Arterial placement of central venous catheters
Case reports:
Case 1: “Patient admitted last night and had central line inserted. Inotropes, sedation and fluids given via central line for 4+ hours. On assessment [in morning], noted CVP reading high and an arterial trace, suspected that central line was in artery. All infusions stopped and transferred peripherally. Patient became hypotensive and metaraminol given neat by anaesthetist. Patient became profoundly bradycardic and peri arrest… on review of the never event guidance this incident is a never event under the wrong site surgery category.”
Case 2: “Patient admitted to ITU with liver impairment and AKI secondary to mass in head of pancreas causing biliary obstruction. Need for central venous access and dialysis line for urgent treatment. Both lines inserted sequentially to right internal jugular vein. Ultrasound guidance used for both procedures, same operator. CVVH line correctly sited. CVC line had in fact been inserted into carotid artery despite use of ultrasound. CXR post-procedure, with hindsight shows the 2 lines taking very separate paths and would be difficult to interpret that they were in the same vessel. CVC line was apparently transduced. It is unclear how the interpretation of the CVC pressure was made but a recording of MAP value 60-80 was apparently recorded but not acted upon… the patient was sedated and intubated in preparation for a PTC. As attempts were made to attach a propofol infusion to the CVC after intubation pulsatility in the CVC was noted. Re-transducing the CVC revealed an arterial waveform. The CVC line had been used for infusion of FFP but not for any medication.”
Case 3: “Patient had Central line inserted on admission to critical care for vasopressors, for management of sepsis, by ICU resident. 2 lines sited (CVC and VasCath) at same time into Right side of neck. Vasopressor infusions (Noradrenaline) were started through the CVC overnight. The following day the patient was confused and the decision was to sedate, intubate and ventilate to facilitate a PTC drain, as believed would not tolerate procedure. FFP was started to correct coagulopathy pre-procedure, which was running through the CVC transduced line. After induction of anaesthesia a propofol infusion was connected to the CVC (to maintain sedation) and pulsatile flow was noted. The transduced pressure in the CVC was checked and shown to be consistent with arterial trace. Vasopressor infusion (Noradrenaline) was stopped and converted to peripheral vasopressor (Metaraminol). The patient went for a CT scan which confirmed the CVC was sited in the common carotid artery… The CVC was removed from the carotid artery through an Interventional Radiology procedure and returned to critical care.”
Commentary:
Although these cases presented on ICU, they are valuable lessons to all anaesthetists. Checks to exclude arterial placement of central venous catheters should always be undertaken before the line is used. These should be set out in each organisation’s LocSSIP governing central line placement. It is not clear which confirmatory checks were used in all cases, but in case 2, it appears that a non-reassuring check (presence of arterial pressures) was not acted upon and the line was used anyway.