Recognizing inadvertent central venous catheter complications and effective management options for patient with COVID-19 infection requiring bilateral lung transplant

Ahmad R. Parniani, MD and Yong G. Peng, MD, PhD, FASE, FASA

Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL

Summary: We describe the case of a 50-year-old man with COVID-19 who underwent a successful bilateral lung transplant. We also review the anesthetic management strategies for these patients including the role of ECMO and discuss complications associated with central venous catheter placement for lung transplant.

After reviewing the case, readers will be able to:

• Identify the selection criteria of patients with severe COVID-19 for lung transplant.
• Recognize the complications associated with central venous catheter placement for lung transplant.
• Describe the pathophysiology of cardiac tamponade and management strategies.
• Understand the role of ECMO in the management of patients with COVID-19.
• Review the anesthetic challenges of patients infected with COVID-19 who are undergoing lung transplant.

Case   

            We describe the case of a 50-year-old man with a past medical history of prostate cancer and prostatectomy, chronic back pain, hypothyroidism, and hypertension. He tested positive for COVID-19 on April 26, 2021 after developing shortness of breath and cough and was sent home from the emergency department for quarantine. However, his condition deteriorated and he was admitted to the hospital 5 days later. He received a combination of remdesivir, dexamethasone, convalescent plasma, and tocilizumab as recommended medical therapy. Unfortunately, on hospital day 20 he was intubated and underwent a percutaneous tracheostomy on hospital day 34. Due to increasing ventilatory requirements, including positive end-expiratory pressure (PEEP) of 24 cm H₂O with 100% fraction of inspired oxygen (FiO₂), he was placed in the prone position with little improvement. The patient was subsequently placed on venovenous extracorporeal membrane oxygenation (VV-ECMO) on hospital day 60 and transferred to our facility to be evaluated for lung transplant. Given his worsening right ventricular function, he underwent conversion of VV-ECMO to veno-arterio-venous ECMO (VAV-ECMO) on hospital day 64. Epoprostenol and inhaled nitric oxide were continued to treat his pulmonary hypertension and support his worsening right ventricular systolic function. Continuous veno-venous hemofiltration was also initiated given his worsening acute kidney injury.

The patient underwent lung transplant evaluation during his hospital stay and was listed as a lung transplant candidate on August 27, 2021. On September 26, 2021, he underwent a bilateral lung transplant. He was transported to the operating room on VAV-ECMO. Anesthesia was induced with 250 mcg of fentanyl, 130 mg of propofol, and 100 mg of rocuronium. He was intubated orally with a 41-Fr left double-lumen endotracheal tube and the tracheostomy was removed. A transesophageal echocardiography (TEE) probe was inserted for intraoperative monitoring.

Before central venous catheter placement, the left side of his neck was scanned with the ultrasound probe because the ECMO cannulation was in place in his right internal jugular (IJ) vein. However, we could not identify the patent lumen of the left IJ vein (Figure 1).

Figure 1.

As a result, we decided to obtain central venous access through the left subclavian vein. A 9-Fr introducer catheter was successfully placed after one attempt and no resistance was encountered during the insertion. Shortly after the central venous catheter placement, the patient became hemodynamically unstable and unresponsive to multiple vasopressor boluses, including epinephrine. We administered fluids and medication boluses through the newly placed left subclavian central venous catheter. TEE was immediately used to assess his cardiac function and showed an enlarging pericardial effusion with tamponade physiology. At this point, the surgical team was immediately called and resuscitation with intravenous (IV) fluids and epinephrine was continued. We noticed that our boluses of epinephrine were not effective in maintaining his blood pressure, so we switched our infusions and boluses from the central venous catheter into the indwelling peripherally inserted central catheter (PICC). We also started transfusing blood through the ECMO circuit. A peripheral IV was inserted in his left external jugular vein and resuscitation was continued.

