To the Editor,

Central venous catheters (CVC) are commonly used in intensive care units and operating rooms. Several different vessels can be introduced for catheter insertion, including the subclavian, internal jugular, or femoral veins. The subclavian vein is preferred when patients are without palpable pulse and are in profound shock status. However, many complications have been reported. We report a rare complication of concomitant subcutaneous emphysema and pneumothorax after subclavian central venous catheterization via the supraclavicular approach.

An 82-year-old woman with several systemic diseases including hypertension, cardiomegaly, arrhythmia with pacemaker placement, type II diabetes mellitus, chronic hepatitis C with liver cirrhosis, scoliosis, and dementia with bedridden state was admitted to the Surgical Intensive Care Unit due to acute pyelonephritis with septic shock. CVC was indicated in both the right internal jugular and right subclavian veins using the supraclavicular approach. These were attempted without success. The patient was restless and little air was aspirated during supraclavicular tapping. A follow-up chest radiograph showed pneumothorax of the right lung and subcutaneous emphysema in the right chest wall, right shoulder, and bilateral neck regions (Figure 1). A chest surgeon was consulted and a 20-gauge Fr chest tube was inserted with low-pressure suction. The chest tube functioned well and the right lung re-expanded. Unfortunately, 2 days later, the chest radiograph showed worsened subcutaneous emphysema, extending into the bilateral chest walls, neck, and extremities, and crepitation was also noted at the face and both eyelids, accompanied by deteriorated oxygenation. The patient was intubated with mechanical ventilation. Meanwhile, the chest tube was replaced with 26-gauge Fr chest tube. The subcutaneous emphysema improved and the patient was extubated 7 days later. A few days later, the patient developed refractory pneumonia and was re-intubated. She subsequently died from fungemia-induced septic shock 3 weeks later.

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Figure 1. Chest radiograph shows pneumothorax in the right lung and subcutaneous emphysema over the right chest wall, right shoulder, and bilateral neck regions.

Compared with other techniques, subclavian CVC, either by the supraclavicular or infraclavicular approach, has many advantages, such as fewer thrombosis, more secured fixation, and better patient tolerance.¹Factors that may increase the risk of complications of internal jugular and subclavian vein at the time of insertion include chronic obstructive pulmonary disease, morbid obesity, marked cachexia, presence of chest tube, scoliosis, prior central venous access, and abnormal cardiothoracic anatomy.²Our patient had scoliosis, cardiomegaly, and dementia, making it more difficult to approach the internal jugular and subclavian vein.

Reports have shown that the use of ultrasound before vessel puncture reduces the number of complications.³ As in other surgical procedures, adequate training and experience reduce the risk of complication from CVC catheterization. If a physician fails to insert a catheter after three attempts, he or she should call for help rather than continue attempting the procedure.

Since the central venous pressure and central venous oxygen saturation do not demonstrate superiority in all patients with septic shock,4, 5, 6 femoral vein catheterization could be an option for fluid resuscitation to prevent severe cardiopulmonary complications at insertion.