The complications of jugular venepuncture include:

Inadvertent carotid arterial puncture:
This complication is reported to have an incidence of 2% - 8% 1, 2 and usually results in localised haematoma formation. The haematoma may enlarge rapidly if the patient is coagulopathic, or if a large puncture wound is produced by the introduction of the sheath itself into the carotid artery. Airway obstruction 3, 4 , pseudoaneurysm 5, 6, arterio-venous fistula formation 7 and retrograde aortic dissection 8 have all been reported as a consequence of carotid puncture. In the presence of occlusive (atheromatous) carotid disease, inadvertent puncture may carry the risk of precipitating a cerebrovascular accident 9.

If carotid puncture occurs immediately before surgery, the question of whether or not to proceed is a difficult one. A series of case reports by Golden 10 illustrates the serious consequences of carotid puncture with a large bore cannula and an extensive review of the problem by Eckhardt et al 11, also emphasises the potential for complications. The Eckhardt study concluded that if the carotid artery was punctured by a small bore needle or cannula (18-gauge or smaller), then serious damage was unlikely to result. However, if a dilator or PAC was inserted into a coagulopathic patient then the risks of complication were significant and in such cases, the catheter should be removed during exploratory surgery of the neck.

In our opinion, there are enough isolated case reports of major problems following large bore cannula damage to recommend delaying surgery if possible. Major complications are particularly likely if the patient is sick, coagulopathic, heparinised, elderly, or has atheromatous carotid disease.

The decision to proceed with surgery should thus be based on the following considerations:

1.The urgency of surgery.

2.The general condition of the patient.

3.The possibility that other vascular damage has occurred 12.

4.The possibility that arterial thrombosis, dissection or embolisation might precipitate a neurological event.

5.The requirement for heparinisation during surgery and whether this might compound any of the above factors.

On the basis of present evidence, we recommend the following management plan for inadvertent carotid cannulation (with a large bore cannula) should it occur:

Initially, leave the cannula or sheath in the vessel and consider the options.

If the patient is judged to be at low risk of complication, remove the cannula and apply firm pressure for ten minutes. Monitor the neurological, haemodynamic and airway state during this time and be prepared for emergency intubation. Contemplate proceeding to surgery according to the considerations outlined above.

If the patient is judged to be at high risk of complication, consider intubating the patient (in order to prevent airway compression) before removing the sheath. Removal of the sheath can then be performed, or, on the recommendation of some authors 11, can be carried out at an exploratory operation.

If the sheath is removed, apply carotid pressure for ten minutes, being mindful that this may not be successful due to a coagulopathic state, extensive damage to the vessel or bleeding from a site distal to the puncture site 12.

Remember that pressure on the carotid artery can in itself precipitate a neurological event. This is a powerful argument for recommending that pressure only be applied in a conscious, cooperative patient.

Monitor the general state of the patient. - Bleeding can occur proximal to the puncture site producing a rapid deterioration in the susceptible patient.

Consult a vascular surgeon as soon as is practical to determine if surgical exploration or repair is warranted. Indications for exploration may include an enlarging haematoma, airway compression, pre-existing carotid artery disease, a neurological event or cardiovascular instability. Some authors advise exploration in all patients who have had puncture with 17-gauge or larger needle. Caution is strongly recommended in the patient group more prone to complications. The reader is again reminded that damage to other vessels beyond the puncture site has been reported 12. Hence vigilance is still advised even if exploration of the puncture site has been undertaken.

Seriously consider delaying surgery for twenty four hours to allow stabilisation and observation.

If repeat cannulation is required, avoid venepuncture at the same site. Puncture of the carotid artery may not always be related to poor technique but to anatomical variation and thus repeat cannulation may produce the same result. Neither is it advisable to attempt insertion via the opposite internal jugular vein. - Right handed operators find left internal jugular venepuncture technically difficult and if the internal carotid artery is damaged on this side as well, the patient's cerebral circulation may be significantly compromised. For this reason we recommend the use of the subclavian vein on the contralateral side unless contraindicated.

Inadvertent vertebral arterial puncture:
Inadvertent vertebral arterial puncture and vertebral arterial cannulation have both been reported after attempted internal jugular cannulation 13. Vertebral arterial puncture has resulted in vertebral arterio-venous fistula on several occasions 14, 15.

Pneumothorax:
Pneumothorax can complicate internal jugular venepuncture 16, but is usually reported more commonly with the subclavian approach. However, in one recently reported large series, the incidence of this complication occurred in 2.6% of IJV cannulations and only 1.3% of subclavian attempts 17.

