Saudi Critical Care Journal

CASE REPORT
Year
: 2019  |  Volume : 3  |  Issue : 2  |  Page : 92--94

Hairpin coiling of central line catheter: Pinch-off syndrome?


Ravneet Kaur Gill, Uma Rathi, Charmila Choudhary, Aravind B Guledagudd 
 Department of Anaesthesia, Government Medical College and Hospital, Chandigarh, India

Correspondence Address:
Uma Rathi
Department of Anaesthesia, Government Medical College and Hospital, Sector 32, Chandigarh
India

Abstract

Central line insertion is a commonly performed procedure in the intensive care unit. Although technical difficulty is moderate, experience decreases the failure rate. Central vein catheter (CVC) insertion is associated with various complications such as pneumothorax and arterial puncture, but rare possibilities such as coiling of catheter can still occur and every intensivist should be cautious about it. Chest X-ray remains the gold standard to confirm the course and position of CVC and should be correlated with clinical findings. We report a case where CVC insertion was associated with coiling and led to occlusion of the proximal port.



How to cite this article:
Gill RK, Rathi U, Choudhary C, Guledagudd AB. Hairpin coiling of central line catheter: Pinch-off syndrome?.Saudi Crit Care J 2019;3:92-94


How to cite this URL:
Gill RK, Rathi U, Choudhary C, Guledagudd AB. Hairpin coiling of central line catheter: Pinch-off syndrome?. Saudi Crit Care J [serial online] 2019 [cited 2019 Nov 13 ];3:92-94
Available from: http://www.sccj-sa.org/text.asp?2019/3/2/92/267615


Full Text



 Introduction



A central venous catheter is placed into a large vein to administer medications or fluids. Although regarded as a safe technique, it is associated with many complications such as injury to local structures, hematoma formation at the insertion site, inadvertent arterial puncture, pneumothorax, hemothorax, arrhythmia, and catheter malposition. We report a case of pinch-off of central venous catheter in the right subclavian vein where coiling of the catheter led to the occlusion of proximal port although the distal port was working.

 Case Report



A 53-year-old female presented to our emergency department with the alleged history of road traffic accident. On examination, she was disoriented and agitated. General examination revealed tachypnea (respiratory rate of 36/min), tachycardia (122 beats/min), and blood pressure of 94/56 mmHg. Radiological evaluation revealed multiple rib fractures and right shaft of femur fracture with right tibial fracture. The decision to intubate the trachea was undertaken in view of decreasing trends of oxygen saturation (86%) even after oxygen supplementation by high-flow venturi mask. After tracheal intubation, the patient was shifted to the intensive care unit (ICU) for mechanical ventilation and further management. An intercostal drain on the right side was in situ which was placed in the emergency department to drain the hemothorax. In view of hemodynamic instability, operative management for fractures was deferred. Persistent fall of blood pressure warranted the need to use multiple vasopressors as per the institutional protocol. The decision to cannulate the right subclavian vein was taken to administer multiple blood products and drugs. After confirming the normal coagulation profile and platelet count, with all aseptic precautions under local anesthesia, right subclavian vein was cannulated with double-lumen heparin saline flushed central vein catheter (CVC) (Certofix, B Braun ®) using standard Seldinger method through infraclavicular approach by landmark technique. The procedure of CVC insertion was uneventful. The central line was inserted till 13 cm mark. The guidewire was withdrawn without any resistance. Free flow of blood was obtained from the distal port, but there was no free flow of blood from the proximal port, although heparinized saline could be pushed through both the ports. In view of urgency for administration of drugs, the central line was started through the distal port only. Post central line chest X-ray (CXR) was done to confirm the position of the central line. The patient developed intractable hypotension and ultimately underwent cardiopulmonary arrest. Cardiopulmonary resuscitation was started according to the advanced cardiac life support protocol. However, the patient could not be revived and was declared dead. We got the CXR after 2 h, in which folding of the central venous catheter was noted [Figure 1]. The hairpin loop coiling was noted at the point of opening of the proximal port which may have rendered it nonfunctional. All the lines were removed after the death of the patient, and central venous catheter was thoroughly examined but was found to be normal.{Figure 1}

