Abstract and Introduction
Abstract
We present a case of fatal cardiac tamponade that occurred in association with a peripherally inserted central catheter (PICC) inserted from the right antecubital fossa. Migration of the catheter from the right atrium within 24 h of insertion lead to the administration of a potassium-enriched sodium chloride solution into the pericardial space with the development of ST-segment elevation and progression to pulseless electrical activity and, subsequently, ventricular fibrillation. Although signs of tamponade were seen on echocardiography, we propose that myocardial hyperkalaemia from the diffusion of potassium through the epicardium accounted for some of the clinical picture. PICC lines carry a greater risk of migration because of the tip movement associated with arm abduction and, therefore, care must be taken to ensure that the catheter tip is correctly positioned to reduce this risk. When such catheters are used for intra-operative central venous access, we believe chest radiography is mandatory before fluid administration through the catheter, but that this is unnecessary when the catheter is being used solely for central venous pressure monitoring. The use of softer catheters may reduce the risk of vessel perforation. Once tamponade is suspected, all drugs and infusions administered via the catheter should be reviewed, the catheter aspirated and echocardiography performed urgently. This may be facilitated by the greater availability of limited bedside echocardiography within critical care units and theatre complexes.
Introduction
Central venous access is normally obtained by cannulation of either the internal jugular, the subclavian, or the femoral veins. Central venous access may also be obtained from more distal sites, typically the antecubital veins, using a peripherally inserted central catheter (PICC). Such catheters are used widely for the long-term administration of chemotherapy, parenteral nutrition, and antibiotics. In anaesthetic practice, they can be used for short-term central venous access when more central access is limited, for instance, during major head and neck surgery. Cardiac tamponade has been reported in association with PICC lines, especially in neonatal medicine, but seems rare in adults, although it has been reported in a 14-yr-old female during surgery for scoliosis. We report a case of fatal cardiac tamponade that developed in an adult after the administration of a solution containing potassium chloride for correction of postoperative hypokalaemia.