Right phrenic nerve palsy as a complication of indwelling central venous catheters

Spontaneous Recovery Following Traumatic Phrenic Nerve Palsy

This is a case report of unilateral traumatic phrenic nerve palsy with spontaneous recovery over a period of 31 months. This adds to the literature, demonstrating that extended conservative management can lead to successful resolution even in the setting of traumatic aetiology.

Transient right hemidiaphragmatic paralysis following subclavian venous catheterization: possible implications of anatomical variation of the phrenic nerve -a case report-

Phrenic nerve paralysis is an unusual complication associated with central venous catheterization. Various mechanisms have been proposed. We present a case of transient right hemidiaphragmatic paralysis after subclavian venous catheterization. We hypothesize that anatomical variation of the phrenic nerve was responsible for this complication.

Phrenic nerve injury and diaphragmatic paralysis following pacemaker pulse generator replacement

Diaphragmatic paralysis (DP) is a common condition. It can be unilateral or bilateral and the diagnosis is usually based on a clinical and radiological findings. Bilateral diaphragmatic paralysis is usually symptomatic with dyspnea and acute respiratory failure while unilateral diaphragmatic paralysis is typically asymptomatic and when present, symptoms usually depend on the presence of underlying pulmonary or neurologic disease. DP can be the result of various chest conditions that affect the phrenic nerve such as tumors, vascular abnormalities or traumatic incidents during surgery as well as blunt or penetrating chest or neck injuries. We report a unique case of phrenic nerve injury and unilateral diaphragmatic paralysis secondary to pacemaker pulse generator replacement that was successfully treated with diaphragmatic plication.

Phrenic nerve injury after image-guided insertion of a tunnelled right internal jugular central venous catheter

Central venous catheters (CVC) are now commonly inserted by radiologists. Although complications are infrequent, they must be avoided where possible and recognized when they occur. We present a 10-year-old boy who developed right hemidiaphragmatic paralysis, requiring surgical plication, following US-guided insertion of a tunnelled right internal jugular CVC. The needle trajectory for internal jugular puncture must be planned to avoid the phrenic nerve.

Variable anatomical relationship of phrenic nerve and subclavian vein: clinical implication for subclavian vein catheterization

BACKGROUND

During subclavian vein catheterization, a potential, but rare, hazard is the phrenic nerve injury, which compromises respiratory function. We conducted a cadaver study focused on the possible anatomical relationships between the subclavian vein and the phrenic nerve.

METHODS

Forty-two adult cadavers (84 heminecks) were dissected. Special attention was given to the topography of the phrenic nerve and subclavian vein.

RESULTS

In all but three cases (81 of 84), normal topography was present, that is, the nerve was posterior to the vein. In two cases, the phrenic nerve crossed anterior to the subclavian vein and in one case traversed the anterior wall of the subclavian vein.

CONCLUSIONS

Variants of the relationship of the subclavian vein and the phrenic nerve should be familiar to anaesthesiologists during subclavian vein cannulation in order to achieve successful vein approach without causing phrenic nerve palsy.

Right hemi-diaphragm paralysis following cardiac radiofrequency ablation

Diaphragm paralysis may occur after traumatic phrenic nerve injury. Here we report three patients in whom right hemi-diaphragmatic paralysis developed after cardiac radiofrequency ablation. We hypothesise that local focused thermal energy at the time of the ablation may have caused direct neuronal damage by axonal coagulation necrosis. The prognosis for this type of injury may be reasonably good; two of the three patients fully recovered diaphragm function by 1 year.

Intrapulmonal dislocation of a totally implantable venous access device

Background

Totally implantable venous access devices are widely used for infusion of chemotherapy or parenteral nutrition. Device associated complications include technical operative problems, infections, paravasal infusions and catheter or punction chamber dislocation.

Case presentation

We present the case of a 49-year-old patient with the rare complication of a intrapulmonal catheter dislocation of a totally implantable venous access system. Treosulfane for chemotherapy of metastatic breast cancer was infused via the catheter causing instant coughing and dyspnoea which lead to the diagnosis of catheter dislocation. The intrapulmonal part of the catheter was removed under thoracoscopic control without further complications.