A clamshell incision was performed and the surgical exposure entered the pleural cavity on the fourth intercostal space. The pericardium was then opened, and a large amount of blood was evacuated. Afterward, the patient’s condition stabilized, the arterial line tracing became pulsatile once again, and the heart was filling and ejecting appropriately. We noted that the central venous catheter coming from the left subclavian vein tracked outside of the vessel on the thoracic inlet, perforating the pericardium and creating a small tear on the adventitia of the aorta (Figure 2).

Figure 2.

Vasa-vasorum from the aorta adventitia was copiously bleeding, which was controlled with bovie coagulation. The patient became hemodynamically stable and TEE confirmed that his bilateral ventricular function was improving. The surgical team could not access his left femoral vein because ultrasonography revealed thrombosis of the vein.  The case proceeded and a bilateral lung transplant was performed successfully. The patient was transported to the intensive care unit (ICU) postoperatively in a hemodynamically stable condition. He was decannulated from ECMO 1 week after his lung transplant and his tracheostomy was eventually removed. He remained stable on room air and was transferred to rehabilitation facility for further recovery.

What are the current medical therapies available for COVID-19 infection?

Randomized placebo-controlled trials have shown that remdsesivir has enhanced the recovery of hospitalized patients.^1,2 Another randomized clinical trial demonstrated that a single dose of bamlanivimab (monoclonal antibody) reduced the viral load in outpatients.² A large randomized controlled trial showed a mortality benefit with dexamethasone in hospitalized patients requiring oxygen.² A combination of medical treatments is considered the most effective therapy for patients with COVID-19.

What are the potential treatments for refractory hypoxemia in patients with COVID-19 acute respiratory distress syndrome (ARDS)?

Prone positioning should be considered in patients with PaO₂:FiO₂ <150 mm Hg during respiration and FiO₂ of 0.6 despite an appropriate PEEP. However, prone positioning requires equipment and training that may not be available at some medical centers. Inhaled pulmonary vasodilators such as inhaled nitric oxide can also improve oxygenation in refractory respiratory failure. ECMO can also be considered as an alternative rescue therapy for refractory respiratory failure; however, ECMO is associated with an increased risk of bleeding and requires extensive resources and trained staff.¹

What are the ventilatory management strategies in patients with COVID-19 who are intubated?

Autopsies performed on patients with severe COVID-19 have revealed the presence of diffuse alveolar damage, which is a hallmark of ARDS. Essential ventilatory management should focus on avoiding further ventilator-induced lung injury. The main goals are reducing alveolar overdistension, hyperoxia, and cyclical alveolar collapse. Lung-protective ventilation is used by setting the ventilator for tidal volume at 6 mL/kg of predicted body weight. To prevent alveolar overdistention, the plateau pressure should not exceed 30 cm H₂O. PEEP prevents alveolar collapse and facilitates the recruitment of unstable lung regions.²

What are the proposed criteria for the selection of patients with severe COVID-19 for lung transplant?

The general criteria are age younger than 65 to 70 years, preference for single organ failure, no malignancy, no substance misuse, and postoperative social support. Other criteria include healthy neurocognitive status, general condition (if the patient is participating in physical therapy while hospitalized), and evidence of irreversible lung damage.¹

How long after the onset of ARDS secondary to COVID-19 should lung transplant be considered?

The exact time needed to determine irreversibility is not clear, but the recommendation is to wait approximately 6 weeks after ARDS onset. Ideally, when lung recovery is deemed unlikely after ARDS onset, lung transplant should be considered. Exceptions to these criteria include severe pulmonary complications such as severe pulmonary hypertension with concomitant right ventricular failure, refractory nosocomial pneumonias, or recurrent pneumothoraces that cannot be medically managed with or without ECMO.¹

What are some of the concerns regarding ongoing infection at the time of transplant and reinfection of the allograft?

The risk of reinfection should be carefully reviewed as part of the pretransplant evaluation workup. Studies suggest that it is rare to detect replicating virus more than 10 days after infection with SARS-CoV-2 even though the PCR result may remain positive for weeks after infectivity. In cases where the PCR remains positive for extended durations, high-cycle thresholds are seen (Ct >24), but infectivity is usually not evident.¹

What are some considerations regarding deep sedation and neuromuscular blockade effects on post-transplant outcomes?

