Acute Back Pain and Paresthesia After Femoral Venous Catheter Placement

Abstract

We report a case of inadvertent cannulation of the ascending lumbar vein during femoral venous catherization, resulting in acute lower back pain and paresthesia. A 43-year-old, 4-ft, 7-in tall woman awaiting liver transplantation presented with a massive bleed from esophageal varices. A 16-cm, 7F, triple-lumen right femoral venous catheter (FVC) was placed emergently for volume management in the intensive care unit because peripheral venous access was difficult to obtain. There was good venous blood return in all ports, and rapid transfusion with packed red blood cells was begun. Within 30 minutes of FVC insertion, the patient reported intense right lower back pain radiating down the right anterior side of her thigh to the knee, associated with paresthesia in the same area of the right extremity. Body repositioning and intravenous morphine did not relieve the pain or the paresthesia. After the patient was stabilized, an abdominal computed tomography (CT) scan was obtained to rule out the possible diagnosis of retroperitoneal hematoma. The CT scan showed the FVC entering the right epidural venous plexus via the right ascending lumbar vein (Fig 1). The ascending lumbar vein connected with the external lumbar vein, which drained into the common iliac vein. There was no evidence of retroperitoneal or epidural hematoma or perforation. The catheter was withdrawn 9 cm back into the external iliac vein and the correct position as confirmed by a radiogram. The patient’s back pain and the anterior thigh paresthesia resolved within 1 hour without further complications. The FVC remained functional. Femoral lines are relatively fast and easily placed access ports for volume resuscitation. Common risks associated with FVC placement are retroperitoneal hematoma, arterial and venous perforation, nerve injury, catheter migration, infection, and thrombotic complications.1Merrer J. De Jonghe B. Golliot F. et al.Complications of femoral and subclavian venous catheterization in critically ill patients A randomized controlled trial.JAMA. 2001; 286: 700-707Crossref PubMed Scopus (974) Google Scholar, 2Deshpande K. Hatem C. Ulrich H. et al.The incidence of infectious complications of central venous catheters at the subclavian, internal jugular, and femoral sites in an intensive care unit population.Crit Care Med. 2005; 33: 13-20Crossref PubMed Scopus (174) Google Scholar, 3Izuishi K. Hashimoto S. Uchinomura S. et al.Malposition of femoral venous cannulation.Am J Surg. 2005; 189: 47-48Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Inadvertent malposition of the FVC into the ascending lumbar vein is a rare complication, with only a few pediatric and 1 adult case reported previously.3Izuishi K. Hashimoto S. Uchinomura S. et al.Malposition of femoral venous cannulation.Am J Surg. 2005; 189: 47-48Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 4Lavandosky G. Gomez R. Montes J. Potentially lethal misplacement of femoral central venous catheters.Crit Care Med. 1996; 24: 893-896Crossref PubMed Scopus (43) Google Scholar This is, to our knowledge, the first report of such a complication associated with acute-onset pain and paresthesia. Heightened clinical suspicion of a misplaced FVC must be present when unusual and acute-onset back pain or lower extremity paresthesia results after FVC placement. In this case, the patient’s small stature of 4-ft, 7-in might have contributed to the malpositioning of the FVC. Proper diagnosis and correction of the misplaced FVC can decrease the risk of iatrogenic injuries including neurologic sequelae, paraplegia, seizure, urinary retention, and even respiratory or cardiac arrest.3Izuishi K. Hashimoto S. Uchinomura S. et al.Malposition of femoral venous cannulation.Am J Surg. 2005; 189: 47-48Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 4Lavandosky G. Gomez R. Montes J. Potentially lethal misplacement of femoral central venous catheters.Crit Care Med. 1996; 24: 893-896Crossref PubMed Scopus (43) Google Scholar, 5Odaibo F. Fajardo C.A. Cronin C. Recovery of intralipid from lumbar puncture after migration of saphenous vein catheter.Arch Dis Child. 1992; 67: 1201-1203Crossref PubMed Scopus (27) Google Scholar A radiograph and CT scan may elucidate improper location of the catheter. With proper FVC repositioning, a critical venous access may be salvageable and iatrogenic injuries can be avoided.