Dilator-associated complications of central vein catheter insertion: Possible mechanisms of injury and suggestions for prevention

Abstract

This report discusses different types of dilators used in central line insertion, describes the mechanisms of injury, and proposes guidelines tor safer dilator insertion and improvements in dilator design.* CASE 1 A double-lumen hemodialysls catheter was inserted in an 84-year-old woman with a history of congestive heart failure and renal failure. The anterior approach to the right internal jugular vein (RIJV) at the apex of the triangle formed by the sternocleidomastoid muscle was chosen. The RIJV was entered with the 18-gauge introducer needle and penetrated to a depth of 2 to 3 cm. Dark nonpulsatile blood return was noted. The guidewire was passed smoothly through the needle. A small incision was made around the guidewire with a scalpel. The 12F dilator was passed over the guldewlre to its full extent (about 19 cm) and then withdrawn. The catheter was then inserted over the wire, and blood return was obtained from both ports. Ten minutes after the procedure, the patient complained of respiratory distress and immediately went into cardiac arrest (pulseless electrical actwity). During intubation and resuscitation, a right-side chest tube was inserted, and it drained more than 700 mL of blood A chest radiograph showed that the dialysis catheter was in place in the superior vena cava (SVC), well above the right atrium. It *The authors did not xdentlfy manufacturers by name To their knowledge, all of the currently available central hne kits suffer from dilator design flaws.