Subclavian artery perforation and hemothorax after right internal jugular vein catheterization

Corresponding author: Dong Jun Lee, M.D., Department of Anesthesiology and Pain Medicine, Seoul Paik Hospital, Inje University College of Medicine, Jeodong 2-ga, Jung-gu, Seoul 100-032, Korea. Tel: 82-2-2270-0096, Fax: 82-2-2270-0095, E-mail: [email protected] This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC Internal jugular vein (IJV) catheterization is a common practice in the operating room for perioperative management. However, many complications associated with IJV catheterization has been reported such as adjoining arterial puncture and if subclavian arterial puncture occurs during IJV catheterization, it can be a life-threatening complication [1]. A 19 kg, 122 cm, 7-year-old Vietnamese boy with a known ventricular septal defect (VSD) was admitted for surgical intervention. A preoperative echocardiogram revealed small sized perimembranous type VSD with a left to right shunt. A chest x-ray showed cardiomegaly with increased pulmonary vasculature and an EKG showed left axis deviation. The peripheral blood test results were: Hemoglobin (Hb) 15.0 g/ dl, Hematocrit 43%, platelet 374,000/μl. Upon arrival in the operating room, the patient's blood pressure was 105/80 mmHg, pulse rate was 112 beats/min, and SpO2 was 100%. For anesthetic induction, propofol 40 mg and rocuronium 20 mg were intravenously administered and an endotracheal intubation with a 5.5 mm tube was performed. After induction of general anesthesia, the patient was positioned for right internal jugular vein catheterization. He was laid in a supine position with his head turned to the left. After identifying the triangle made by the sternal clavicular bellies of the sternocleidomastoid muscle and the clavicle, the 22-gauge fine needle was intended at the lateral edge of the sternal belly of the sternocleidomastoid muscle and punctured the internal jugular vein. Dark non pulsatile venous blood was aspirated. But as we inserted an 18-gauge introducer needle to the same site, fresh pulsatile arterial blood was aspirated and the puncture site had swollen up. The needle was withdrawn and the puncture site was pressed for over 5 minutes. The next attempt to the same site was successful and a central venous catheter (7 Fr Threelumen Central Catheterization Set with Arrowgard Blue, Arrow international Inc., PA, USA) was inserted to the right internal jugular vein. Before cardiopulmonary bypass (CPB), central venous pressure was 7-8 mmHg and well preserved. However, blood pressure continuously decreased during CPB, and did not respond to the administration of fluid and inotrophic agent. We maintained blood pressure until the CPB and during the first one hour of CPB, mean arterial pressure was 40 mmHg. Approximately 2 hours after central venous catheterization, in the CPB state, the mean arterial pressure dropped to 35 mmHg and Hb was 5.8 g/dl. Inotropic agents were started immediately: dobutamine infusion rate was 10 μg/kg/hr, norepinephrine infusion rate was 0.1 μg/kg/hr and epinephrine infusion rate was 0.1 μg/kg/hr. At that time we noticed that the right pleura side of the patient was bulging, suggesting a hemothorax. Surgeons opened the right pleura and found huge clots and fresh blood filled the entire chest. After removal of the clots, the operator noticed that blood was pumping from the right apical chest wall with surrounding tissue hematoma. Full sternotomy was done to expose the right chest apical portion and a right subclavian arterial rupture near the brachiocephalic trunk was found. It was directly repaired and 3 units of packed red blood cells were infused. The patient’s systolic blood pressure rose to 100 mmHg and all inotropic agents were discontinued. After insertion of a mediastinal and pleural drainage, the patient was transferred to the intensive care unit in a stable condition (Fig. 1).