Central venous catheter occlusion during mitral valve replacement surgery

Abstract

We have previously highlighted the potential problem of awareness during cardiac anaesthesia for mitral valve surgery [1] and recommended insertion of left sided central venous lines to reduce the risk of this complication. We now report a cardiac surgical case in which lumens of a left central venous line were occluded intraoperatively during mitral valve replacement. In a middle-aged gentleman undergoing mitral valve replacement, central venous access was established using a 4-lumen central venous catheter and a pulmonary artery sheath, both inserted into the left internal jugular vein. When the superior venacaval cannualation was performed by the surgeon, it compressed and occluded both the distal lumen and one medial lumen of the central venous catheter. It also occluded the arm of the pulmonary artery sheath which had the infusions of propofol and remifentanil. This was detected almost immediately when the anaesthetist noted resistance to an injection of phenylephrine. On careful checking, it was discovered that two lumens of the central venous catheter and the arm of the pulmonary artery sheath were allowing neither blood withdrawal nor passage of injected fluid. Immediately, propofol and remifentanil infusions were transferred onto the working lumens and midazolam 10 mg was given to prevent any awareness. As soon as the superior venacaval line was decannulated by the surgeon, all the lumens were freely aspirating blood and infusion through these lumens was again possible. In an earlier letter we highlighted a possible cause of interruption of intravenous infusions during cardiac cases where bicaval cannulation is employed, leading to awareness and haemodynamic instability. It is important to ensure that the tip of the central venous catheter is proximal to the superior venacava cannualation line. In accordance with our recommendation [1], it is our routine practice to gain central venous access on the left side in mitral valve surgery so as to minimise the risk of the central venous catheter getting occluded. Nevertheless, this case highlights the possibility of the lumen delivering anaesthetic agents being occluded or even isolated from the circulation even after the precaution of left-sided insertion is followed. We recommend attaching a separate three-way tap to the anaesthetic line to ensure that blood can be aspirated from this lumen following superior venacaval cannulation to verify functionality after surgical superior venacaval cannulation. The patient was not able to recall any of the intra-operative events.