Cardiac tamponade caused by central venous catheter perforation of the heart: a preventable complication

Pericardial tamponade caused by central venous catheter perforation of the heart is a catastrophic complication that can be prevented by attention to proper positioning of the catheter tip proximal to the cardiac silhouette. This study was performed to determine awareness of this potential complication among physicians and to suggest measures to minimize the incidence of this problem.

Clinical and radiologic features of 11 cases were evaluated. House officers and attending staff who frequently pass central venous catheters and train junior physicians to place these catheters were questioned specifically to test their awareness of this complication and their knowledge of optimal catheter tip positioning. Attending radiology staff physicians were questioned similarly. The written protocols of local community hospitals with respect to central venous catheter placement were reviewed to determine their criteria for optimal catheter placement.

Ten of the 11 cases reviewed resulted in death; the 11th case resulted in severe anoxic brain insult with a persistent vegetative state. In the ten cases that had radiologic studies available for review, the central venous catheter tip was seen to lie malpositioned within the cardiac silhouette. Questioning of house officers and attending staff as well as attending radiology staff revealed a lack of awareness of this problem generally and a lack of knowledge of optimal catheter tip positioning specifically. The protocols of area hospitals revealed similar findings with respect to this potential complication.

Pericardial tamponade resulting from central venous catheter perforation of the heart can be avoided by adherence to proper technique in the placement of these catheters, ensuring that the catheter tip lies proximal to the cardiac silhouette, optimally in the superior vena cava, 2 cm proximal to the pericardial reflection. Physicians who place these catheters and train others to do so must be aware of this issue and they must educate their trainees as well. Radiologists responsible for interpreting the roentgenographs of the chest obtained after catheter placement should be alert to catheter malposition and communicate this information promptly. Hospital protocols should deal with this issue explicitly and insist on repositioning of catheters if catheter tips are seen to lodge in suboptimal positions.