Accepted Manuscript Subcutaneous emphysema and pneumothorax secondary to subclavian vein catheterization via supraclavicular approach Chih-Dou Chou, MD. M.S., Yu-Chi Tsung, MD., Fwu-Lin Yang, M.D., Ph. D PII:
S1875-4597(15)30008-4
DOI:
10.1016/j.aat.2015.12.003
Reference:
AAT 245
To appear in:
Acta Anaesthesiologica Taiwanica
Received Date: 28 July 2015 Revised Date:
10 December 2015
Accepted Date: 14 December 2015
Please cite this article as: Chou C-D, Tsung Y-C, Yang F-L, Subcutaneous emphysema and pneumothorax secondary to subclavian vein catheterization via supraclavicular approach, Acta Anaesthesiologica Taiwanica (2016), doi: 10.1016/j.aat.2015.12.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Letters to the editor Subcutaneous emphysema and pneumothorax secondary to subclavian vein catheterization via supraclavicular approach
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Central venous catheters ( CVC) are commonly used in intensive care units and operating rooms. Several different vessels can be introduced for catheter insertion, including subclavian, internal jugular, or femoral vein. The subclavian vein is preferred when patients are without palpable pulse and are in profound shock status. However, many complications have been reported. We reported a rare complication of concomitant subcutaneous emphysema and pneumothorax after subclavian central venous catheterization via supraclavicular approach.
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A 82-year-old female with several systemic diseases including hypertension, cardiomegaly, arrhythmia with pacemaker placement, type II diabetes mellitus, chronic hepatitis C with liver cirrhosis, scoliosis, and dementia with bedridden state was admitted to Surgical Intensive Care Unit (SICU) due to acute pyelonephritis with septic shock. The CVC is indicated, both right internal jugular and right subclavianveins using supraclavicular approach were attempted without success. Patient was restless and few air were aspirated during supraclavicular tapping. A follow-up chest radiograph showed pneumothorax of the right lung and subcutaneous emphysema in the right chest wall, right shoulder, and bilateral neck regions (Fig. 1). Chest surgeon was consulted and a 20-gauge Fr. chest tube was inserted with low-pressure suction. The chest tube functioned well and right lung re-expanded. Unfortunately, two days later, the chest radiograph showed worsened subcutaneous emphysema, extending into bilateral chest walls, neck and extremities and crepitation was also noted at face and both eyelids, accompanied by deteriorated oxygenation. The patient was intubated with mechanical ventilation. Meanwhile, the chest tube was replaced with 26-gauge Fr. chest tube. The subcutaneous emphysema improved and the patient was extubated 7 days later. A few days later patient developed refractory pneumonia and was re-intubated. She subsequently died from fungemia-induced septic shock three weeks later. Compared with other techniques, subclavian CVC, either by the supraclavicular or infraclavicular approach, has many advantages, such as fewer thrombosis, more secured fixation and better patient tolerance1. Factors that may increase risk of complications of internal jugular and
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subclavian vein at the time of insertion include chronic obstructive pulmonary disease, morbid obesity, marked cachexia, presence of chest tube, scoliosis, prior central venous access, and abnormal cardiothoracic anatomy2. Our patient has scoliosis, cardiomegaly and dementia make it more difficult to approach the internal jugular and subclavian vein.
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Reports have shown that the use of ultrasound before vessel puncture reduce the number of complications3. As in other surgical procedures, adequate training and experience reduce the risk of complication from CVC catheterization. If a physician fails to insert a catheter after three attempts, he or she should call for help rather than continue attempting the procedure.
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Since the central venous pressure (CVP) and central venous oxygen saturation (ScvO2) do not demonstrate superiority in all patients with septic shock4,5,6. Femoral vein catheterization could be an option for fluid resuscitation to prevent severe cardiopulmonary complications at insertion.
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Referernces 1. Brahos GJ. Central venous catherization via the supracavicular approach. The J. of Trauma; 1977;17:872-877 2. Gu X, Paulsen W, Tisnado J, et al. Malposition of a central venous catheter in the right main pulmonary artery detected by transesophageal echocardiography. J Am Soc Echocardiogr 2009; 22:1420.e5-1420.e7 3. Hind D, Calvert N, McWillians, et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 2003; 327-361 4. ProCESS Investigators, Yealy DM, Kellum JA, Juang DT, et al. A randomized trial of protocolbased care for early septic shock. N Engl J Med 2014; 370:1683-1693 5. The ARISE Investigators and the ANZICS Clinical Trials Group. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014; 371:1496-1506 6. Mouncey PR, Osborn TM, Power GS, et al for the ProMISe trial investigators. Trial of early, goaldirected resuscitation for septic shock. N N Engl J Med 2015; 372:1301-1311 Chih-Dou Chou, MD., M.S. Yu-Chi Tsung, MD. Fwu-Lin Yang, M.D.,Ph. D.
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Surgical ICU, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation; No.289, Jianguo Rd., Xindian Dist., New Taipei City 23142, Taiwan (R.O.C) E-mail:
[email protected]
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