Neurologic manifestations of cerebral air embolism as a complication of central venous catheterization

OBJECTIVE, PATIENTS, AND METHODS: A severe case of cerebral air embolism after unintentional central venous catheter disconnection was the impetus for a systematic literature review (1975-1998) of the clinical features of 26 patients (including our patient) with cerebral air embolism resulting from central venous catheter complications. RESULTS: The jugular vein had been punctured in eight patients and the subclavian vein, in 12 patients. Embolism occurred in four patients during insertion, in 14 patients during unintentional disconnection, and in eight patients after removal and other procedures. The total mortality rate was 23%. Two types of neurologic manifestations may be distinguished: group A (n = 14) presented with encephalopathic features leading to a high mortality rate (36%); and group B (n = 12) presented with focal cerebral lesions resulting in hemiparesis or hemianopia affecting mostly the right hemisphere, with a mortality rate as high as 8%. In 75% of patients, an early computed tomography indicated air bubbles, proving cerebral air embolism. Hyperbaric oxygen therapy was performed in only three patients (12%). A cardiac defect, such as a patent foramen ovale was considered the route of right to left shunting in 6 of 15 patients (40%). More often, a pulmonary shunt was assumed (9 of 15 patients; 60%). For the remainder, data were not available. CONCLUSION: When caring for critically ill patients needing central venous catheterization, nursing staff and physicians should be aware of this potentially lethal complication.     

Venous air embolism: clinical and experimental considerations.

OBJECTIVE: To examine the existing literature concerning venous air embolism. Causes, pathophysiology, and management are emphasized. DATA SOURCES: The literature that was reviewed was retrieved from the MEDLINE System under the headings "venous air embolism," "air embolism," "therapy of air embolism," "etiology of venous air embolism," and "pathophysiology of venous air embolism" for the years 1970 to 1991. A manual search, derived from the references of these papers, was performed to obtain relevant citations for the years preceding 1970. STUDY SELECTION: Experimental (animal) data, case reports, case series, and clinical investigations are included. CONCLUSIONS: Venous air embolism is an infrequent complication of invasive diagnostic and therapeutic maneuvers. The cardiovascular, pulmonary, and central nervous systems may all be affected, with severity ranging from no symptoms to immediate cardiovascular collapse. Therapeutic interventions include mechanical measures, such as positioning, withdrawal of air from the right atrium, and measures aimed at reducing bubble size. Hyperbaric oxygen therapy holds some promise in accomplishing the latter, but randomized, controlled trials demonstrating efficacy have yet to be performed.     

Venous thromboembolism and gliomas: the need for increased vigilance

Brain tumors, particularly malignant gliomas, have a high incidence of venous thromboembolism (VTE), but current guidelines do not support primary VTE prophylaxis for ambulatory patients with brain tumors. The often subtle presentation of VTE warrants increased vigilance for early diagnosis and treatment. This article presents a case study of a patient with VTE and offers suggestions for future research.     

Unusual catheter tip placement from attempted central venous catheterization

Percutaneous catheterization of the subclavian and internal jugular veins is rapid and has overall complication rates from 0% to 11.2%. Noncentral placement of catheter tips has been reported in 1% to 16% of all cases. Two previously unreported locations for noncentral placement of catheter tips are described.     

Air embolism: a serious hazard of central venous catheter systems

Central venous catheter systems are an important yet little recognised source of serious air embolism. Scrupulous care and vigilant observation of this equipment is necessary to prevent the severe cardio-respiratory and neurological sequelae which may occur. Air embolism following central venous catheterisation is one of the most serious complications of this procedure. We describe an unusual and hitherto unreported mechanism by which air accidentally entered the circulation; fortunately in this case there were no serious sequelae.     

Deep venous thrombosis and pulmonary embolism. The importance of heightened awareness.

Left untreated, deep venous thrombosis and pulmonary embolism have a high rate of mortality and long-term morbidity. Physicians therefore must maintain a high index of suspicion for these conditions. Accurate diagnosis is facilitated by knowing the most common sites of thrombus formation, the likelihood of propagation, which patients are at greatest risk, signs and symptoms, and which tests to order. Prompt administration of anticoagulants and, in some cases, thrombolytic agents can minimize the consequences of these diseases. Interruption of the inferior vena cava, thrombectomy, and thromboembolectomy are other treatment options.     

