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Respiratory Distress Requiring Surgical Intervention Following Traumatic Central Internal Jugular Vein Cannulation: Review Of 2 Cases
David J Archibald, MD; Matthew L Carlson, MD; Jan L. Kasperbauer, MD
Department of Otolaryngology-Head and Neck Surgery; Mayo Clinic School of Medicine, Rochester, MN
INTRODUCTION
INTRODUCTION
Acute upper airway obstruction may occur secondary to hematoma formation following traumatic internal jugular vein (IJV) cannulation. Though uncommon, hematoma after central access can be a life-threatening event that requires early and prompt intervention. We present two different
Acute upper airway obstruction may occur secondary to hematoma formation following traumatic internal jugular vein (IJV) cannulation. Though uncommon, hematoma after central access can be a life-threatening event that requires early and prompt intervention. We present two different
cases of airway obstruction caused by hematoma formation following IJV central line placement and discuss key management strategies.
cases of airway obstruction caused by hematoma formation following IJV central line placement and discuss key management strategies.
CASE
CASE #1
#1
A 67-year-old man with a history of coronary artery disease underwent
A 67-year-old man with a history of coronary artery disease underwent
elective percutaneous intervention with drug-eluting stent placement in his
elective percutaneous intervention with drug-eluting stent placement in his
LAD. The patient had been anticoagulated for the procedure with both
LAD. The patient had been anticoagulated for the procedure with both
heparin and anti-platelet therapy. During the procedure multiple failed
heparin and anti-platelet therapy. During the procedure multiple failed
attempts had been made at obtaining right IJV access for hemodynamic
attempts had been made at obtaining right IJV access for hemodynamic
monitoring. The patient developed immediate swelling in the region of the IJV
monitoring. The patient developed immediate swelling in the region of the IJV
puncture sites and was admitted for observation. After arrival to the hospital
puncture sites and was admitted for observation. After arrival to the hospital
floor, the primary service noted increasing hematoma formation. Additionally,
floor, the primary service noted increasing hematoma formation. Additionally,
the patient was complaining of worsening pain, new-onset hoarseness, and
the patient was complaining of worsening pain, new-onset hoarseness, and
difficulty swallowing his own secretions. An ENT consultation was requested.
difficulty swallowing his own secretions. An ENT consultation was requested.
A CT of the neck demonstrated a large (2x10x5 cm) hematoma in the right
A CT of the neck demonstrated a large (2x10x5 cm) hematoma in the right
neck abutting the IJV at the level of the glottis and infiltrating the
neck abutting the IJV at the level of the glottis and infiltrating the
retropharyngeal tissues (Figure A) resulting in a narrowing of the supraglottic
retropharyngeal tissues (Figure A) resulting in a narrowing of the supraglottic
airway. No contrast extravasation was noted.
airway. No contrast extravasation was noted.
On physical exam the patient was drooling and hoarse but did not have
On physical exam the patient was drooling and hoarse but did not have
any audible stridor. He had minimal swelling of his right neck from just below
any audible stridor. He had minimal swelling of his right neck from just below
the level of the cricoid to the supraclavicular region; however, there was
the level of the cricoid to the supraclavicular region; however, there was
significant ecchymosis around multiple puncture sites. The trachea was
significant ecchymosis around multiple puncture sites. The trachea was
midline. Flexible nasopharyngoscopy revealed pooling secretions in the
midline. Flexible nasopharyngoscopy revealed pooling secretions in the
hypopharynx and soft tissue fluctuance of the posterior pharyngeal wall with
hypopharynx and soft tissue fluctuance of the posterior pharyngeal wall with
airway encroachment. The patient underwent immediate fiberoptic
airway encroachment. The patient underwent immediate fiberoptic
nasotracheal intubation.
nasotracheal intubation.