As soon as 2 to 3 days after the start of mechanical ventilation, the diaphragm can lose approximately 50% of its fibers. This can have a significant impact on post-transplant recovery. As a result, weaning of sedation and participation in physical therapy should be highly encouraged.¹ In addition, if patients can be weaned from sedation, they can actively participate in discussions regarding the direction of their care and therapeutic goals.

Why are patients with COVID-19 more prone to bleeding during their hospital stay?

ARDS is associated with a significantly increased bleeding risk. In addition, prolonged ECMO can lead to platelet dysfunction in a significant portion of patients. Pleural adhesions and the fragile tissue of these patients increase the risk of intraoperative bleeding.²

What is the approach for placing a subclavian central venous catheter using anatomic landmarks?

Starting 2 cm lateral and 2 cm caudal to the bend of the clavicle, a needle is inserted through the skin at a 30° angle toward the sternal notch. We recommend placing a finger of the nondominant hand in the sternal notch to help find the landmark. Once the needle is under the skin, the needle and syringe are lowered to run parallel to but beneath the clavicle. Access to the vein typically happens just beneath the clavicle, but it may be several centimeters under the skin.³ Medical professionals should be alert to possible complications such as pneumothorax, vascular injury leading to hemothorax, and other inadvertent injury to the adjacent thoracic structures.  

How frequent are complications associated with central venous catheter placement? 

Central venous catheter placement is an invasive procedure that requires planning and an organized approach. There are a number of potential complications associated with central venous catheter placement, most commonly infection, bleeding, pneumothorax, hemothorax, and vascular injury. A prospective randomized trial of patients undergoing subclavian central venous catheter placement at the University of Texas examined the rate of complications. There was a 6% rate of misplacement, 3.7% rate of arterial puncture, 1.5% rate of pneumothorax, and 0.6% rate of mediastinal hematoma.⁴ Another retrospective chart review was performed for all central venous catheters placed between November 1, 2012, and June 30, 2013, at MedStar Washington Hospital Center (MWHC). In that study, the rate of arterial injury was 1.3% of subclavian central venous catheters, 0.4% of IJ central venous catheters, and 1.4% of femoral central venous catheters.^4,5

What is the pathophysiology of pericardial tamponade?

The primary abnormality in cardiac tamponade is impaired diastolic filling of the heart. This is caused by increased intrapericardial pressure that leads to compression of the atria and ventricles. Diastolic filling pressures increase and start to equilibrate with all cardiac chambers. Cardiac filling is reduced, resulting in decreased stroke volume, cardiac output, and systemic blood pressure. Compensatory mechanisms attempt to counteract the decrease in stroke volume by increasing systemic vasoconstriction and tachycardia.⁶

What are the treatment options and hemodynamic goals during management of patients with pericardial tamponade?

Definitive treatment is emergent drainage and/or relief of the pericardial compression. This can be achieved through pericardiocentesis or surgical decompression. The highlights of hemodynamic management include maintaining contractility and systemic vascular resistance with inotropes and vasopressors. Preload should be maintained with IV fluids and avoiding large tidal volumes of positive pressure ventilation. Additionally, reductions in heart rate should be strongly prohibited to preserve cardiac output because these patients have a fixed and reduced stroke volume.⁶

What is the role of ECMO in the management of patients with COVID-19?

VV-ECMO is a complicated and labor-intensive tool that is used in severe hypoxemic respiratory failure refractory to conventional mainstays of medical therapy including mechanical ventilation with optimal PEEP, neuromuscular blockade, and prone positioning. VA-ECMO is different from VV-ECMO in that it is typically initiated for patients in cardiac or circulatory failure with or without concomitant respiratory failure. VV-ECMO is commonly considered as a bridge to specific endpoints, such as recovery or lung transplant. Unfortunately, VV-ECMO may also become a bridge to nowhere; a careful assessment of the end goals of therapy is warranted.^1,6

What are some of the complications associated with ECMO in patients with COVID-19?

