Case Report

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used for hemodialysis (HD) either as permanent dialysis accesses in ... [Downloaded free from on Friday, June 19, 2015, IP:] ...

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Saudi J Kidney Dis Transpl 2009;20(6):1061-1064 © 2009 Saudi Center for Organ Transplantation

Saudi Journal of Kidney Diseases and Transplantation

Case Report Supraventricular Tachycardia Following Insertion of a Central Venous Catheter Onder Yavascan, Sevgi Mir, Hakan Tekguc Ege University, Faculty of Medicine, Department of Pediatric Nephrology, Izmir, Turkey ABSTRACT. Placement of central venous catheters (CVCs) in patients is associated with several risks including endocardial injury and dysrhythmias. In addition, CVC extending into intracardiac chambers can provoke premature atrial and ventricular complexes, which have been reported to initiate supraventricular tachycardia (SVT). A 15-year-old boy with end-stage renal failure developed SVT after insertion of a CVC. Introduction Central venous catheters (CVCs) are widely used for hemodialysis (HD) either as permanent dialysis accesses in patients with severe peripheral vascular disease or transiently during the maturation period of an arteriovenous fistula (AVF). Placement of percutaneous CVCs has become a common procedure in adult intensive care units1,2 and pediatric patients.3-6 Despite their advantages, CVCs can manifest a number of complications such as pneumothorax, chylothorax, hemothorax, air embolisms, infections, vessel injuries, thrombosis, malposition, clavicle osteomyelitis, brachial plexus palsy, phrenic nerve injuries and cardiac dysrhythmias.1-6 Correspondence to: Dr. Onder Yavascan 9105/14 Sokak, No. 9/5, Serdar Apartmani Akevler 35370, Yesilyurt-Izmir, Turkey

E-mail: [email protected]

To our knowledge there is a few reports of supra ventricular tachycardia (SVT) in children associated with CVCs.7 Here we report a pediatric case with SVT after placement of a percutaneous CVC. Case Report A 15-year-old boy (height 165 cm, weight 55 kg) who had been on chronic peritoneal dialysis (CPD) for 3 months due to reflux nephropathy presented with acute peritonitis which was intractable to therapy and mechanical obstruction that rendered peritoneal dialysis treatment impossible. Therefore, the decision was made to insert a CVC under local anesthesia and transfer the patient temporarily to HD. The insertion was performed by a pediatric nephrologist skilled in this procedure under continuous monitoring of the patient’s electrocardiogram (ECG), heart rate, and oxygen saturation. Before the procedure, his blood pressure, pulse and respiratory rates were 118/74 mmHg, 88 beats per minute and 18

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Yavascan O, Mir S, Tekguc H

Figure 1. The ECG findings in the index patient; A) SVT triggered by the central vein catheter, B) Normal sinus rhythm after adenosin administration

Figure 2. This chest roentgenogram shows the distal fragment of the central vein catheter touch on the base of the right atrium

breaths per minute, respectively. The complete blood count, liver profile and serum chemistry except for urea (244 mg/dL), creatinine (7.8 mg/ dL), K (5.7 mmol/L) were within normal limits. Room air oxygen saturation (SatO2) was 98%. Sedation was achieved with midazolam (0.05 mg/kg, i.v.). For local anesthesia 1% lidocain was used. The CVC was inserted by the Seldinger technique as described previously.2,6 Briefly, a 12F, double lumen CVC line was inserted without difficulty via the right subclavian vein to a length of 15 cm; however, there was no blood

flow. After the line was advanced 1 cm further to a final length of 16 cm, the blood flow was satisfactory. At this point the patient reported a “strange” feeling in the chest; his SatO2 was 99%. At that time, the ECG showed an SVT at a rate of 180 bpm. The line was immediately withdrawn by 1 cm but the sinus rhythm could not be achieved. The ECG showed a persistent SVT at a rate of 180-200 bpm (Figure 1A). A chest roentgenogram revealed that the distal fragment of the catheter touched on the base on the right atrium (Figure 2). We assumed that the SVT was induced by the irritation caused by the catheter to the atrial wall. The catheter was withdrawn by 1 cm again but the patient did not return to sinus rhythm even by vagal maneuvers. We administered adenosin (Adenocard IV®, 0.1 mg/kg rapid i.v. push), and he recovered after a few moments (Figure 1B) and the SVT did not recur. After the rapid improvement, the patient was hemodialyzed uneventfully. The PD catheter was removed on day 20 because of persistence of a high dialysate WBC count and malposition. The patient was continued on HD via the CVC. As living renal transplantation is under consideration, an AVF was not performed. There was no recurrence of SVT during the following 3 months of follow-up.

