Step-by-step guide to averting and managing a central line insertion misadventure

Abstract

Background: Central venous cannulation or catheterization (CVC) forms the core of managing critically ill patients. Inadvertent arterial or venous injury, despite the use of duplex ultrasound (DUS), can lead to significant and devastating complications, especially when large-bore cannulas are used. This article explains the way we managed four different scenarios and suggests a step-by-step guide to insertion of a CVC and management of a misadventure. Methods: We maintained the records and followed up four adult patients requiring hemodialysis who had misadventures with CVC insertion between March 2018 and January 2019, with large-bore (>7Fr) cannulas. They were all followed up for 6 months. Results: Four patients, 2 males and 2 females, between 25 and 82 years of age, underwent CVC insertion in an intensive care setting. The youngest had a carotid-jugular arteriovenous fistula that was detected after discharge and managed successfully by open surgery. The eldest, a male patient, had a perforation of the external iliac vein, which was managed successfully with endovascular balloon inflation. The third patient had femoral artery pseudoaneurysms, which were managed successfully with serial DUS compression. The fourth had an inadvertent puncture of the right common carotid artery during the insertion of jugular CVC and was managed by manual and DUS compression. Conclusion: DUS has reduced the incidence of complications from the insertion of CVC. However, in order to further reduce or nullify the possibility of arterial punctures during CVC insertion, whether it be a small ( 7Fr) cannula, the operator needs to follow certain basic steps, be aware of potential complications and know how to approach an inadvertent arterial/venous/nerve injury. The literature mostly deals with how complications were managed while we impress on the need for prevention. The authors recommend that clinical guidelines be formulated and followed in hospitals.