Prevention of Airway Fires

Abstract

T he right internal jugular vein is most often used for central venous cannulation because all structures to be cannulated are in line. Because of the closeness of the jugular vein to the carotid artery, heart, cervical spine, major nerves, and pleura, life-threatening complications are common. After 2 unsuccessful cannulation attempts, associated complications are more likely to occur. The unintended intrathecal placement of a central venous catheter is extremely rare but did occur in the patient discussed in this case report.The 66-year-old man had a history of coronary artery disease with severe stenosis of the proximal right coronary circumflex artery and proximal and distal left coronary artery. He was to undergo elective coronary artery bypass grafting surgery. After general anesthesia and tracheal intubation, the patient was placed in a 10-degree head-down position for placement of a pulmonary artery catheter. The technique consisted of locating the carotid artery and aiming the finder needle lateral to it toward the right nipple away from the artery. At a depth of 1.5 cm, venous blood was aspirated. A guidewire (J-wire) was introduced, but during 2 attempts to advance it intravascularly, resistance was felt. During the third attempt, the straight soft end of the wire was introduced first, leading to successful guidewire advancement. The pulmonary artery catheter introducer was inserted, but aspiration of the introducer yielded a large amount of clear fluid. Because intrathecal placement of the introducer was suspected, the head and neck were immobilized, and the aspirated fluid was confirmed to be cerebrospinal fluid (CSF). Based on a 3-dimensional computed tomographic reconstruction of the cervical spine, the introducer was placed through the foramen of C6 to C7 up to C7 to T1. It was positioned on the right side in the spinal canal without visualization of blood. The catheter was removed, and the patient allowed to awaken. A lumbar drain was introduced at the L3 to L4 interspace without difficulty. The average draining volume was 10 mL/h. After he recovered from anesthesia, the patient was able to move his upper and lower extremities without motor weakness or decreased sensation other than minor paresthesia in the second and third digits of the right hand. Magnetic resonance imaging a day later found no evidence of CSF leakage or injury to the blood vessels or spinal cord. The paresthesia and hypesthesia resolved in 4 days. At day 5, the patient had severe postural headache, nausea, and vomiting possibly because of persistent CSF leakage that did not respond to treatment. A lumbar epidural blood patch with 20 mL of autologous blood alleviated all of his complaints. He was discharged 2 days after the blood patch and readmitted 1 month later for the coronary artery bypass grafting surgery. Ultrasound-guided puncture of the internal jugular vein confirmed the location of the internal jugular vein at a depth of 1 cm, followed by easy insertion of the guidewire and uneventful anesthesia and surgery.This comp...