Venous air embolism:
Venous air embolism is a rare complication of the technique and can occur whenever there is a sub-atmospheric pressure in the venous system at a point where it is open to the atmosphere. These conditions are most likely exist in a patient in whom the central venous pressure is low and / or the fluctuations in intrathoracic pressure are large. Such conditions would include:

- Jugular venepuncture of patients in the semi-upright or sitting position - unless the central venous pressure is extremely high.

- Jugular venepuncture of patients with unrelieved inspiratory airway obstruction (snoring).

During central venous cannulation, air embolism can usually be prevented by appropriate positioning of the patient.

Most PAC introducer sheaths incorporate a seal that is intended to prevent accidental air-entrainment. If the catheter is in position for a prolonged period, this seal has been reported to fail 18. Seldinger needles are also available which incorporate a valved side-arm for introduction of the wire. These needles allow the user to maintain a completely closed system during wire introduction (Figure M6).

It should also be remembered that paradoxical embolism is a risk in the presence of a patent foramen ovale or an atrial or ventricular septal defect.

Venous air embolism should be suspected when there is a sudden onset of tachycardia associated with pulmonary hypertension and systemic hypotension. A new murmur caused by turbulent flow in the right ventricular outflow tract may also be heard. The diagnosis can be confirmed by echocardiography.

The subject of venous air embolism has been comprehensively reviewed by Albin 19.

The clinical picture is determined by the total volume of air entering the circulation and the rate of entrainment of air.

These two factors determine the fate of the bubbles - whether they dissipate as they traverse the heart, or coalesce, leading to an obstruction of the right ventricular outflow tract.

Slow entrainment of small volumes of air presents with a gradually rising CVP and PAP. The ETCO2 shows a gradual fall as the air passing into the pulmonary circulation dilutes the alveolar CO2. The ECG at this stage may either show no change or abnormalities such as ventricular ectopic beats, tachycardia, bradycardia, ST segment changes, P wave abnormalities or heart block. Systemic hypotension and the classical ‘millwheel’ murmur are late developments.

In contrast, the patient who has entrained a large volume of air will usually present with cardiovascular collapse. The signs include a sudden increase in CVP and PAP accompanied by a sudden fall in ETCO2, saturation and systolic blood pressure. ECG changes may include any of the changes listed above. The volume of air thought to be lethal in the adult has been estimated to be between 300 and 500ml, entering at a rate of 100ml/sec. This is easily achieved through a 14G cannula with a pressure gradient of 5cmH2O 20.

The potential for paradoxical embolism is higher in this presentation due to the sudden rise in right heart pressures which may then open a probe-patent foramen ovale.

Surprisingly, the time of greatest risk of air embolism appears to be on catheter removal 21, 22, 23.

Nerve Injury:
The brachial plexus, stellate ganglion, vagus, accessory, hypoglossal and phrenic nerves are all closely associated with the internal jugular vein. Any of these structures may be injured during cannulation attempts 24, 25, 26, 27, 28, 29. More commonly, local anaesthetic injected at the time of cannulation may transiently block these nerves.

Jugular vein thrombosis:
Jugular vein thrombosis can complicate both pulmonary arterial and central venous cannulation by the jugular route and occurs more commonly than subclavian thrombosis 30. It is much more likely to occur with prolonged use of catheters or when catheter-related sepsis complicates the clinical picture. The incidence has probably been reduced by heparin coating of catheters.

Other miscellaneous complications:
Transient Horner's syndrome complicating internal jugular catheterisation has recently been reported 31.

References:
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2. Patel C; Laboy V; Venus B; Mathru M; Wier D Acute complications of pulmonary artery catheter insertion in critically ill patients. Crit Care Med, 14(3):195-7 1986 Mar

3. Knoblanche GE Respiratory obstruction due to haematoma following internal jugular vein cannulation. Anaesth Intensive Care 7: 286, 1979

4. Kua JS; Tan IK Airway obstruction following internal jugular vein cannulation. Anaesthesia, 52:776-80, 1997

5. Shield CF, Richardson JD, Buckley CJ, et al: Pseudoaneurysm of the brachiocephalic arteries: A complication of percutaneous internal jugular vein catheterization. Surgery 78:190-193, 1975

6. Aoki H. Mizobe T. Nozuchi S. et al: Vertebral artery pseudoaneurysm: A rare complication of internal jugular vein catheterization. Anesth Analg 75:296-298,1992

7. Gobeil F. Couture P. Girard D, Plante R: Carotid Artery-lnternal Jugular Fistula: Another Complication following Pulmonary Artery Catheterization via the Internal Jugular Venous Route. Anesthesiology 1994, 80:23-232.

