European Journal of Anaesthesiology 1998, 15, 501–504

CASE REPORT

Haemopericardium: a rare fatal complication of

attempted subclavian vein cannulation. A report of

two cases

D. L. Hamilton and R. M. Jackson

Department of Anaesthesia, Huddersfield Royal Infirmary, Acre Street, Lindley, Huddersfield HD3 3EA, UK

Summary central venous access are aware of the danger ofcausing this condition, and how the use of a careful

This paper describes two otherwise unrelated casestechnique of insertion can minimize the risk.

of fatal haemopericardium resulting directly from at-tempted cannulation of the right subclavian vein. Al-

Keywords: subclavian vein, haemopericardium,though this is an extremely rare complication, it is

aorta, cannulation, central line, complication.essential that all physicians involved in establishing

Introduction own airway and breathing spontaneously. Her heartrate was 80 beats min−1 and blood pressure 190/

Many complications of the subclavian approach to115 mmHg. Neurological examination revealed a Glas-

central venous cannulation have been described. Com-gow coma score (GCS) of 6/15 (E2, M3, V1), and

monly they are described as those occurring earlygeneralized brisk reflexes with bilateral upgoing plant-

or late [1,2]. Recognized early complications includears. The pupils were fixed and dilated and there was no

subclavian artery puncture, malposition, cardiac arrhy-papilloedema. An emergency computed tomography

thmias, localized haematoma, pneumothorax, haem-(CT) scan of the head revealed a large space-occupying

othorax and air embolism. While late complicationslesion in the parietal lobe of the left cerebral hemi-

include infection, thrombosis, embolism and peri-sphere with surrounding oedema and midline shift.

cardial effusion or mediastinal haemorrhage due toInitial treatment with intravenous dexamethasone and

erosion of the cannula through the great veins or rightmannitol resulted in a significant neurolgical im-heart [1–3]. In this paper we describe two cases ofprovement: the GCS increased to 15/15 and arrange-fatal haemopericardium occurring as a direct result ofments were made for urgent craniotomy.attempted cannulation of the right subclavian vein

Following pre-oxygenation with full non-invasiveusing the infraclavicular approach.monitoring general anaesthesia was induced withintravenous fentanyl (100 lg) and propofol (150 mg).

Case 1 Neuromuscular block was produced with vecuronium10 mg, the trachea was intubated and intermittentA 44-year-old woman was admitted to hospital withpositive pressure ventilation undertaken with an oxy-a history of a decreasing level of consciousness lessgen, nitrous oxide and isoflurane mixture. Invasivethan 24 h in duration. Her only medical history wasarterial blood pressure monitoring was establishedof hypertension treated with a calcium channel an-via the dorsalis pedis artery.tagonist. On examination she was maintaining her

Right subclavian vein cannulation was then at-tempted. On the first pass of a standard 70 mm 18Accepted February 1997

Correspondence: D. L. Hamilton s.w.g. needle arterial puncture was recognized. The

1998 European Academy of Anaesthesiology 501

502 D. L. Hamilton and R. M. Jackson

needle was withdrawn and pressure applied to the the patient became pale, diaphoretic and hypotensiveduring the venepuncture attempt. Subsequently ven-insertion site. Within 1 min the invasive systolic blood

pressure (SBP) decreased from 150 to 80 mmHg. There ous access was secured: initially via a small peripheralforearm vein, and finally by insertion of a right femoralwas no clinical evidence of a pneumothorax or

haemothorax and despite ventilation with 100% oxy- central line. There was no clinical or radiological evi-dence of a pneumothorax. The patient continued togen, rapid infusion of 1000 mL of gelofusine, and

15 mg of ephedrine administered intravenously (i.v.), deteriorate in spite of aggressive fluid resuscitationand sustained a cardiopulmonary arrest from whichthe SBP continued to decline to 40 mmHg. Adrenaline

1 mg was administered i.v. and external cardiac mas- he could not be resuscitated. The mode of cardiacarrest was ventricular fibrillation.sage was commenced. The SBP increased to 80 mmHg

and cardiac massage was stopped. A second suc- At autopsy bruising and skin punctures were notedin the right infraclavicular region consistent with atcessful attempt at right subclavian vein cannulation

revealed a central venous pressure of 30 mmHg and least five venepuncture attempts. A puncture woundwas noted in the right brachiocephalic vein im-in the absence of lung pathology cardiac tamponade

was diagnosed. An urgent transthoracic echo- mediately prior to its confluence with the left bra-chiocephalic vein to form the superior vena cava (SVC).cardiogram confirmed the presence of a pericardial

effusion with poor left ventricular function; 70 mL of This puncture wound was found to extend throughthe vessel into a haematoma encasing the SVC, fillingblood were aspirated by pericardiocentesis but the

patient further deteriorated into electromechanical dis- the mediastinum in that area, and extending into thepericardium. Continuity was demonstrated betweensociation and further resuscitation was unsuccessful.

