An unusual complication following central venous catheter placement

Abstract : A 38 year old female, diagnosed with rheumatic mitral stenosis was posted for an elective mitral valve replacement surgery. In the operating room, prior to induction of anaesthesia, central venous cannulation of the right internal jugular vein was performed by the central approach using Seldingers technique. In spite of the free venous blood flow on aspiration, the guide wire failed to advance beyond 10 cm in two attempts. Following this, guide wire was introduced with the opposite straight end first, which passed freely, and catheter was inserted. On check aspiration, there was free flow of blood from all three lumens, CVP trace was present and initial CVP read 7 cm H2O. The patient vitals were stable. No check X-ray was obtained. Attempts to induce the patient into anaesthesia by administering drugs through the central venous line failed, following which the catheter was suspected to be defunct. Intra operatively, the surgeons traced the catheter tip which was found to have punctured the right internal jugular vein, right subclavian artery and the right side pleura on its course into the right intrapleural space. Keyword :Central venous cannulation, J-tip, guide wire, central venous catheter insertion complications, malposition, internal jugular vein