Catheterization of a large central vein is a standard clinical procedure in the ICU. It allows central venous pressure monitoring and provides secure long-term vascular access for drug administration and fluid resuscitation. Central venous access is also required for cardiac pacing, temporary haemodialysis or pulmonary artery catheterization [1,2]. Complications as a consequence of central access are rare and have been observed and described since the introduction of central venous catheterization into clinical practice in the late 1960s . We describe a case of tracheal injury with lethal complications in a 66-year-old woman.
A 66-year-old woman (68 kg weight and 168 cm height) with a recent history of 2 days of gastrointestinal symptoms was hospitalized in the surgical ward of a primary hospital for mechanical ileus with nausea/vomiting following colon cancer. Additional medical history included ischaemic heart disease, arterial hypertension and obesity for 15 years. On the second day after her operation, she developed serious respiratory failure with pneumonia that required tracheal intubation and mechanical ventilation. There was no evidence of difficult tracheal intubation. She was hypotensive, and inotropic therapy was started. A single-lumen catheter (Cavafix Certo Bbraun, Melsungen, Germany) was inserted into the right internal jugular vein with posterior approach for rapid fluid resuscitation and administration of vasoactive agent (dopamine dose of 20 μg kg−1 min−1). The same day, subcutaneous emphysema appeared in the neck, face and thoracic region. The patient required mechanical ventilation with 100% oxygen and positive end expiratory pressure (10 cmH2O). Chest radiograph showed neither pneumothorax nor abnormalities. The catheter's position was correct.
At this time, the patient was transferred to our ICU. On admission, the patient was sedated and ventilated with 100% oxygen, with administration of dopamine (dose of 20 μg kg−1 min−1). Blood pressure was 40/0 mmHg, and peripheral oxygen saturation was 30%. The patient went into cardiac arrest, and she was immediately resuscitated. Physical examination showed the large subcutaneous emphysema in the neck, face and thoracic region. We performed a chest radiograph, which showed pneumomediastinum, subcutaneous emphysema and bilateral pneumonia. The patient was mechanically ventilated, given fluid resuscitation, vasopressor agents (dopamine, the same dosage, and norepinephrine, 6 μg min−1) and antimicrobial therapy. We observed an increase in the subcutaneous emphysema on the second day after admission. We performed flexible bronchoscopy, which did not show the tracheal injury. Bronchoscopy was repeated on day 7 with the same result. On day 12 of the patient's ICU hospitalization and mechanical ventilation, tracheostomy was performed in the operating room without any problems, and, after that, the emphysema lessened from all regions. She was comatose all the time during her stay in the ICU.
Additionally, she had local peritonitis and was taken to the operating room and underwent a resection of an ischaemic distal segment of colon. After that, she developed septic shock with lactic acidosis, renal insufficiency and required continuous veno-venous haemofiltration. She developed refractory multiorgan failure and died on day 20 of treatment. An autopsy was performed, and the report described a perforation on the anterior right side of the trachea.
We describe a case of a fatal complication during a routine placement of a central venous catheter in the postoperative surgical unit. The procedure was performed by an experienced anaesthesiologist. We suspect that the tracheal perforation took place during the routine placement of the central venous catheter. When the patient was intubated and air leakage was present, we also observed the appearance and growth of the subcutaneous emphysema and pneumomediastinum during positive pressure ventilation. After tracheostomy, the emphysema decreased. The tracheal injury was 1 cm below the tracheostomy, and the tracheostomy tube cuff prevented the air leak. The injury was not confirmed by bronchoscopy.
Many complications of central venous catheterization have been described. Mechanical complications are reported ranging from 5 to 19% of patients . Typical early complications during placement of central venous access are mechanical complications including vascular injury puncture, cardiac tamponade and also respiratory compromise such as airway compression from haematoma, pneumothorax, perforation of trachea, nerve injury, arrhythmias, thromboembolic complications including venous thrombosis, pulmonary embolism, catheter or guidewire embolism and late infectious complications . The incidence of complications depends upon a number of factors, including the catheter insertion site and the patient's medical condition. The most common mechanical complication is unintended arterial puncture ranging from 3 to 15% . Ultrasound-guided catheterization has been investigated and described to improve the technique and decrease the complications of central cannulation. Fatal or catastrophic complications such as pneumothorax, tension pneumothorax, vascular perforation, tracheal perforation and other respiratory tract injury are rare. Tracheal injury is rarely published [5–7]. The subclavian approach has a much higher incidence of respiratory complications than the jugular approach . Konichezky et al. reported two cases of tracheal puncture as a complication of internal jugular vein cannulation by the posterior approach. Flatley and Shapira  described delayed complications, such as hydropneumomediastinum and bilateral hydropneumothorax, after inserting a central venous catheter through the left internal jugular vein.
Diagnosis of acute complications should be quickly stated. A chest radiograph should be ordered routinely in all patients after any central venous catheterization. This can immediately confirm complications such as a pneumothorax or subcutaneous emphysema. Every hospital should have standard protocols for all invasive, interventional procedures such as central venous catheterization.
1 Lewis CA, Allen TE, Burke DR, et al
. Quality improvement guidelines for central venous access. The Standards of Practice Committee of the Society of Cardiovascular & Interventional Radiology. J Vasc Interv Radiol 1997; 8:475–479.
2 Mark JBM, Slaughter TF. Cardiovascular monitoring. In: Miller RD, editor. Miller's anesthesia. 6th ed. Philadelphia: Elsevier Churchill Livingstone; 2005. pp. 1286–1301.
3 Merrer 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; 286:700–707.
4 Benter T, Teichgräber UKM, Klühs L, Dörken B. Percutaneous central venous catheterization with a lethal complication. Intensive Care Med 1999; 25:1180–1182.
5 Breen MT, Kageler WV. Puncture of the trachea during catheterization of the subclavian vein. N Engl J Med 1989; 320:1148.
6 Dutkowsky-Kanz J. Endotracheal tube cuff perforation during subclavian venipuncture attempt. AANA J 1975; 43:298.
7 Blitt CD, Wright WA. An unusual complication of percutaneous internal jugular vein cannulation, puncture of an endotracheal tube cuff. Anesthesiology 1974; 40:306–307.
8 Añel RL, Pingleton SK, Dellinger RPH. Respiratory and nonrespiratory complications of critical ill. In: Parrillo JE, Dellinger RPH, editors. Critical care medicine principles of diagnosis and management in the adult. St. Louis: Mosby; 2002. pp. 846–880.
9 Konichezky S, Saguib S, Soroker D. Tracheal puncture. A complication of percutaneous internal jugular vein cannulation. Anaesthesia 1983; 38:572–574.
10 Flatley ME, Shapira RM. Hydropneumomediastinum and bilateral hydropneumothorax as delayed complications of central venous catheterization. Chest 1993; 103:1914–1916.