At autopsy a tense haemopericardium consisting of the puncture wound through the haematoma and twosmall puncture wounds in the ascending aorta 5 cm250 mL of fresh blood and clot was noted. A 1 mm

puncture wound was found in the right side of the above the aortic valve ring. The volume of the haem-opericardium was estimated to be 500 mL. Re-ex-ascending aorta 4.5 cm above the aortic valve ring. It

was clear that the attempt at pericardial aspiration amination of the supine chest X-ray taken prior to thepatient’s death showed mediastinal widening.had been unsuccessful as there was no evidence that

the inferior pericardium had been penetrated.

Discussion

Case 2The infraclavicular approach to the subclavian veinwas first described by Aubaniac in 1952 [4,5]. TenA 50-year-old man was admitted to hospital with a

12-month history of a progressive deterioration in years later Wilson et al. described the introduction ofa cannula into the SVC via this route [6]. Since thencognitive function, associated with generalized tonic

clonic convulsions. During this period extensive in- infraclavicular subclavian vein cannulation has beenused widely in clinical practice for a variety of diag-vestigation, including a CT scan of the head, psy-

chological assessment and brain and muscle biopsies nostic and therapeutic procedures [2,3]. Many com-plications of this procedure have been described,had failed to reveal a definitive diagnosis. During his

final admission he presented with status epilepticus including haemopericardium resulting in cardiac tam-ponade either due to immediate puncture of the venawhich proved resistant to conventional medical ther-

apy. Peripheral venous access was lost during the cava or the heart during line insertion [7], or later dueto erosion of the catheter through the vena cava,course of a prolonged generalized seizure and an

attempt was made to insert a right subclavian central right atrium, right ventricle or pulmonary artery [8–11].However, puncture of the ascending aorta resulting inline. Several attempts to gain access to the subclavian

vein were made using a standard 70 mm 18 s.w.g. fatal haemopericardium is extemely rare: only onecase has been reported previously in the literature [12].needle. Blood was aspirated on the third attempt, but

the procedure was discontinued at this stage. No It is our opinion that in both of the cases describedin this account haemopericardium occurred as a resultrecord was made as to whether the aspirated blood

had been arterial in appearance, but it was noted that of an incorrect needling technique. This could be due

1998 European Academy of Anaesthesiology, European Journal of Anaesthesiology, 15, 501–504

Haemopericardium: a rare fatal complication 503

to either gross misinterpretation of the anatomical should be considered, and if central venous access isthe only option for emergency i.v. access the femorallandmarks or due to inadequate knowledge or training

on the part of the operators. It is important to note approach is the safest.The symptoms and physical signs of cardiac tam-that a guidewire was not introduced in either of these

cases and so cannot be implicated. ponade vary considerably, depending on the amountof blood and clot in the pericardial cavity. Agitation,Several methods for cannulation of the subclavian

vein using the infraclavicular route have been de- air hunger and a deteriorating level of consciousnessmay progress rapidly to deep coma and death. Thescribed, with variations in both the site of initial needle

insertion, ranging between a point just lateral to the classic triad of Beck (distended neck veins, arterialhypotension and muffled heart sounds) may only bemidpoint of the clavicle to the junction of the medial

thirdand themiddle third of theclavicleand thedistance present in a minority of cases [13]. If cardiac arrestoccurs it is typically due to electromechanical dis-between the clavicle and the entry point. However, in all

these techniques after the initial needle puncture the sociation. Tension pneumothorax may mimic cardiactamponade and should quickly be excluded. The im-needle is thenadvancedbehindtheclavicleanddirected

towards either the triangle formed between the two mediate treatment of cardiac tamponade is per-icardiocentesis. If this is unsuccessful emergencyheadsof thesternocleidomastoidor towardsthe jugular

notch [3]. Consequently, in order to direct the needle thoracotomy should be undertaken without delay. Al-though cardiac tamponade was diagnosed promptly,towards the aorta either the site of initial skin puncture

would have to be incorrect, or following selection of a in Case 1 pericardiocentesis was unsuccessful andthoracotomy was not attempted. In Case 2 the initialcorrect skin puncture site the needle would have to be

grossly misdirected. This is the probable explanation mode of cardiac arrest was ventricular fibrillation andcardiac tamponade was not suspected at the time.for why this complication is so rare.