8. Applebaum RM, Adelman MA, Kanschuger MS, Jacobowitz G, Kronzon I Transesophageal echocardiographic identification of a retrograde dissection of the ascending aorta caused by inadvertent cannulation of the common carotid artery. J Am Soc Echocardiogr 1997 Sep;10(7):749-51

9. Zaidi NA, Khan M, Naqvi HI, Kamal RS Cerebral infarct following central venous cannulation. Anaesthesia, 53:186-91, 1998 Feb

10. Golden LR Incidence and Management of Large-Bore Introducer Sheath Puncture of the Carotid Artery. J Cardiothorac Vasc Anesth 1995, 425-428

11. Eckhardt WF, Iaconetti DJ, Kwon JS et al Inadvertent Carotid Artery Cannulation During Pulmonary Artery Catheter Insertion. J Cardiothorac Vasc Anesth 1996, 283-290

12. Jain U, Shah KB, Belusko RJ et al Subclavian Artery Laceration and Acute Hemothorax on Attempted Internal Jugular Vein Cannulation. J Cardiothorac Vasc Anesth 1991, 608-610

13. Irita K, Noda E, Karashima Y, Okamoto H, Takahashi S Tension hemothorax caused by inadvertent insertion of an introducer dilator into the vertebral artery. J Cardiothorac Vasc Anesth. 1999 Apr;13(2):241-2.

14. Majeski JA Vertebral arteriovenous fistula as a result of Swan-Ganz catheter insertion: surgical correction in a symptomatic patient. Int Surg 1999 Jan-Mar;84(1):74-7

15. Colley DP Vertebral arteriovenous fistula: an unusual complication of Swan-Ganz catheter insertion. Am J Neuroradiol 1985 Jan-Feb;6(1):103-4

16. Damen J; Bolton D A prospective analysis of 1,400 pulmonary artery catheterizations in patients undergoing cardiac surgery. Acta Anaesthesiol Scand, 30:386-92, 1986

17. Miller JA, Singireddy S, Maldjian P, Baker SR A reevaluation of the radiographically detectable complications of percutaneous venous access lines inserted by four subcutaneous approaches. Am Surg 1999 Feb;65(2):125-30

18. Doblar DD, Hinkle JC, Fay ML et al: Air embolism associated with pulmonary artery catheter introducer kit. Anesthesiology 56:307, 1982.

19. Albin MS Air Embolism. Anesthesiology Clinics of North America 11(1) :1-24,1993

20. Bailey AR A Close Shave: Air embolism following laceration of central venous catheter. Anaesthesia 51:294-295,1996

21. Sing RF; Steffe TJ; Branas CC Fatal venous air embolism after removal of a central venous catheter. J Am Osteopath Assoc, 95:204-5, 1995 Mar

22. Mennim P; Coyle CF; Taylor JD Venous air embolism associated with removal of central venous catheter. BMJ, 305:171-2, 1992 Jul 18

23. Turnage WS; Harper JV Venous air embolism occurring after removal of a central venous catheter. Anesth Analg, 72:559-60, 1991 Apr

24. Burns S; Herbison GJ Spinal accessory nerve injury as a complication of internal jugular vein cannulation. Ann Intern Med, 125:700, 1996

25. Depierraz B; Essinger A; Morin D; Goy JJ; Buchser E Isolated phrenic nerve injury after apparently atraumatic puncture of the internal jugular vein. Intensive Care Med, 15:132-4, 1989

26. Vest JV; Pereira MB; Senior RM Phrenic nerve injury associated with venipuncture of the internal jugular vein. Chest, 78:777 - 9, 1980 Nov

27. Paschall RM; Mandel S Brachial plexus injury from percutaneous cannulation of the internal jugular vein. Ann Emerg Med, 12:58-60, 1983

28. Sylvestre DL; Sandson TA; Nachmanoff DB Transient brachial plexopathy as a complication of internal jugular vein cannulation. Neurology, 41:760, 1991

29. Whittet HB, Boscoe MJ. Isolated palsy of the hypoglossal nerve after central venous catheterization. Br Med J (Clin Res Ed). 1984 Apr 7;288(6423):1042-3.

30. Timsit JF, Farkas JC, Boyer JM et al Central vein catheter-related thrombosis in intensive care patients: incidence, risks factors, and relationship with catheter-related sepsis. Chest, 114:207-13, 1998 Jul

31. Taskapan H, Oymak O, Dogukan A, Utas C. Horner's syndrome secondary to internal jugular catheterization. Clin Nephrol. 2001 Jul;56(1):78-80.

Last edited on: 21/03/2003