Acute and Critical Care

Cardiology/Pediatric
Suspected Pulmonary Embolism during Hickman Catheterization in a Child: What Else Should Be Considered besides Pulmonary Embolism?: Haemi Lee, Jonghyun Baek, Sangyoung Park, Daelim Jee; Korean J Crit Care Med. 2016;31(1):63-67. Published online February 29, 2016; DOI: https://doi.org/10.4266/kjccm.2016.31.1.63

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Abstract PDF: A 16-month-old girl with acute lymphoblastic leukemia expired during Hickman catheter insertion. She had undergone chemoport insertion of the left subclavian vein six months earlier and received five cycles of chemotherapy. Due to malfunction of the chemoport and the consideration of hematopoietic stem cell transplantation, insertion of a Hickmann catheter on the right side and removal of the malfunctioning chemoport were planned under general anesthesia. The surgery was uneventful during catheter insertion, but the patient experienced the sudden onset of pulseless electrical activity just after saline was flushed through the newly inserted catheter. Cardiopulmonary resuscitation was commenced aggressively, but the patient was refractory. Migration of a thrombus generated by the previous central catheter to the pulmonary circulation was suspected, resulting in a pulmonary embolism.

Pulmonary
Central Venous Catheter-Related Hydrothorax: Se Hun Kim, Charles Her; Korean J Crit Care Med. 2015;30(4):343-348. Published online November 30, 2015; DOI: https://doi.org/10.4266/kjccm.2015.30.4.343

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Abstract PDF: This report describes a case of 88-year-old women who developed central venous catheter-related bilateral hydrothorax, in which left pleural effusion, while right pleural effusion was being drained. The drainage prevented accumulation of fluid in the right pleural space, indicating that there was neither extravasation of infusion fluid nor connection between the two pleural cavities. The only explanation for bilateral hydrothorax in this case is lymphatic connections. Although vascular injuries by central venous catheter can cause catheter-related hydrothorax, it is most likely that the positioning of the tip of central venous catheter within the lymphatic duct opening in the right sub-clavian-jugular confluence or superior vena cava causes the catheter-related hydrothorax. Pericardial effusion can also result from retrograde lymphatic flow through the pulmonary lymphatic chains.

Vascular Surgery
Guide Wire Entrapment during Central Venous Catheterization: Kyung Woo Kim, Jun Hyun Kim, Se Hyeok Park, Ji Yeon Kim, Sang Il Lee, Kyung Tae Kim, Jang Su Park, Jung Won Kim, Won Joo Choe; Korean J Crit Care Med. 2014;29(2):137-140. Published online May 31, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.2.137

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Abstract PDF: We experienced a case of venous vessel wall entrapment between the introducer needle and the guide wire during an attempt to perform right internal jugular vein (IJV) catheterization. The guide wire was introduced with no resistance but could not be withdrawn. We performed ultrasonography and C-arm fluoroscopy to confirm the entrapment location. We assumed the introducer needle penetrated the posterior vessel wall during the puncture and that only the guide wire entered the vein; an attempt to retract the wire pinched the vein wall between the needle tip and the guide wire. Careful examination with various diagnostic tools to determine the exact cause of entrapment is crucial for reducing catastrophic complications and achieving better outcomes during catheterization procedures.

Air Embolism in the Left Ventricle after the Removal of a Central Venous Catheter: Duk Song Cho, Moo Hyun Kim, Dong Hyun Lee, Hye Won Lee, Eun Bin Kim, Seok Hyun Kim, Hyo Jin Jung, Soo Jin Kim, Hyun Jeong Kim; Korean J Crit Care Med. 2013;28(4):318-322.; DOI: https://doi.org/10.4266/kjccm.2013.28.4.318

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Abstract PDF

Air embolism is a rare, potentially critical complication that can induce death. Central venous catheterization, which is commonly used for critically ill patients, is a possible cause of air embolism. We experienced a severe air embolism with abnormal air in left ventricle after CVC removal in a patient who was treated for eosinophilic pneumonia. Although the neurologic symptoms were severe, the patient was successfully treated with immediate hyperbaric oxygen therapy and the neurologic deficit was minimal.

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Lethal coronary air embolism caused by the removal of a double-lumen hemodialysis catheter: a case report
Sung Ha Mun, Dong Ai An, Hyun Jung Choi, Tae Hee Kim, Jung Woo Pin, Dong Chan Ko
Korean Journal of Anesthesiology.2016; 69(3): 296. CrossRef

How to Decrease the Malposition Rate of Central Venous Catheterization: Real-Time Ultrasound-Guided Reposition: Hongjoon Ahn, Gundong Kim, Byulnimhee Cho, Wonjoon Jeong, Yeonho You, Seung Ryu, Jinwoong Lee, Seungwhan Kim, Insool Yoo, Yongchul Cho; Korean J Crit Care Med. 2013;28(4):280-286.; DOI: https://doi.org/10.4266/kjccm.2013.28.4.280

