Vascath misplacement
Reviewed and revised 14 July 2015
OVERVIEW
- unfortunate complication with possible serious sequelae for the patient
- well recognized but uncommon
- similar issues apply to inadvertent intra-arterial placement of central lines, however effects are typically less serious as the catheter is of smaller diameter
POTENTIAL COMPLICATIONS
- bleeding (hypovolaemia, haemothorax)
- fistula formation (if internal jugular was transfixed before entering the carotid artery)
- haematoma formation with compression of surrounding structures
- Airway obstruction (trachea)
- Cerebral venous outflow obstruction
- Jugular venous thrombosis due to stasis
- Haemomediastinum
- Compromised cardiac function due to RV compression by down-tracking haematoma
- Peripheral nerve compression injuries (e.g. vagus nerve, phrenic nerve, brachial plexus roots)
- Esophageal compression
- vascular injury
- Pseudoaneurysm
- Carotid dissection
- Retrograde aortic dissection
- Arteriovenous fistula
- Occlusion by flap, catheter or thrombus
- cerebral injury
- ischaemic stroke (luminal occlusion by vascath +/- thrombus formation)
- atherembolic stroke (disruption of atherosclerotic plaque)
- thromboembolic stroke
- air embolism
- inadvertent administration of drugs before position recognized (e.g. vasopressors, or sclerosing agents such as thiopentone) [more likely with CVCs rather than vascaths)
RECOGNITION
Clinical assessment
- potentially asymptomatic
- local swelling and bleeding
- airway compromise (neck swelling, stridor, respiratory distress, impaired gas exchange)
- dysphagia
- vagal effects (bradycardia, hypotension)
- focal signs consistent with stroke
- discomfort or abnormal noise heard ipsilaterally on flushing a line placed in the carotid
Investigations
- arterial blood gas
- arterial waveform and blood pressure when transduced
- intra-arterial placement on bedside ultrasound
- abnormal position on CXR
- evidence of complications (e.g. infarct on CTB, haemothorax on CXR)
MANAGEMENT
Immediate
- early recognition is important
- notify vascular surgeon as surgical haemostasis is typically required given size of the hole in artery (direct closure or patching)
- leave catheter in situ unless causing vascular insufficiency to the brain
- if surgical repair not indicated and catheter removed then prolonged pressure must be maintain on artery until surgical assessment has been made (be aware of potential problems: carotid body compression and distal flow)
- patient may need to be intubated (due to risk of airway compromise probably already is given is in multi-organ failure)
- correct coagulopathy (cessation of anti-platelets and anti-coagulants, blood products, factor VIIIa)
Post-removal of line
- assess end organ injury (brain function – clinically +/- imaging)
- keep intubated until haematoma and swelling settles
- extubate after ensuring coagulopathy resolved and airway not threatened
- may need placement of a vascath at another site to facilitate renal replacement therapy
Other issues
- root cause analysis
- discussion with proceduralist (non-judgemental, supportive)
- open disclosure with family and patient
- follow up with family and trainee
- education (e.g. ultrasound guidance teaching)
- hospital event form
- full documentation
References and links
Journal articles
- Nair S, et al. A case of accidental carotid artery cannulation in a patient for hemofilter: complication and management. Brit J Med Pract 2.3 (2009): 57-58. [Free Full Text]
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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