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]

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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