Pulmonary venous air embolism following accidental patient laceration of a hemodialysis catheter.

As the number of patients at home with indwelling central venous catheters increases, more complications from their use will present to the emergency department. We report a case of pulmonary venous air embolism after a patient inadvertently severed the distal few centimeters of an indwelling central venous catheter.     

Successful retrograde tracheal intubation using a central venous catheterization set: two cases

Retrograde tracheal intubation (RTI) is an airway management technique requiring relatively simple skills that can be learned easily and retained. However, proper RTI equipment is not generally available in many ED. RTI requires through‐the‐needle catheters and flexible‐tip guidewires, which are included in the more generally available central venous catheterization set. We performed RTI using the central venous catheterization set in two patients with obstructed airways where specific RTI equipment was unavailable and demonstrated successful intubation in both cases. Our method might be a useful alternative for RTI in situations where the purpose‐specific equipment is unavailable.     

Subclavian central venous catheterization complicated by guidewire looping and entrapment.

The placement of central venous catheters is a technically challenging procedure with known risks and complications. We report an attempted left subclavian central venous catheterization that was complicated by looping and entrapment of the guidewire. We hypothesize that this complication occurred because the straight guidewire that was used may have perforated the wall of the vein, allowing the guidewire to loop upon itself. Although catheter looping and knotting are well known potential complications of central venous catheterization, similar complications are rarely reported with guidewires. Clinicians should be aware of these potential complications when performing or teaching central venous catheterization.     

Comparison of central venous catheterization with and without ultrasound guide.

PURPOSE: To compare the effectiveness, safety and time needed to perform central venous catheterization (CVC) in the presence or absence of an ultrasound (US) guide. METHODS: Between January 1999 and February 2002 we performed CVCs in 196 patients: 105 patients received US guided CVC (group I) and 91 patients had CVC without US guide (group II). RESULTS: The average time to perform CVC was shorter with US guide (4 vs 7 min). The utilization of the US guide was also associated with improved success (98.09% vs 91.2%, p<0.025) and lack of major complications (0% vs 9.8%, p<0.001). CONCLUSIONS: US-guided CVC affords an easier, safer and more rapid cannulation of a central vein. It is especially helpful in those patients with anatomical variation or difficult veins (small or not visible, non-palpable landmarks) and in those with coagulative disorders.     

Cardiac tamponade complicating central venous catheterization for total parenteral nutrition: A review

Tamponade of the heart resulted when a central venous catheter penetrated the wall of the right atrium in a patient receiving total parenteral nutrition. All previously reported cases (13) of this complication were reviewed. The mortality rate was 64%. In 5 of 12 (42%) of the cases silastic catheters were involved. Although the hyperosmolar nature of the infusate would appear to compound the risk, we believe malposition of the catheter to be the principle cause of this catastrophic complication. Central venous catheters must not be advanced into the right atrium or ventricle.     

Use of ultrasound guidance for central venous catheterization: a national survey of intensivists and hospitalists

PurposeThe purpose of the study is to evaluate the frequency and barriers to use of ultrasound guidance for central venous catheter (CVC) insertion by physicians specializing in critical care and hospital medicine.Materials and methodsA national cross-sectional electronic survey of intensivists and hospitalists was administered from November 2014 to January 2015.ResultsThe survey response rate was 5.9% (1013/17 233). Moderate to very frequent use of ultrasound guidance varied by site: internal jugular vein (80%), subclavian vein (31%), and femoral vein (45%). Nearly all physicians (99%) who insert internal jugular CVCs daily use ultrasound guidance, whereas only 46% of physicians who insert subclavian CVCs daily use ultrasound guidance. Use of real-time ultrasound guidance varied by insertion site: internal jugular vein (73%), subclavian vein (28%), and femoral vein (42%). Most physicians (59%) reported not being comfortable with real-time needle tracking at the subclavian site. The most frequently reported barriers to use of ultrasound guidance were (1) limited availability of ultrasound equipment (28%), (2) perception of increased total procedure time (22%), and (3) concern for loss of landmark skills (13%).ConclusionsMost intensivists routinely use ultrasound guidance to insert internal jugular CVCs but not subclavian CVCs. The most commonly reported barrier to ultrasound use was limited access to an ultrasound machine.