We would like to make some remarks to the case report on pericardial tamponade as a delayed lethal complication of central venous catheterization by B. Yavaşcaoğlu and his colleagues . Their case report demonstrates vividly the need for clinical tests and vigilant operators who respond to the clues that something might be wrong.
On the chest radiograph a curved appearance of the distal catheter was found to be a specific radiographic sign of superior vena cava (SVC) perforation preceding other clinical or radiological signs . We agree that the use of the electrocardiogram is less helpful for localizing the catheter tip: such a technique can tell the operator only whether the tip is within the atrium, not where it is within the venous system or whether it has even left the venous system. However, we strongly disagree with their statement on optimal catheter tip position. As the authors state correctly, catheter tip position shifts slightly with movements of the neck. Therefore, the upper segment of the superior vena cava or even the innominate vein are not the best places for the catheter tip. Here it may migrate into the azygos arch or may erode and perforate the vein and then cause pleural effusion, hydrothorax, haemothorax, hydromediastinum, pneumothorax and pneumomediastinum. Although the effects are less dramatic than for perforation of the heart, there is appreciable morbidity and mortality. Perforation of the medial wall of the superior vena cava can produce tamponade directly. This is explained by the finding that the pericardium may ascend alongside the medial wall of the SVC by 3 cm and up to 5 cm . Perforation is thought to occur as a result of mechanical trauma from the catheter tip or chemical damage from infused solutions. Factors affecting the risk of perforation are numerous. Stiffer catheters are more likely to perforate. Furthermore, the angle that the tip of the catheter makes with the wall of the vein or heart is crucial; the more perpendicular the catheter is to the wall, the greater the risk of perforation . Finally, in the case described here, perforation may be due to trauma from the guidewire or dilator. The overall thrombosis rate from central venous catheterization (CVC) is up to 70% . Thrombosis occurs at the place of repeated trauma to the endothelium from the catheter tip. There is increasing evidence of a relationship between high placement of the catheter tip (upper SVC and above) and thrombosis . The catheter tip should be placed in as large a vein as possible, ideally outside the heart and parallel with the long axis of the vein such that the tip does not abut the vein or heart wall end-on.
Percutaneous central venous puncture is a procedure requiring advanced operating skills, expert supervision of inexperienced doctors, and meticulous attention to detail. To prevent potentially lethal hazards clinicians should have detailed knowledge of the complications of CVC, and a high index of suspicion that clinical deterioration may be due to the catheter.
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