Line complications and the child with limited access
Key points
Central line insertion is generally safe when correct techniques are used, however whilst rare, the potential complications are severe and can be fatal
Potential scenarios
The pleura is punctured during percutanous access of IJV, causing a pnemothorax or haemothorax
The line is malpositioned into the carotid artery, or the pleura
The dilator becomes kinked on the wire, tearing the SVC as it is advanced (the dilator should always be screened in with fluoroscopy)
The dilator is advanced in the wrong position, puncturing the SVC or right atrial wall (the wire should ideally be advanced into the IVC below the diaphragm, stabilising it)
A neonate with a long term line with a tip in the right atrium - the tip erodes through the wall causing cardiac tamponade (should not place tips in the atrium in neonates)
During a line revision the distal segment breaks off and embolises (Interventional radiology/cardiothoracics are required)
During a line removal the line snaps (should open the neck and either remove or transfix with non-absorbable suture to prevent embolisation). Higher risk if the line has been in for 3 years or more
Child in shock post line insertion
Potential causes:
Pneumothorax - needle decompression
Cardiac tamponade - get interventional radiology, Cardothoracics
Bleeding
Limited access
Always consult Interventional radiology
If all jugular veins are used, try the following in approximate order of preference:
Femoral
Subclavian
Balloon dilatation of occluded veins
Percutaneous transhepatic venous access
Translumbar catheters
Direct right atrial cannulation in extreme circumstances via right thoracotomy
Line seen entering left side of heart
Possibly due to persistent left SVC (Failure of regression of left cardinal vein) - 90% drain to coronary sinus, 10% to left atrium
Can leave in if aspirated blood is venous, but must be left slightsly short so the tip is not in the coronary sinus
Umbilical catheters
Thromboembolism
Occlusion of the mesenteric arteries (UAC) - bowel infarction, NEC - no evidence to withhold feeds prophylactically though
Ischaemic injury to the back, buttocks, and lower extremities
Other complications:
Vessel perforation
Peritoneal perforation - TPN ascites - consider if persistent hypoglycaemia and abdominal distension)
In rare cases, if the line enters a spinal vessel - can cause PN meningitis - likely fatal
Bladder injury
False aneurysm
High-position UAC may cause refractory hypoglycaemia
References
Kornbau C, Lee KC, Hughes GD, Firstenberg MS. Central line complications. Int J Crit Illn Inj Sci. 2015 Jul-Sep;5(3):170-8. doi: 10.4103/2229-5151.164940. PMID: 26557487; PMCID: PMC4613416.