The following day the patient was taken to the operating room where he
The following day the patient was taken to the operating room where he
underwent tracheotomy for a more secure airway (Figure B). Direct
underwent tracheotomy for a more secure airway (Figure B). Direct
laryngoscopy was subsequently performed, revealing a severe amount of
laryngoscopy was subsequently performed, revealing a severe amount of
posterior pharyngeal wall ecchymosis and edema (Figure C), though the
posterior pharyngeal wall ecchymosis and edema (Figure C), though the
glottic structures themselves appeared minimally edematous (Figure D). The
glottic structures themselves appeared minimally edematous (Figure D). The
patient was decannulated without event on postoperative day #9.
patient was decannulated without event on postoperative day #9.
A
B
C
CASE
CASE #2
#2
A 75-year-old man with a history of paroxysmal atrial fibrillation underwent
A 75-year-old man with a history of paroxysmal atrial fibrillation underwent
a right heart catheterization via IJV access for radiofrequency ablation of his
a right heart catheterization via IJV access for radiofrequency ablation of his
pulmonary veins. Prior to successful venous access for the procedure,
pulmonary veins. Prior to successful venous access for the procedure,
multiple attempts had been made, during which a hematoma developed in
multiple attempts had been made, during which a hematoma developed in
the patient’s right neck. The patient had been anticoagulated for this
the patient’s right neck. The patient had been anticoagulated for this
procedure. He immediately underwent orotracheal intubation, and an ENT
procedure. He immediately underwent orotracheal intubation, and an ENT
consultation was requested.
consultation was requested.
On physical exam the patient was noted to have marked soft tissue edema
On physical exam the patient was noted to have marked soft tissue edema
on the right side of his neck extending from the mandible down to the clavicle.
on the right side of his neck extending from the mandible down to the clavicle.
He had ecchymosis around the intravenous site and his trachea was
He had ecchymosis around the intravenous site and his trachea was
significantly deviated to the contralateral, left side. The remainder of the
significantly deviated to the contralateral, left side. The remainder of the
physical examination was normal.
physical examination was normal.
A CT angiogram of the neck (Figure E) showed a prominent hematoma in
A CT angiogram of the neck (Figure E) showed a prominent hematoma in
the right neck (8x7x12cm). There was no evidence of contrast extravasation.
the right neck (8x7x12cm). There was no evidence of contrast extravasation.
The trachea was deviated approximately 2.5cm as a result of the mass effect
The trachea was deviated approximately 2.5cm as a result of the mass effect
from the hematoma.
from the hematoma.
The following day the patient was taken to the operating room where he
The following day the patient was taken to the operating room where he
underwent neck exploration and hematoma evacuation. Intraoperatively, the
underwent neck exploration and hematoma evacuation. Intraoperatively, the
patient was found to have a large hematoma extending into the
patient was found to have a large hematoma extending into the
retropharyngeal space and a moderate amount of bleeding around the
retropharyngeal space and a moderate amount of bleeding around the
entrance point of the central venous line. The line was removed, revealing a
entrance point of the central venous line. The line was removed, revealing a
3-mm hole in the IJV, which was oversewn. The patient was extubated the
3-mm hole in the IJV, which was oversewn. The patient was extubated the
following day without event.
following day without event.
D
E
DISCUSSION
DISCUSSION
IJV cannulation resulting in a cervical hematoma and airway obstruction is uncommon (0IJV cannulation resulting in a cervical hematoma and airway obstruction is uncommon (04.7%) but can be fatal [1-3]. When this occurs, one must suspect inadvertent arterial puncture by
4.7%) but can be fatal [1-3]. When this occurs, one must suspect inadvertent arterial puncture by
a large bore cannula or vessel dilator, though this can occur from venous effusion alone, as
a large bore cannula or vessel dilator, though this can occur from venous effusion alone, as
seen in case #2. Pseudoaneurysm of the carotid, vertebral, and subclavian arteries, have been
seen in case #2. Pseudoaneurysm of the carotid, vertebral, and subclavian arteries, have been
described following IJV cannulation [4-6]. Early diagnosis is important, as smaller aneurysms are
described following IJV cannulation [4-6]. Early diagnosis is important, as smaller aneurysms are
easier to treat surgically.
easier to treat surgically.