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Abstract PDF

BACKGROUND
The purpose of this retrospective and prospective study is to evaluate the efficiency of ultrasound (US) guidance as a method of decreasing the malposition rate of central venous catheterization (CVC) in the emergency department (ED).
METHODS
We retrospectively enrolled 379 patients who underwent landmark-guided CVC (Group A) and prospectively enrolled 411 patients who underwent US-guided CVC (Group B) in the ED of a tertiary hospital. Malposition of the CVC tip is identified when the tip is not located in the superior vena cava (SVC). In Group B, we performed US-guided intravascular guide-wire repositioning and then confirmed the location of the CVC tip with chest radiography when the guide-wire was visible in any three other vessels rather than in the approached vessel. In the case of a guide-wire inserted into the right subclavian vein (SCV), the left SCV and both internal jugular veins (IJV) were referred to as the three other vessels. The two subject groups were compared in terms of the malposition rate using Fisher's exact test (significance = p < 0.05).
RESULTS
There were 38 malposition cases out of a total of 790 CVCs. The malposition rates of Groups A and B were 5.5% (21) and 4.1% (17), respectively, and no statistically significant difference in malposition rate between the two groups was found. In Group B, the malposition rate was decreased from 4.1% (17) to 1.2% (5) after the guide-wire was repositioned with US guidance, which led to a statistically significant difference in malposition rate (p < 0.01).
CONCLUSIONS
The authors concluded that repositioning the guide-wire with US guidance increased correct placement of central venous catheters toward the SVC.

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Safety and Feasibility of Ultrasound-guided Peripherally Inserted Central Catheterization for Chemo-Delivery
Tak-Joong Song, Shin-Seok Yang, Woo-Sung Yoon
Journal of Surgical Ultrasound.2019; 6(1): 14. CrossRef
Single Center Experience of Ultrasonography-guided Bedside Procedures for Surgical Patients
Dooreh Kim, Dae Hyun Cho, Yun Tae Jung, Jae Gil Lee
Journal of Surgical Ultrasound.2018; 5(2): 61. CrossRef
Direction of the J-Tip of the Guidewire to Decrease the Malposition Rate of an Internal Jugular Vein Catheter
Byeong jun Ahn, Sung Uk Cho, Won Joon Jeong, Yeon Ho You, Seung Ryu, Jin Woong Lee, In Sool Yoo, Yong chul Cho
The Korean Journal of Critical Care Medicine.2015; 30(4): 280. CrossRef

Surgical Management for Pulmonary Artieriole Rupture During Subclavian Vein Catheterization: A Case Report: Jiae Min, Hyun Koo Kim, Ho Kyung Sung, Hyun Joo Lee, Young Ho Choi; Korean J Crit Care Med. 2012;27(1):59-61.; DOI: https://doi.org/10.4266/kjccm.2012.27.1.59

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Abstract PDF: We experienced an extremely unusual case of a 37-year-old woman who suffered from hemothorax soon after subclavian vein catheterization. Many case reports of a hemothorax or hematoma after central vein catheterization through the great vessels, such as the subclavian vein and internal jugular vein, have been published. However, this rare case showed a pinpoint-sized active bleeding site from a pulmonary arteriole rupture. During an emergency operation using thoracoscopy-assisted minithoracotomy, this bleeding site was successfully managed by primary repair.

Central Venous Catheter Misplaced in the Innominate Vein after Penetrating the Left Subclavian Vein in a Neonate: A Case Report: Sang Wook Shin, Ji Uk Yoon, Hyeon Jeong Lee, O Sun Kwon, Hyun Mok Kim; Korean J Crit Care Med. 2012;27(1):49-51.; DOI: https://doi.org/10.4266/kjccm.2012.27.1.49

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Abstract PDF: In the pediatric ICU and operating room, a central venous catheter (CVC) provides accurate hemodynamic information and serves as a reliable route for the administration of vasoactive drugs, fluids and allogeneic blood products. The placement of CVC is associated with a complication rate of 0.4% to 20%, including hemothorax, pneumothorax, thrombosis, infection and cardiac tamponade. We describe a case of CVC being misplaced in the innominate vein after penetrating the subclavian vein during anesthesia induction for arterial switch operation. Our report discusses the mechanisms by which this mishap took place, and reviews the proper positions of the head, arm, thorax and safe depth of venipuncture for the placement of a CVC in neonates.

Knotting and Kinking of the Guidewire during Central Venous Catheterization: A Case Report: Deokkyu Kim, Ji Hye Lee, Dong Chan Kim, Hyungsun Lim, Seonghoon Ko, Ji Seon Son; Korean J Crit Care Med. 2011;26(1):38-40.; DOI: https://doi.org/10.4266/kjccm.2011.26.1.38

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Abstract PDF: Central venous catheterization is often necessary to manage critically ill patients in the intensive care unit and some surgical patients in the operating room. However, this procedure can lead to various complications. We experienced a case of subclavian venous catheterization that was complicated by looping, kinking, knotting, and entrapment of the guidewire. We were able to identify the extravascular looping and knotting of the guidewire under fluoroscopy and consequently removed it successfully. We suggest that a guidewire should be confirmed by fluoroscopic imaging if it has become entrapped.