ECMO is associated with thrombotic and hemorrhagic complications. A high proportion of patients with COVID-19 develop life-threatening thrombotic complications. In an autopsy series, most of the patients were diagnosed with deep vein thrombosis (DVT) or pulmonary embolisms. The mechanism of this hypercoagulable state is related to the major systemic inflammatory response along with endothelial dysfunction.⁷ The combination of a prothrombotic state and long-term use of ECMO cannulas can increase the risk of blood clots. In 80% of patients on ECMO, heparin can be used as a systemic anticoagulant. In patients with COVID-19 or heparin-induced thrombocytopenia (HIT), bivalirudin may be considered as an alternative anticoagulation strategy. Activated clotting times (ACTs) of 160 to 180 s for VV-ECMO and 180 to 220 s for VA-ECMO are necessary to avoid thrombotic complications. Other complications include vascular injury, infections, kidney failure, stroke, and mechanical equipment failure. Closely monitoring ECMO function is essential to the success of this unique bridge therapy.⁸

References

1. Bharat A, Machuca TN, Querrey M, Kurihara C, Garza-Castillon R Jr, Kim S, Manerikar A, Pelaez A, Pipkin M, Shahmohammadi A, Rackauskas M, Kg SR, Balakrishnan KR, Jindal A, Schaheen L, Hashimi S, Buddhdev B, Arjuna A, Rosso L, Palleschi A, Lang C, Jaksch P, Budinger GRS, Nosotti M, Hoetzenecker K. Early outcomes after lung transplantation for severe COVID-19: a series of the first consecutive cases from four countries. Lancet Respir Med. 2021 May;9(5):487–497. doi: 10.1016/S2213-2600(21)00077-1. Epub 2021 Mar 31. PMID: 33811829; PMCID: PMC8012035.
2. Berlin DA, Gulick RM, Martinez FJ. Severe Covid-19. N Engl J Med. 2020 Dec 17;383(25):2451–2460. doi: 10.1056/NEJMcp2009575. Epub 2020 May 15. PMID: 32412710.
3. Braner DA, Lai S, Eman S, Tegtmeyer K. Videos in clinical medicine. Central venous catheterization–subclavian vein. N Engl J Med. 2007 Dec 13;357(24):e26. doi: 10.1056/NEJMvcm074357. PMID: 18077803.
4. Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med. 1994 Dec 29;331(26):1735–1738. doi: 10.1056/NEJM199412293312602. PMID: 7984193.
5. Bell J, Goyal M, Long S, Kumar A, Friedrich J, Garfinkel J, Chung S, Fitzgibbons S. Anatomic site-specific complication rates for central venous catheter insertions. J Intensive Care Med. 2020 Sep;35(9):869–874. doi: 10.1177/0885066618795126. Epub 2018 Sep 19. PMID: 30231668.
6. Gravlee GP. Hensley’s Practical Approach to Cardiothoracic Anesthesia. 6th ed. Wolters Klumer; 2018.
7. Falcoz PE, Monnier A, Puyraveau M, Perrier S, Ludes PO, Olland A, Mertes PM, Schneider F, Helms J, Meziani F. Extracorporeal membrane oxygenation for critically ill patients with COVID-19-related acute respiratory distress syndrome: worth the effort? Am J Respir Crit Care Med. 2020 Aug 1;202(3):460–463. doi: 10.1164/rccm.202004-1370LE. PMID: 32543208; PMCID: PMC7397791.
8. Huang J, Firestone S, Moffatt-Bruce S, Tibi P, Shore-Lesserson L. 2021 Clinical Practice Guidelines for Anesthesiologists on Patient Blood Management in Cardiac Surgery. J Cardiothorac Vasc Anesth. 2021 Dec;35(12):3493–3495. doi: 10.1053/j.jvca.2021.09.032. Epub 2021 Sep 24. PMID: 34654633.