Proper cannulation of the IJV is dependent on the IJV running just lateral to the carotid artery,
Proper cannulation of the IJV is dependent on the IJV running just lateral to the carotid artery,
which occurs in the vast majority of patients (92-97%) [7-9]. The use of ultrasound to aid
which occurs in the vast majority of patients (92-97%) [7-9]. The use of ultrasound to aid
cannulation of the vein is associated with a reduced number of attempts and arterial puncture,
cannulation of the vein is associated with a reduced number of attempts and arterial puncture,
and is recommended in high-risk patients, e.g. obesity, short neck, coagulopathy, and repeated
and is recommended in high-risk patients, e.g. obesity, short neck, coagulopathy, and repeated
cannulations [8]. Both of our patients were anticoagulated but did not undergo ultrasound-guided
cannulations [8]. Both of our patients were anticoagulated but did not undergo ultrasound-guided
IJV cannulation.
IJV cannulation.
Direct compression of the trachea by a hematoma can result in airway obstruction [10]. Many
Direct compression of the trachea by a hematoma can result in airway obstruction [10]. Many
authors, alternatively, believe that the rigidity of the trachea is difficult to compress and that a
authors, alternatively, believe that the rigidity of the trachea is difficult to compress and that a
more likely mechanism of airway obstruction is pharyngolaryngeal edema secondary to venous
more likely mechanism of airway obstruction is pharyngolaryngeal edema secondary to venous
and lymphatic obstruction by the hematoma [11-13]. This second mechanism may explain why
and lymphatic obstruction by the hematoma [11-13]. This second mechanism may explain why
more significant airway obstruction can be delayed.
more significant airway obstruction can be delayed.
Initial presentation of a patient with hematoma development following IJV central line access
Initial presentation of a patient with hematoma development following IJV central line access
may be subtle as in case #1. This patient had rather unremarkable cervical neck edema but
may be subtle as in case #1. This patient had rather unremarkable cervical neck edema but
nasopharyngoscopy revealed the inception of a retropharyngeal hematoma. The IJV and carotid
nasopharyngoscopy revealed the inception of a retropharyngeal hematoma. The IJV and carotid
artery are encircled in a sheath of deep cervical fascia, separated by a thin fascial slip from the
artery are encircled in a sheath of deep cervical fascia, separated by a thin fascial slip from the
retropharyngeal space. Perforation of the IJV, and possibly the carotid artery, may cause blood
retropharyngeal space. Perforation of the IJV, and possibly the carotid artery, may cause blood
extravasation into the retropharyngeal space, leading to severe swelling of this area.
extravasation into the retropharyngeal space, leading to severe swelling of this area.
The retropharyngeal space is the most anterior of three potential spaces (prevertebral and
The retropharyngeal space is the most anterior of three potential spaces (prevertebral and
danger spaces) in the midline prevertebral neck, and is a potential space lined by loose
danger spaces) in the midline prevertebral neck, and is a potential space lined by loose
connective tissue lying between the pharynx and the fascia overlying the vertebral column. This
connective tissue lying between the pharynx and the fascia overlying the vertebral column. This
space is key to an understanding of downward spread of infections of the head and neck or
space is key to an understanding of downward spread of infections of the head and neck or
extravasating blood from a traumatic IJV central line. It extends upward to the base of the skull
extravasating blood from a traumatic IJV central line. It extends upward to the base of the skull
and extends downward behind the lower portion of the pharynx and esophagus to form the
and extends downward behind the lower portion of the pharynx and esophagus to form the
posterior portion of the visceral compartment of the neck, communicating with the pretracheal
posterior portion of the visceral compartment of the neck, communicating with the pretracheal
space, ending at the level of the bifurcation of the trachea.
space, ending at the level of the bifurcation of the trachea.
A retropharyngeal hematoma may have variable presentation, depending on its size and rate
A retropharyngeal hematoma may have variable presentation, depending on its size and rate
of formation. Patients classically present with clinical symptoms of tracheal and esophageal
of formation. Patients classically present with clinical symptoms of tracheal and esophageal
compression, manifesting as dysphagia, odynophagia, or dyspnea. A compression of the
compression, manifesting as dysphagia, odynophagia, or dyspnea. A compression of the
arytenoid cartilages can also occur, leading to hoarseness or complete airway obstruction.
arytenoid cartilages can also occur, leading to hoarseness or complete airway obstruction.