Delayed Pleural Effusion after Right Subclavian Vein Catheterization: A Case Report: Ji Ung Kim, Ji Hyun Cheon, Il Soo Kim, Sun Kwang Kim, Sung Hyun Ko, Sea Won Lee, Sang Hee Kim, Su Hong Kim; Korean J Crit Care Med. 2010;25(3):190-193.; DOI: https://doi.org/10.4266/kjccm.2010.25.3.190

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Abstract PDF: Central venous catheterization is commonly used for supplying large amounts of fluids, total parenteral nutrition and for monitoring central venous pressure. Numerous complications exist with the technique, including pneumothorax, arterial puncture with vessel injury, catheter embolus, mediastinal hematoma, hydrothorax, and the thrombus of the vein. We reported an uncommon case of pleural effusion, due to catheter tip migration and penetration, which occurred 4 days after central venous catheterization.

Malfunction due to Kinking and Bending of a Double Lumen Central Venous Catheter : A Case Report: Kyung Bong Yoon, Won Oak Kim, Jae Ho Cha, Ki Young Lee; Korean J Crit Care Med. 2006;21(2):131-134.

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Abstract PDF: Central venous catheters provide an important means of vascular access and are increasingly used. Catheter occlusion refers to the inability to infuse or withdraw fluids from a catheter and could be caused by either thrombotic or nonthrombotic origin. We report an unusual malfunction of double lumen central venous catheter due to kinking and bending of the catheter at the opening site of proximal lumen.

Medicolegal Aspects on Central Venous Catheterization Related Injury: Hyuna Bae, Sungeun Kim, Seokbae Lee, Rack Kyung Chung; Korean J Crit Care Med. 2006;21(1):42-50.

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Abstract PDF: BACKGROUND
We describe the characteristics of malpractice claims related to central venous catheterization and identify causes and potential preventability of such claims. METHODS: A retrospective study was performed by reviewing records at Lawnb and Lx CD-rom. The records on closed malpractice claim related to central venous catheterization were abstracted from the files available for analysis. The records were reviewed and were analysed to determine the factors associated with a successful defense.
RESULTS
Twelve closed claim cases, related to central venous cathetertization were reviewed in the data for malpractice. Catheter-related complications were pneumothorax, hemothorax, cardiac tamponade, pyothorax, hematoma due to arterial puncture, pseudoaneurysm. Almost cases resulted in indemnity payment and verdict for patient. CONCLUSIONS: Although malpractice claims related to central venous catheterization were uncommon, they resulted in high rate and amount of indemnity payments. In pediatric patient, catheterization should be performed with attention. Clinicians should consider the underlying disease of patients and do any pretreatment if needed. Post-procedural radiologic confirmation can improve patient outcome and is also associated with decreased indemnity risk. Informed consent is also important.

The Carina as a Landmark for Evaluation of Adequate Central Catheter Tip Position with Computerized Tomography: Il Woo Shin, Mi Young Park, Ju Young Choi, Ju Tae Sohn, Heon Keun Lee, Young Kyun Chung; Korean J Crit Care Med. 2006;21(1):37-41.

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Abstract PDF: BACKGROUND
The aim of this study was to determine whether the carina can be used as a landmark for evaluation of adequate central catheter tip position, and to examine the relationship between easily measurable body size and variable anatomical parameter.
METHODS
The SVC dimensions and relationship to radiographic landmarks were retrospectively determined from computerized tomography (CT) scans of 200 patients. The CT findings were assessed in terms of SVC length (SVCL), the distance between the carina and the right atrium inlet (CAL), and the sternal length (STL). Pearson's correlation and a regression test for height versus SVCL, STL versus SVCL and CAL were performed.
RESULTS
The median length of the SVC was 4.2 cm (range; 1.6 to 7.2 cm) and the distance between the carina and the right atrium inlet was 2.4 cm (range; 0.8 to 5.6 cm). With the regression test, height was correlated with SVCL (r(2)=0.09), and STL was correlated with both SVCL (r(2)=0.12) and STL (r(2)=0.04).
CONCLUSIONS
The carina was located always above the right atrium inlet. The carina was a reliable, simple anatomical landmark for the determination of correct placement with computerized tomography.

Cutting of Guide Wire and Hydrothorax after Subclavian Venous Catheterization for Premature Infant: A case report: Hyun Soo Moon, Sung Hee Han; Korean J Crit Care Med. 1999;14(1):37-41.

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Abstract PDF: Central venous catheterization is one of the common procedures in the care of critically ill patients but numerous major complications have been reported. This report is about a case of sequential complications that were developed after two attempts of subclavian venous catheterization via supraclavicular approach for a critically ill 1.5 kg premature infant in intensive care unit. In the first attempt, the guidewire was cut and remained in the right atrium but fortunately removed without surgery. In the second attempt for the same patient, the catheter positioned out of the vessel. It was in right pleural cavity and caused hydrothorax. After third attempt, successful left subclavian vein catheterization was done.

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