British Journal of Radiology (2006) 79, e75-e77
© 2006 British Institute of Radiology
doi: 10.1259/bjr/30451779
Central line pump infusion and large volume mediastinal contrast extravasation in CT
P O'Sullivan, MRCPI, FFR, RCSI
M Brown, MD
B Hartnett, BSc, RT(R)
and
J R Mayo, MD
Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
Correspondence: Dr Paul O'Sullivan, 899 West 12 Avenue, Vancouver, BC, Canada, V6J 1V9. E-mail: paul.osullivan@vch.ca
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Abstract
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The use of multidetector CT scanners for CT angiography requires rapid injection of radiographic contrast media. Central venous catheters are now widely used for this purpose. Several complications may occur while using central venous access for rapid, large volume contrast injection such as catheter rupture and contrast extravasation. We describe a case in which inadvertent malposition of a central venous catheter led to a high volume extravasation of contrast in the mediastinum in a trauma patient.
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Introduction
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The use of multidetector CT scanners for CT angiography and CT brain perfusion studies requires rapid injection (2–5 ml s–1) of radiographic contrast media. Peripheral intravenous access is preferred. However, in patients in whom this is unavailable, the use of central venous catheters for rapid power injection of contrast media may be considered [1, 2]. Possible complications that may occur while using central catheters for high flow rate injection include catheter rupture, contrast extravasation and delayed catheter malfunction [3].
We describe a case in which inadvertent malposition of the central venous catheter led to a high volume (100 ml) extravasation of contrast within the mediastinum in a young male trauma patient.
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Case report
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A 24-year-old male patient was admitted to the emergency department after a high-speed motor vehicle accident. His vital signs were stable, and clinically lower and upper limb fractures were suspected. Initial chest, spine, pelvis and lower limb radiographs showed bilateral lower limb fractures, knee dislocations and hand fractures. The chest radiograph was interpreted as normal. A CT scan of the head, abdomen and pelvis did not reveal any significant abnormality. The patient was admitted to the intensive care unit for ventilatory support. Upon admission to ICU, a left sided, triple lumen, 16 cm, 7-French Arrow-Howes (Arrow International, Reading, PA) [3] central venous catheter was placed in the left subclavian vein by a staff anaesthetist. Peripheral access was avoided due to the multiple upper limb injuries. The post-placement chest radiograph demonstrated the line tip against the lateral wall of the superior vena cava (SVC). This catheter was pulled back 2 cm to avoid possible SVC trauma [4–6] (Figure 1
). The patient deteriorated over the next 24 h, with a drop in haemoglobin from 11.2 g dl–1 to 8.0 g dl–1. A contrast enhanced CT scan of the thorax was ordered to evaluate for undiagnosed chest traumatic injury.
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Figure 1. Following withdrawal of the subclavian line by 2 cm, the tip (arrow) of the multilumen catheter appears to be in a satisfactory position within the left brachiocephalic vein.
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Upon arrival in the CT suite, the attending ICU nurse flushed, without difficulty, the proximal port of the central catheter with normal saline. She then connected the contrast power injection pump to this port of the multilumen central catheter. A trauma protocol chest CT scan was performed using an 8 channel multidetector row CT scanner (GE Light Speed QX1 Ultra; GE Medical Systems, Milwaukee, WI) with an injection of 100 cm3 of intravenous contrast media (Optiray/Ioversol 320) at 2.5 ml s–1. The flow rate was reduced from 3 ml s–1 (our usual for trauma protocol) to 2.5 ml s–1 (the maximum flow rate we allow via central access). Contiguous 1.25 mm sections were reconstructed using the standard algorithm and showed a 4 cm oval shaped area of high attenuation within the anterior mediastinum (Figure 2), in keeping with a large volume of intravenous contrast media extravasation. As the patient was intubated and under sedation, there were no abnormal symptoms reported. The patient's vital signs remained stable during this time.
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Figure 2. Transverse CT section at the level of(a) the manubrium and (b) the carina, demonstrating a large volume of extravasated contrast within soft tissues of the anterior mediastinum. (c) Sagittal image shows extensive anterior mediastinal extravasation.
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A repeat non-contrast chest CT performed 5 h later showed diffuse spread of the extravasated contrast media throughout the mediastinum, pleural spaces (Figure 3) and into the soft tissues of the neck.
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Figure 3. Transverse CT section at the level of the right pulmonary artery shows contrast media outlining the pericardium(arrows) and diffusing into the left and right pleural spaces.
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The central line was left in place for the next 24 h, although the ICU staff did not use it. The following day, a hand-injected venogram was performed to assess line position, showing the proximal port to be partially outside the vein (Figure 4). The line was subsequently removed without further complication. The line was noted to be fully intact, with no evidence of rupture after removal.
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Figure 4. Hand injection of the proximal port of the multilumen catheter shows extravasation from the proximal side port(arrow) confirming the malposition of the line. Superior vena cava (SVC) is also shown.
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The patient had an uneventful recovery from the mediastinal extravasation. He received another chest CT scan 1 week later to exclude pulmonary embolism. No embolus was identified, and the previously identified extravasated contrast media in the mediastinum was seen to have completely resorbed.
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Discussion
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The use of central venous catheters for rapid power injection of contrast is controversial, with manufacturers cautioning their use in this role and with clinicians reporting rare complications including catheter rupture, malfunction, cardiac arrhythmias, contrast extravasation and infection [3].
We report an unusual cause of contrast extravasation associated with injection of the proximal port of an otherwise correctly functioning multilumen central catheter. The large volume contrast extravasation that occurred in our case was due to the combination of factors including the large patient size, repositioning of the catheter to avoid perforation of the vein wall and injection of the lumen exiting 5 cm proximal to the end of the catheter.
To avoid this complication in multilumen catheters, staff should be aware of the position of ports relative to the catheter tip and recognize that ports may appear to function normally using hand injections of saline but prove to be malpositioned when a power injector is used. Ideally, contrast media should only be administered through the distal port. If there is doubt as to the adequacy of line placement, a limited volume non-contrast CT scan of the line can be performed to confirm line position prior to the large volume power contrast media injection.
Received for publication July 14, 2005.
Revision received September 8, 2005.
Accepted for publication September 19, 2005.
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References
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- Herts BR, Cohen MA, McInroy B, Davros WJ, Zepp RC, Einstein D. Power injection of intravenous contrast through central venous catheters for CT: in vitro evaluation. Radiology 1996;200:731–5.[Abstract/Free Full Text]
- Sanelli PC, Deshmukh M, Ougorets I, Caiati R, Heier LA. Safety and feasibility of using a central venous catheter for rapid contrast injection rates. AJR Am J Roentgenol 2004;183:1829–34.[Abstract/Free Full Text]
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Abstract
Introduction