Frequently, though often unnecessary, imaging studies are performed in assessment of a
Frequently, though often unnecessary, imaging studies are performed in assessment of a
retropharyngeal hematoma. In general, the retropharyngeal soft tissue should measure no more
retropharyngeal hematoma. In general, the retropharyngeal soft tissue should measure no more
than one-third to one-half the width of the cervical vertebrae [15].
than one-third to one-half the width of the cervical vertebrae [15].
The insidious nature of retropharyngeal hematomas may lead to serious consequences.
The insidious nature of retropharyngeal hematomas may lead to serious consequences.
Careful observation must be undertaken, even in patients who do not immediately present with a
Careful observation must be undertaken, even in patients who do not immediately present with a
compromised airway. Dyspnea can begin suddenly with a possible fatal outcome [14]. Early
compromised airway. Dyspnea can begin suddenly with a possible fatal outcome [14]. Early
precautions to secure the airway should be undertaken when patients present with dyspnea.
precautions to secure the airway should be undertaken when patients present with dyspnea.
Endotracheal intubation was performed in both of our patients; however, this may be difficult in
Endotracheal intubation was performed in both of our patients; however, this may be difficult in
some situations because of the hematoma compression on the airway. Traumatic intubation may
some situations because of the hematoma compression on the airway. Traumatic intubation may
result in the rupture of the hematoma and worsening edema, leading to further airway
result in the rupture of the hematoma and worsening edema, leading to further airway
compromise. Fiberoptic endoscopy, as performed in case #1, may aid in performing a noncompromise. Fiberoptic endoscopy, as performed in case #1, may aid in performing a nontraumatic intubation.
traumatic intubation.
The second stage of treatment is management of the hematoma. This may be evacuated
The second stage of treatment is management of the hematoma. This may be evacuated
through a lateral cervical approach, as in case #2, and drains may be placed into the
through a lateral cervical approach, as in case #2, and drains may be placed into the
retropharyngeal space. Some authors prefer transoral aspiration. This is not an emergency
retropharyngeal space. Some authors prefer transoral aspiration. This is not an emergency
procedure and should be performed only after the airway has been secured. Waiting for the
procedure and should be performed only after the airway has been secured. Waiting for the
resorption of the hematoma is also possible.
resorption of the hematoma is also possible.
Surgery for cervical and/or retropharyngeal hematoma formation is not always mandatory.
Surgery for cervical and/or retropharyngeal hematoma formation is not always mandatory.
When a hematoma does not cause any dyspnea or dysphagia, hospitalization for observation
When a hematoma does not cause any dyspnea or dysphagia, hospitalization for observation
(24-72 hours) and supportive treatment are acceptable.
(24-72 hours) and supportive treatment are acceptable.
CONCLUSIONS
CONCLUSIONS
The development of a hematoma following
The development of a hematoma following
traumatic IJV cannulation is a rare but potentially
traumatic IJV cannulation is a rare but potentially
life-threatening event that requires early
life-threatening event that requires early
recognition and may require urgent intervention. It
recognition and may require urgent intervention. It
is important to consider inadvertent arterial
is important to consider inadvertent arterial
puncture and retropharyngeal hematoma
puncture and retropharyngeal hematoma
formation when evaluating these patients.
formation when evaluating these patients.
Anticoagulated patients are at a higher risk of
Anticoagulated patients are at a higher risk of
hematoma progression and resultant airway
hematoma progression and resultant airway
compromise. Early precautions to secure the
compromise. Early precautions to secure the
airway by intubation or tracheostomy placement
airway by intubation or tracheostomy placement
are critical in some cases. Others may only require
are critical in some cases. Others may only require
close observation in the hospital. Hematoma
close observation in the hospital. Hematoma
evacuation by a transoral or lateral cervical
evacuation by a transoral or lateral cervical
approach may also be necessary. The outcome in
approach may also be necessary. The outcome in
these patients is good when the diagnosis is made
these patients is good when the diagnosis is made
early and followed by the appropriate treatment.
early and followed by the appropriate treatment.
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