 Discussion



Central venous catheter placement is a routine practice in ICUs and in the perioperative period for monitoring the fluid status or assessing circulating blood volume, cardiac status, and vasomotor tone in critically ill patients and during major surgeries.[1]

Although routinely practiced, it requires expertise and can cause various complications. Commonly associated complications are arterial puncture, pneumothorax, hemothorax, hematoma formation, laceration of thyrocervical trunk, and carotid jugular fistula. The rate of incidence of complication in subclavian vein cannulation is 6%–10%.[2] Maximum chances (9.1%) of malposition of CV catheter occur when the right subclavian route is used.[3] Even if free flow of blood is noticed from the ports, it does not necessarily confirm proper placement of the catheter tip.[4] It can get obstructed between the first rib and the clavicle characteristically known as pinch-off syndrome. Catheter pinch-off syndrome leads to mechanical obstruction, thereby leading to failure of infusion.

Coiled and occluded catheters may pose a risk to the patient as it may end in catheter fracture and a part may embolize which can culminate into fatal endings.[5] No free blood aspiration from the port is a marker of some occlusion; therefore, a nonfunctional catheter must be removed under caution and replaced in a different site to minimize the complications. Negative aspiration from the proximal port in our case was due to acute coiling at that level, but the urgent need to resuscitate the patient made us to use the distal port.

Different landmarks, CXR, central vein pressure (CVP) waveform, right atrial electrocardiography, ultrasonography, and fluoroscopy have been used to ensure the correct placement of CVC.[6] Utilization of ultrasound decreases the failure rate but does not help in detecting malposition of the tip of the CVP catheter.[5] The use of ultrasound in subclavian vein cannulation had a 100% overall success rate in a study conducted by Marek in 40 cardiac surgical patients.[7] CXR remains the gold standard to confirm the tip of catheter.[8]

Similarly, in our case, the coiling was confirmed after CXR and supported the reason behind nonfunctional distal port. It was hypothesized that the coiling occurred at the level of opening of the proximal port. The coiled catheter should be removed and a new one should be inserted for optimal function of CVC. However, time did not permit it in our case.

 Conclusion



Although CVC obstruction is rare, it still should be kept in mind and should be ruled out whenever feasible. Confirmation by CXR remains the mainstay for the course of the catheter and should be obtained as soon as possible. Nonaspiration of blood from any port warrants the attention of some occlusion or obstruction, and whenever feasible, the line must be removed and reinserted.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We are thankful to the Department of Anesthesia and Critical Care, Government Medical College and Hospital. Chandigarh.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Ghatak T, Azim A, Baronia AK, Muzaffar SN. Malposition of central venous catheter in a small tributary of left brachiocephalic vein. J Emerg Trauma Shock 2011;4:523-5.
2McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33.
3Goyal V, Sahu S. Coiling of central venous catheter in the left subclavian vein, a rare complication. Indian J Crit Care Med 2014;18:105-6.
4Hohlrieder M, Schubert HM, Biebl M, Kolbitsch C, Moser PL, Lorenz IH, et al. Successful aspiration of blood does not exclude malposition of a large-bore central venous catheter. Can J Anaesth 2004;51:89-90.
5Hayaran N, Goyal N, Joy S, Jain A. Coiling of central venous catheter: A rare and preventable complication. Anesth Essays Res 2017;11:773-5.
6Kumar A, Gupta K, Bhandari S, Singh R. Folding back of central venous catheter in the internal jugular vein: Methods to diagnose it at the time of insertion? Indian J Anaesth 2013;57:104-5.
7Marek T. Real-time in-plane ultrasound-guided supraclavicular approach to subclavian vein cannulation in cardiac surgery: An underused approach. Egypt J Anaesth 2014;30:175-80.
8Ambesh SP, Pandey JC, Dubey PK. Internal jugular vein occlusion test for rapid diagnosis of misplaced subclavian vein catheter into the internal jugular vein. Anesthesiology 2001;95:1377-9.