Videothoracoscopic management of a perforated central vein and pleura after ultrasound-guided internal jugular vein cannulation: a case report

Lower Double-Wall Puncture Rate During Ultrasound-Guided Internal Jugular Vein Cannulation Using Sharper, Narrower-Gauge, and/or Length-Optimized Needles: A 6-Year Quality Improvement Clinical Series in Adult Patients

Background: During internal jugular vein (IJV) cannulation, needle tip injury to vulnerable subjacent cervical anatomic structures can be prevented if the cannulating needle tip is not permitted, even momentarily, to penetrate the deep portion of the IJV wall, an event known as double-wall puncture (DWP), also called posterior wall puncture. Methods: We conducted a 6-year ultrasound-guided IJV cannulation quality improvement project, seeking to minimize the occurrence of DWP in 228 adult patients using needles of different gauge and tip sharpness. Most needles were length-optimized to the distance between the skin puncture site and the IJV mid-lumen for a selected angle of needle insertion by (1) using a nylon screw-on needle stop or (2) using a cannulating needle that already had the desired shaft length. Results: Standard central venous cannulation kit needles were long enough to reach or traverse the deepest portion of the IJV wall in nearly all patients. Use of extra-sharp, smaller-diameter needles in place of standard needles was associated with a 26.3% relative reduction in DWP rate. Use of needles length-optimized to reach only the IJV mid-lumen was associated with a 78.4% relative reduction in DWP rate. A 0% DWP rate was attained using length-optimized 21-gauge extra-sharp needles and length-optimized 20-gauge needles of intermediate sharpness. Conclusion: The 9.2% DWP rate achieved during this project was approximately half the rate reported at the time of project inception. Use of length-optimized, sharper, narrower-gauge cannulating needles may help avoid DWP during ultrasound-guided IJV cannulation.

Management of venous perforation during central venous catheterization in hemodialysis patients: Three case reports

RATIONALE

In recent years, central venous catheterization (CVC) has become widely used for hemodialysis patients. Based on 3 cases, we discussed the detection and management of venous perforation at an early stage.

PATIENTS CONCERNS

Patients 1 (male, 77 years), 2 (male, 82 years), and 3 (male, 30 years) were diagnosed with uremia and underwent hemodialysis.

DIAGNOSES

Computed tomography suggested pneumomediastinum in patient 1 and pneumothorax in patient 2 after a replacement of the temporary hemodialysis catheter. In patient 3, X-ray suggested that the tip of the catheter was approximately at the plane of the fifth thoracic vertebrate after the temporary catheter was placed.

INTERVENTIONS

In patients 1 and 2, the catheters were maintained where they were for about 2 weeks until a false lumen formed outside the catheter. In patient 3, the catheter was withdrawn at once when vein perforation was observed.

OUTCOME

In patients 1 and 2, the catheters were adjusted successfully under digital subtraction angiography (DSA) guidance 2 weeks later. In patient 3, hemothorax developed, and a total of approximately 1000 mL of bloody fluid was drained.

LESSONS

When venous perforation occurs during CVC, it is safer and more reliable to adjust or withdraw the catheter under DSA guidance after a false lumen forms outside the catheter.