The site of accidental aortic puncture in the two It is of vital importance that all physicians involved inthe insertion of central venous lines receive adequatecases was very similar being, respectively, 4.5 and

5.0 cm above the aortic valve ring. Furthermore, in training in the techniques available, and understandthe anatomical structures likely to be encountered byCase 2 there were two closely related aortic puncture

sites, strongly suggesting that the incorrect needling the needle following its passage through the skinto the chosen vein. Not only is knowledge of thetechnique used by the operator in this case was re-

peated. complications of line insertion essential, but also therecognition and treatment of both the early and lateOne important difference between these two cases

is that in the first, even though surgery was relatively complications [14].urgent, the subclavian cannulation was attempted asan elective procedure, while in the second it wasundertaken as an emergency procedure. The infra- Referencesclavicular approach to the subclavian vein is com-

1 Kaye CG, Smith DR. Complications of central venousmonly and appropriately used for monitoringcannulation. Br Med J 1988; 297: 56–57.

purposes during elective neurosurgical cases. A long2 Ridley SA. Complications of central venous cath-

line inserted via the antecubital fossa is a useful al- eterization. In: Kaufman L, ed. Anaesthesia Review 8.ternative (although it is worth noting that cardiac London: Churchill Livingstone, 1991: 255–275.tamponade has even been reported as a complication 3 Rosen M, Latto IP, Ng WS. Handbook of Percutaneous

Central Venous Catheterisation. London: WB Saunders &following brachial vein cannulation [7]). However,Company Ltd, 1981: 51–75.there is no place for attempting subclavian line in-

4 Aubaniac R. L’injection intraveineuse sous-claviculaire;sertion in patients who are actively convulsing oradvantages et technique. Presse Med 1952; 60: 1456.

unable to stay still for any other reason. In such cases5 Aubaniac R. Une nouvelle voie d’injection ou de ponction

the chance of causing serious complications is much veineuse: La voie sous-claviculaire: Veine sous-claviere,greater. We suggest that in such patients senior help tronc Brachiocephalique. Semaine des hopitaux de Parisshould be summoned early, peripheral venous access 1952; 28: 3445–3447.

6 Wilson JN, Grow JB, Demong CV, Prevedel AE, Owensis initially preferable, cutdown onto a peripheral vein

1998 European Academy of Anaesthesiology, European Journal of Anaesthesiology, 15, 501–504

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JC. Central venous pressure in blood volume main- 11 Brandt RL, Foley WJ, Fink GH, Regan WJ. Mechanism ofperforation of the heart with production of hydro-tenance. Arch Surg 1962; 85: 563–578.

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8 Barton BR, Hermann & Weil IIIR. Cardiothoracic emer- 12 Bratzke H, Schneider V. Zwischenfalle Nach Punktion DerV. Subclavia. Intensivmedizin 1979; 16: 326–332.gencies associated with subclavian hemodialysis cath-

eters. JAMA 1983; 250: 2660–2662. 13 Ivatury RR, Rohman M. Penetrating cardiac trauma. In:Turney SZ, Rodriguez A, Cowley RA, eds. Management9 Ducatman BS, McMichan JC, Edwards WD. Catheter-

induced lesions of the right side of the heart. JAMA 1985; of Cardiothoracic Trauma. Baltimore: Williams & Wilkins,1990: 311–327.253: 791–795.

10 Hirsch NP, Robinson PN. Pulmonary artery puncture fol- 14 Hoshal VL Jr. The consequences of a cavalier approach tocentral venous catheterization. Acta Anaesthesiol Scandlowing subclavian venous cannulation. Anaesthesia 1984;

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1998 European Academy of Anaesthesiology, European Journal of Anaesthesiology, 15, 501–504