardiac disorders. This important group of patients could potentially be assessed more rapidly than others and could be candidates for interventional therapies. However, delays in recognition and assessment are common, possibly related to comorbidities and the complexities of hospital practice. Risk factors for in-hospital stroke include specific operations and procedures (eg, cardiac surgery), previous medical disorders (especially a history of stroke), and certain physiological characteristics (including fever and dehydration). The stroke subtype is embolic in a large proportion, and there are various possible precipitating mechanisms. Outcome can be poor, with high mortality. Interventional therapies, particularly thrombolysis, are possible options. In the postoperative setting, intra-arterial thrombolysis is feasible and reasonably safe in carefully selected patients. Experimental agents and the manipulation of physiological variables are other treatment possibilities that could be applied early in this group of patients. Increasing the awareness by hospital physicians of such interventions may be an important factor that reduces delays in assessment of patients who have stokes while in hospital.

Transpleural subclavian central venous catheter placement in a child with scoliosis discovered during a thoracotomy

Placement of central venous catheters in dysmorphic children can be difficult because of distortion of normal anatomical landmarks. We present such a case of a 16 year-old child who had a central venous catheter inserted in the left subclavian vein. Although a conventional roentgenogram was consistent with correct placement, the catheter was found to traverse the pleural space before entering the subclavian vein.

Persistent left superior vena cava identified after cannulation of the right subclavian vein

IMPLICATIONS

We report the case of a patient with a chest radiograph suggestive of intraarterial placement of a central venous catheter. On investigation, the catheter was located in a previously undiagnosed persistent left superior vena cava.

Ruptured superior thyroid artery from central vein cannulation: treatment by coil embolization

Central vein cannulation is associated with several complications, some of which may be fatal. This case report describes a life-threatening complication after insertion of a central venous line. An obese female patient with end-stage renal failure due to nephrotic syndrome developed a huge neck swelling and sudden airway obstruction after attempted cannulation of the internal jugular vein for haemodialysis. Tracheal intubation was achieved using a gum-elastic bougie. Investigations revealed abnormal blood clotting. The coagulopathy was treated, but the neck swelling continued to increase in size. Carotid angiography showed a ruptured right superior thyroid artery. The haemorrhage was controlled by coil embolization of the artery. This case report demonstrates the usefulness of the gum-elastic bougie in the presence of a difficult airway and of interventional radiology in the management of vascular accidents.