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LETTER TO EDITOR
Year : 2018  |  Volume : 19  |  Issue : 2  |  Page : 105-106
 

An unexpected cause of occlusion of the lumen of a central venous line during blood administration


1 Department of Anesthesia, PGIMER, Chandigarh, India
2 Department of Anesthesia, GMC, Jammu, Jammu and Kashmir, India

Date of Web Publication15-Nov-2018

Correspondence Address:
Dr. Summit Dev Bloria
Department of Anesthesia, PGIMER, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_49_18

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How to cite this article:
Bhagat H, Bloria SD, Luthra A, Bloria P. An unexpected cause of occlusion of the lumen of a central venous line during blood administration. Indian Anaesth Forum 2018;19:105-6

How to cite this URL:
Bhagat H, Bloria SD, Luthra A, Bloria P. An unexpected cause of occlusion of the lumen of a central venous line during blood administration. Indian Anaesth Forum [serial online] 2018 [cited 2019 Oct 22];19:105-6. Available from: http://www.theiaforum.org/text.asp?2018/19/2/105/245552




Sir,

We report an unexpected cause of occlusion of the lumen of a central venous line during blood administration intraoperatively due to blockage of a patented safety connector of the central line.

A 64-year-old male patient was posted for craniotomy and excision of a petroclival meningioma. After performing standard induction of anesthesia, a central venous line (Certofix trio® B Braun; 7 French) was inserted in left subclavian vein using Seldinger's technique and an iv line was started from one of the ports of the central line using a blood transfusion set and a 100 cm extension. During surgery, the intraoperative blood loss exceeded the maximal allowable blood loss of the patient and we proceeded with the administration of packed red blood cells (RBCs) to the patient. However, after a few minutes, we realized that the flow of blood products through the blood transfusion set had ceased. On trying to flush, the extension tubing using normal saline a continuous resistance was felt. We suspected a kinking of extension tubing or the central venous line port to be the cause and examined the extension tubing as well as central venous line port but could not find any kinking throughout its length. We then disconnected the extension tubing from the central line port to find that normal blood flow from the distal end of extension tubing, making us believe that the site of obstruction was distal to the extension tubing. We were unable to aspirate blood from the central line confirming central venous line to be the site of obstruction. However, when we removed the Safsite® (B Braun) connector and aspirated from the port of central line, we found free aspiration of blood without any resistance. On closer examination of the Safsite connector, we could appreciate that it was blocked due to clotted blood [Figure 1]. We reconnected the extension tubing to the central venous line port directly without the Safsite® connector and there was regular flow of the blood through the central line subsequently. We could not find any case report on Safsite® connector causing acute obstruction of a central venous line, although many authors have described other mechanical causes of central venous lines like a kink in catheter or tubing;[1],[2] catheter tip getting blocked by vessel wall;[3] and the “pinch-off syndrome."[4],[5] There can be many causes for blocked valves such as a manufacturing defect, drug precipitation (phenytoin, heparin, bicarbonate, and mannitol), thrombotic occlusion, and lipid residues in total parenteral nutrition. We could rule out a manufacturing defect because it was working completely fine when iv fluid was being administered before blood administration. Furthermore, we had checked for blood aspiration through the Safsite® connector on the insertion of the central line. Drug precipitation can also be ruled out simply because we did not administer any drug from the central venous line before blood administration.
Figure 1: Safsite connector blocked with blood

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We believe that the inherent structure of Safsite® connector and the rheologic characteristics of the packed RBCs were the main culprits for the resulting obstruction of the Safsite® valve. The Safsite® connector is circular in cross-section and in the middle of which lies the one-way valve. Any fluid being administered has to pass through the narrow zone that lies between the valve and the inside walls of the connector. The way we were administering the packed RBCs also predisposed to clotting of blood, we were administering unwarmed packed RBCs without diluting it with saline. We presume that the cold packed RBCs (possessing high viscosity) got clotted while passing through this narrow part of the connector. We report this experience to highlight the possible complications of Safsite® valves. This becomes an important consideration, especially in neurosurgical patients as the central venous line ports, and extension tubings are inaccessible after placement of surgical drapes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hooke C. Recombinant tissue plasminogen activator for central venous access device occlusion. J Pediatr Oncol Nurs 2000;17:174-8.  Back to cited text no. 1
    
2.
Holcombe BJ, Forloines-Lynn S, Garmhausen LW. Restoring patency of long-term central venous access devices. J Intraven Nurs 1992;15:36-41.  Back to cited text no. 2
    
3.
Bagnall-Reeb HA, Ruccione K. Management of cutaneous reactions and mechanical complications of central venous access devices in pediatric patients with cancer: Algorithms for decision making. Oncol Nurs Forum 1990;17:677-81.  Back to cited text no. 3
    
4.
Fazeny-Dörner B, Wenzel C, Berzlanovich A, Sunder-Plassmann G, Greinix H, Marosi C, et al. Central venous catheter pinch-off and fracture: Recognition, prevention and management. Bone Marrow Transplant 2003;31:927-30.  Back to cited text no. 4
    
5.
Andris DA, Krzywda EA, Schulte W, Ausman R, Quebbeman EJ. Pinch-off syndrome: A rare etiology for central venous catheter occlusion. JPEN J Parenter Enteral Nutr 1994;18:531-3.  Back to cited text no. 5
    


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