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Supraventricular tachycardia with a central venous catheter

Discussion Optimal positioning of the tip of a CVC is a controversial subject. The United States Food and Drug Administration (FDA) strongly disagrees with the practice of positioning the tip of a CVC into the right atrium because of the potential cardiac-related complications.8 National Kidney Foundation: Dialysis Outcomes Quality Initiative (NKF=DOQI) recommends positioning the catheter tip at the superior vena cavaright atrial (SVC-RA) junction or in the SVC.9 Central venous catheters extending into cardiac chambers can provoke premature atrial and ventricular complexes, which have been reported to initiate SVT.10 After blind placement of a CVC, an intracardial position is found in up to 50% of the cases.11,12 Symptomatic dysrhythmia induced by a guide wire or a malposition of a catheter represents an acute complication of the central venous access devices.13 A brief dysrhythmia induced during an insertion of a catheter or a guide wire is usually an indicator of a direct irritation to the right endocardium, which can be deleterious in patients with impaired cardiac output or aortic valvular stenosis.14 Arhythmias occur commonly during CVC insertion. In a recent study, atrial arhythmias and ventricular ectopy occurred with a frequency of 41 and 25%, respectively.15 This is in contrast to the data of McDowell et al16 who described symptomatic ventricular tachycardia in 1% of the hemodialysis patients. It has been reported that patients with acute renal failure are at increased risk for cardiac arhythmias during the insertion of the CVCs. An important risk factor is the guide wire over-insertion, a technical error that should be avoided.17 In our patient, both uremia and catheter over-insertion could have provoked the SVT. In the setting of symptomatic dysrhythmia, immediate retraction of the guide wire or the catheter should be the first interaction. The vagal maneuvers should be attempted, and if the SVT cannot be terminated, then intravenous adenosine or calcium channel blockers should be administered. Adenosine is a short-


acting drug that blocks AV node conduction; it terminates 90% of tachycardias. Synchronized cardioversion can also be used immediately in patients who develop hypotension, pulmonary edema, or ischemic chest pain.18 In our patient, the SVT responded to the administration of adenosine. Also, such dysrhythmias can easily be avoided by using the intravascular ECG monitoring during the advancement of the catheter even with catheters that are too short to reach the atrium.14,19 In conclusion, CVCs placement procedure can induce dysrhythmias. In the setting of SVT, the guide wire or catheter should be immediately retracted. Intravascular ECG monitoring can be helpful during the insertion of the CVCs. References 1.









Dronen SC, Younger JG. Central venous catheterization and central venous pressure monitoring. In: Roberts JR, Hedges JR (eds). Clinical Procedures in Emergency Medicine, 3rd edn. W.B. Saunders, Philadelphia, 1998;359-85. British Committee for Standards in Haematology. BCSH guidelines on the insertion and management of central venous lines. Br J Haemetol 1997;98:1041-7. Fernandez GF, Sweeney MF, Green TP. Central venous catheters. In: Dieckman RA, Fiser DH, Selbst SE (eds). Pediatric Emergency Critical Care Procedures. Mosby, St Louis, 1997;196-202. Stovroff M, Teague WG. Intravenous access in infants and children. Pediatr Clin North Am 1998;45:1373-93. Vane DW, Ong B, Rescorla FJ, West KW, Grosfeld JL. Complications of central venous access in children. Pediatr Surg Int 1990;5:174-8. Aksu N, Kabasakal C, Bak M, Hoscoskun C, Mir S. The application of subclavian catheter in hemodialysis treatment in childhood. Dial Transplant Burn 1993;7:1-5. Hacking MB, Brown J, Chisholm DG. Position dependent ventricular tachycardia in two children with peripherally inserted central catheters (PICCs). Paediatr Anaesth 2003;13:527-9. Food and Drug Administration. Precautions necessary with central venous catheters. FDA Task Force. FDA Drug Bulletin 1989:15-6. Schwab SJ, Besarab A, Beathard G, NKF-DOQI clinical practice guidelines for vasular access.

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National Kidney Foundation Dialysis Outcomes Quality Initiative. Am J Kidney Dis 1997;30 (Suppl.):S150-91. Verdino RJ, Pacifico DS, Tracy CM. Supraventricular tachycardia precipitated by a peripherally inserted central catheter. J Electrocardiol 1996;29:69-72. McGee WT, Ackerman BL, Rouben LR, Prasad VM, Bandi V, Mallory DL. Accurate placement of central venous catheters: a prospective, randomized, multicenter trial. Crit Care Med 1993;21:1118-23. Lumb PD. Complications of central venous catheters. Crit Care Med 1993;21:1105-6. Cobb DK, High KP, Sawyer RG, et al. A controlled trial of scheduled replacement of central venous and pulmonary artery catheters. N Engl J Med 1992;327:1062-8. Pawlik MT, Kutz N, Keyl C, Lemberger P, Hansen E. Central venous catheter placement: comparison of the intravascular guide wire and the fluid column electrocardiograms. Eur J

Yavascan O, Mir S, Tekguc H Anaesthesiol 2004;21:594-9. 15. Stuart RK, Shikora SA, Akerman P, et al. Incidence of arrhythmia with central venous catheter insertion and exchange. JPEN J Parenter Enteral Nutr 1990;14:152-5. 16. McDowell DE, Moss AH, Vasilakis C, Bell R, Pillai L. Percutaneously placed dual-lumen silicone catheters for long-term hemodialysis. Am J Surg 1993;59:568-73 17. Fiaccadori E, Gonzi G, Zambrelli P, Tortorella G. Cardiac arrhythmias during central venous catheter procedures in acute renal failure: A prospective study. J Am Soc Nephrol 1996;7: 1079-84. 18. Trohman RG. Supraventricular tachycardia: implications for the intensivist. Crit Care Med 2000;28(Suppl):129-35. 19. Dionisio P, Valenti M, Cornelia C, et al. Monitoring of central venous dual lumen catheter placement in haemodialysis: improvement of a technique for the practicing nephrologist. Nephrol Dial Transplant 1995;10:874-6.