Rev. Bras. Anestesiol. vol.64 número6

RevBrasAnestesiol.2014;64(6):443---445

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

CLINICAL

INFORMATION

A

unique

case

of

pulmonary

artery

catheter

bleeding

from

the

oximetry

connection

port

Suman

Rajagopalan

_,

_Raja

_R.

_Palvadi

DepartmentofAnesthesiology,BaylorCollegeofMedicine,Houston,USA

Received22April2014;accepted5May2014 Availableonline3June2014

KEYWORDS

Pulmonaryartery catheter; Bleeding; Oximetryport

Abstract Pulmonaryarterycatheterisaninvasivemonitorusuallyplacedinhigh-riskcardiac surgicalpatientstooptimizethecardiacfunctions.Wepresentthiscaseofbloodoozingfrom theoximetryconnectionportofthepulmonaryarterycatheterthatresultedintheinability tomonitorcontinuouscardiacoutputrequiringreplacementofthecatheter.Thecauseofthis abnormalbleedingwaslaterconfirmedtobeduetoamanufacturingdefect.

© 2014SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.

PALAVRAS-CHAVE

Cateterdeartéria pulmonar; Sangramento; Portaoximétrica

Casoúnicodesangramentopelaportadeconexãodocateterdeartériapulmonarao módulodeoximetria

Resumo Ocateter de artéria pulmonaré um monitorinvasivo geralmente usado durante cirurgiascardíacas em pacientesdealto riscopara otimizar asfunc¸ões cardíacas. Apresen-tamosocasodeescoamentodesanguepelaportadeconexãodocateterdeartériapulmonar paraoximetriaqueresultounaimpossibilidadedemonitorarodébitocardíacocontínuoena substituic¸ãodocateter.Acausadosangramentoanormalfoiposteriormenteconfirmadacomo umdefeitodefabricac¸ão.

©2014SociedadeBrasileira deAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.

∗_{Correspondingauthor.}

E-mail:srajagop@bcm.edu(S.Rajagopalan).

Introduction

Perioperative monitoring with a balloon-tipped, flow-directed,pulmonaryarterycatheter(PAC)istypically per-formedinhigh-risksurgicalpatientstofacilitate optimiza-tionofcardiacfunction.PlacementofthePACisaninvasive

http://dx.doi.org/10.1016/j.bjane.2014.05.003

444 S.Rajagopalan,R.R.Palvadi

Figure1 PersistentoozingofbloodfromtheoximetryopticalmoduleconnectionportofthePAC.

procedureassociatedwithcomplications.Thecomplications unique to the insertion and use of this catheter include carotid artery puncture, hematoma, pneumothorax, ven-triculararrhythmias,pulmonary arteryembolism/rupture, sepsis,catheterentrapmentandknotting.1_{Wepresentthis}

uniquecaseof bloodoozingfromtheoximetryconnection portofthePACresultingintheinabilitytomeasurecardiac outputorindexinahigh-risksurgicalpatient.

Clinical

report

A 57-year-old male with aortic coarctation and pseudoa-neurysmofthedescendingthoracicaortawasscheduledfor surgicalrepair.Aftersuccessfulinduction,a9Frintroducer wasinsertedintotherightinternaljugularveinbymodified Seldinger’s technique using ultrasound guidance. A PAC (modelnumber746HF8)wasplacedthroughtheintroducer. Appropriatewaveformsandmonitoringofthemixedvenous saturation were successful. However, when continuous cardiac output monitoring was attempted, an erroneous messagewasdisplayed.While attempting totroubleshoot theerror,persistentoozingofbloodfromtheoximetry opti-calmoduleconnectionsitewasnoted(Fig.1).Duetothe bleedingfromtheconnectionsiteandinabilitytorecord car-diacoutput,thedefectivecatheterwasremovedandanew catheterwasplacedthroughtheexistingintroducersheath. The defective catheter was visually inspected and no obvious external defects or tears were detected. The

catheter was sent back to the manufacturer (Edward

Lifesciences)toevaluatethecauseofbleeding.Thesurgery progressedasplanned andthe patientwastransferred to theICUforfurtherpost-operativemanagement.Acoupleof weekslater,wereceivedthereportfromthemanufacturer confirming the presence of a small tear in the webbing of the catheter (78cm from the tip) that was due to a manufacturingdefect.

Discussion

Theriskofseriouscomplicationsspecificallyassociatedwith PACplacementisknowntobe0.1---0.5%.1_{Hence,assessment}

ofriskbenefitratioandcarefulpatientselection is neces-sarypriortoitsplacement.Manufacturingdefectswiththe PACarerareandaretypicallydiscoveredpriortothe inser-tionwhenthecatheteristestedforabnormalleaks,tears, orrupturedballoon.Fewreportsofbloodoozingbackinto theconnectionportsecondary tointraoperativetraumato thePAChavebeenpreviouslypublised.2,3_{Thetraumacould}

befromastitchgoingthroughorfromscalpelinjurytothe PAC.Inourcase,wenoticedthebloodoozingfromthe con-nection port immediately afterthe placementof the PAC andevenbeforethesurgicalincision.Whatmakesour par-ticular case uniqueis that the bedside testingof the PAC couldnotascertaintheintimaltear.

Defects in the PAC couldbe frustrating asit is placed mostlyinsickpatientsrequiringclosemonitoringofcardiac function.AdefectivePACdefeatsthepurposeofits place-mentasthecardiacoutputandindexcannotbemonitored. Valuabletimemaybelostintryingtotroubleshootandfix theproblem.Ifthisisnotrecognized,itcouldleadto signif-icantcomplicationsincludingbleedingandinfection.Early recognitionoftheproblemcanpreventsomeoftheissues but theriskof complications associatedwiththe replace-mentofthePACcannotbetrivialized.

BleedingfromthePACoximetryconnectionport 445

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

References

1.AmericanSocietyofAnesthesiologistsTaskForceonPulmonary ArteryCatheterization.Practiceguidelinesforpulmonaryartery

catheterization:anupdatedreportbytheAmericanSocietyof AnesthesiologistsTaskForceonPulmonary Artery Catheteriza-tion.Anesthesiology.2003;99:988---1014.

2.Manecke Jr GR, Brown JC, Landau AA, et al. An unusual caseofpulmonaryarterycathetermalfunction.AnesthAnalg. 2002;95:302---4.