Conclusion

Intrapulmonal catheter dislocation is a rare complication of a totally implantable venous access device which can not be avoided by any prophylactic measures. Therefore, the infusion system should be tested before each use and each new symptom, even when not obviously related to the catheter should be carefully documented and evaluated by expert physicians to avoid severe catheter-associated complications.

An elevated hemidiaphragm 3 months after internal jugular vein hemodialysis catheter placement

Phrenic nerve palsy following central venous catheterization is a rare complication and is not well recognized. We present a 33 months old girl who has renal failure secondary to nephrotic syndrome. A left internal jugular catheter was placed using the Seldinger technique after a single injection of 2 ml prilocaine hydrochloride for local anesthesia and a single internal jugular vein cannulation. Subsequent chest roentgenograms confirmed proper catheter and diaphragm position. Three months after catheter placement, decreased breath sounds on the left side of the chest were noted. Left phrenic nerve palsy was demonstrated with fluoroscopy and electromyography with external diaphragmatic electrodes. The nerve damage was delayed after catheter placement, it seems unlikely that it was related to direct nerve trauma from the cannulation needle, local anesthetic infiltration of the nerve, or subsequent hematoma formation in this case. The phrenic nerve is in close proximity to both the catheter and the vein in which the catheter rests, an inflammatory reaction related to the catheter has been suggested as the cause for the nerve damage.

Transient right phrenic nerve palsy associated with central venous catheterization

An 85-yr-old woman with advanced sigmoid colon cancer developed right phrenic nerve palsy following central venous catheterization for preoperative nutritional and fluid balance improvement. The central venous catheter was successfully placed via the left subclavian vein at the first attempt. Blood returned freely through the catheter. The chest x-ray film taken immediately after the catheterization showed the proper placement of the catheter, but it revealed a significant right hemidiaphragmatic elevation indicating phrenic nerve palsy. A chest computed tomography scan and bronchoscopy were normal. As the patient did not complain of dyspnoea and vital signs were normal, tumour resection was performed. The operative and postoperative course was uneventful. The chest x-ray film after the surgery still showed the elevation of the right hemidiaphragm. It resolved completely within 3 days of withdrawing the central venous catheter by 3 cm on the fourth postoperative day. We concluded the likely cause of the phrenic nerve palsy was that the catheter tip impinged upon the thin venous wall and compressed the phrenic nerve running alongside the superior vena cava.

Infusional 5-fluorouracil can be a pain in the neck: A case for repositioning displaced Hickman lines

Increasing numbers of patients receive infusional chemotherapy or total parenteral nutrition via Hickman or Grochong lines. Although the insertion of these indwelling catheters is generally performed under radiological guidance and their positions verified by chest radiography, it is still feasible for them to become displaced at a later date. This possibility should be excluded in patients who develop unusual symptoms during the course of their infusional therapy. We review the reported complications associated with Hickman lines, and present a case history demonstrating that interventional radiology has a valuable role in displaced line repositioning, after the exclusion of thrombosis and infection.

Diaphragmatic plication in the extremely low birth weight infant

A case of acquired diaphragmatic paralysis in an extremely low birth weight infant complicated by respiratory failure, recurrent atelectasis, and pneumonia is described. Diaphragmatic plication led to a rapid improvement in pulmonary function and allowed for discontinuation of mechanical ventilation in less than 1 week. Therapeutic options for acquired diaphragmatic paralysis, including the rationale for early operative intervention, in this patient population are discussed.

Bilateral diaphragmatic weakness: a late complication of radiotherapy

Brachial plexus neuropathy is an unfortunate complication that sometimes follows radiotherapy to the axillary and supraclavicular regions. A patient is described who, 30 years after radiotherapy for Hodgkin's disease and more than 10 years after the development of radiation-induced bilateral brachial plexus neuropathy, presented with bilateral diaphragmatic weakness secondary to bilateral phrenic nerve weakness. Previous radiotherapy was the most probable cause of the condition.