Late perforation of superior vena cava and effusion caused by central venous catheter

Central Venous Catbeterization: A Comprehensive Review, Part II

In Part I of this article, the indications and contraindica tions of central venous catheterization were reviewed, and the antecubital, external jugular, and femoral vein routes discussed. In Part II, the internal jugular and sub clavian vein routes for central venous catheterization are reviewed, and an overview of catheter maintenance and infection control presented. The internal jugular vein and subclavian vein are the two most useful sites for central venous access. There is greater experience with the subclavian vein, and it is largely because of a perceived high complication rate associated with this approach that the internal jugular vein was cultivated as an access route in adults. The debate remains as to which route is preferable. In reality, each method has advantages in a given clinical situation.

Continuing Controversy of Midclavicular Catheters

A review of 50 years of research on catheter tip placement indicates an overwhelming preference for the lower third of the superior vena cava as the appropriate tip location. Despite this evidence, there are still practitioners, physicians, and nurses who advocate tip placement within the axillo-subclavian-innominate vein (also referred to as the midclavicular). This article looks at the arguments presented by practitioners who support midclavicular tip placement. It also reviews some of the research from which the recommendations for superior vena cava placement are derived.

Pleural effusions of extravascular origin

Most pleural effusions are caused by hydrostatic and oncotic pressure imbalance, inflammation or infection, or abnormalities in lymphatic drainage. A select number of effusions are caused by fluid of extravascular origin. Some of these effusions result from complications of treatment, whereas others are a ramification of the underlying disease. The incidence, pathogenesis, clinical presentation, chest radiographic manifestations, pleural fluid analysis, diagnosis, and management are discussed.

Vascular erosion by central venous catheters. Clinical features and outcome

We evaluated the clinical characteristics of eight patients who presented with vascular erosion from central venous catheters and reviewed the available literature. Patients typically presented with dyspnea or chest pain, unilateral or bilateral pleural effusions, and mediastinal widening one to seven days after catheter insertion. Pleural fluid appeared transudative with variable glucose concentrations (range, 174 to 588 mg/dl) that were always greater than concurrent serum values. Diagnosis was delayed 3.0 +/- 1.5 days (range, 0 to 11 days) after vascular erosion. One patient died and four patients received chest tubes. Seven of eight patients had left-sided line placement; six of these seven left-sided catheters abutted the superior vena cava wall within approximately 45 degrees of perpendicular. Results of a literature search confirm the hazards of delayed diagnosis and the importance of left-sided catheter placement as a risk factor for vascular erosion.

Central venous catheter stiffness and its relation to vascular perforation

Delayed central venous perforation is an uncommon but serious complication of central venous catheter insertion. An increase in catheter stiffness may have been responsible for our association of venous perforation with use of a guidewire insertion technique. A bench model was used to investigate the stiffness characteristics of thirty-four different types of catheters. The initial stiffness is poorly described by material or catheter gauge. A large range of values is seen between apparently similar catheters--the 16 gauge polyethylene catheter associated with two perforations at our institution had an initial stiffness value 7.5 Nm2 X 10(-5) at 37 degrees C in comparison with our previous standard--the 16 gauge Deseret Intracath with an initial stiffness of 2 Nm2 X 10(-5). Multilumen catheters had a similar range of stiffness to single lumen catheters, while paediatric catheters in general were less stiff. Dialysis catheters were up to five times as stiff as the stiffest central venous catheter. Stiffness decayed at a rate and to an extent which differed from catheter to catheter. Absorption of water by the catheter appears to be one factor involved in stress relaxation.

Uremic pleuritis

Pleural abnormalities of uremia have been recognized for many years but have been given little attention despite their high incidence. Mechanisms underlying pleural effusion relate to filtration forces across subpleural capillaries and lymphatic absorption, either of which can be abnormal in patients with renal failure. Uremic patients have increased susceptibility to many causes of pleural exudate. In addition, a specific uremic pleuritis has been characterized as necrotizing fibrinous sterile exudate that is often hemorrhagic. Spontaneous remission, often with recurrences, or constrictive pleural thickening requiring surgical decortication may occur. Neither the pathogenesis nor the appropriate treatment of uremic pleuritis has been established definitively.

Late perforation by central venous cannulae

Three cases of hydrothorax secondary to late perforation of the superior vena cava by central venous cannulae are presented. The care of central venous cannulae is discussed.

Use of wire-guided (Seldinger-type) catheters in the emergency department

The use of wire-guided catheters is a major technical advance for emergency physicians. The technique is simple, safe, and efficient, and allows tremendous flexibility in usage.