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LETTER TO EDITOR
Year : 2018  |  Volume : 19  |  Issue : 2  |  Page : 104-105
 

Hissing sound during internal jugular vein cannulation: Tracheal cuff puncture or pneumothorax?


1 Department of Trauma and Emergency, All India Institute of Medical Sciences, Patna, Bihar, India
2 Department of Anaesthesia, All India Institute of Medical Sciences, Patna, Bihar, India

Date of Web Publication15-Nov-2018

Correspondence Address:
Dr. Neeraj Kumar
Department of Trauma and Emergency, All India Institute of Medical Sciences, Patna - 801 507, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_39_18

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How to cite this article:
Kumar A, Kumar N, Kumar A, Kumar A, Kumari P. Hissing sound during internal jugular vein cannulation: Tracheal cuff puncture or pneumothorax?. Indian Anaesth Forum 2018;19:104-5

How to cite this URL:
Kumar A, Kumar N, Kumar A, Kumar A, Kumari P. Hissing sound during internal jugular vein cannulation: Tracheal cuff puncture or pneumothorax?. Indian Anaesth Forum [serial online] 2018 [cited 2022 Aug 13];19:104-5. Available from: http://www.theiaforum.org/text.asp?2018/19/2/104/245546




Sir,

The common indications for the insertion of a central venous catheter (CVC) are the use of vasoactive drugs, parenteral nutrition, central venous pressure monitoring, or in case of difficult peripheral venous access. Several techniques have been described for percutaneous internal jugular vein catheterization.[1] Many complications associated with CVC insertion have been reported including tracheal tube cuff puncture which could be life-threatening in case of difficult intubation.

We report a case of tracheal tube cuff puncture following the right internal jugular vein cannulation by the lateral approach. In the Intensive Care Unit (ICU) All India Institute of Medical Sciences Patna, a 65-year-old female patient admitted with shortness of breath with following hemodynamic parameters heart rate 120/min, blood pressure 60/40 mm Hg, and SpO285%. She was known the case of chronic obstructive pulmonary disease and diabetes mellitus 2. The patient trachea was intubated (Endotracheal tube size 7.5 mm) and mechanically ventilated (control mode). Right-sided internal jugular vein catheterization was planned for inotropic support (noradrenalin 10 μg/min) and central venous pressure monitoring. Following proper aseptic precaution, she was placed in 20° Trendelenburg position. The head was turned toward contralateral side and right-sided internal jugular vein catheterization was attempted. During the attempt of venous cannulation, we observed few air bubbles in the syringe. The puncture needle was removed suspecting pneumothorax. After removal of puncture needle hissing noise from the patient's mouth was heard followed by sudden drop in peak airway pressures from 23 cm H2O to 5 cm H2O noted on ventilator, which ruled out the possibility of pneumothorax, on chest auscultation bilateral breath sound was equal. The acceptable tidal volume could not be maintained, despite of a change in ventilatory settings. Then, we tried to figure out the ventilation problem and found a significant leak from trachea with a deflated pilot balloon. Inflation of the cuff could not provide an adequate tracheal seal. The trachea was re-intubated. About 1-mm tracheal tube cuff puncture was noted on close observation of the removed endotracheal tube and on inflating the pilot balloon. Following stabilization, CVC was reattempted and placed successfully without any complication. Postprocedure chest X-ray showed no signs of pneumothorax or pneumomediastinum.

Technique followed to prevent carotid artery puncture, or tracheal tube cuff puncture includes: (1) head turned aside <15°[2] from its sagittal axis, (2) must not be inserted beyond 3 cm, (3) raise the needle axis about 20° aim downward.

Tracheal or tracheal tube puncture, have been reported during internal jugular vein cannulation using a posterior approach by Konichezky et al.[3] and by Malik and Adams[4] Chances of tracheal or tracheal tube cuff puncture was more on over inflation of tracheal cuff causes more bulging of trachea, tracheal deviation toward puncture side, and head turn >15° opposite to trachea.


  Conclusion Top


Hissing sound during internal jugular vein cannulation may be due to tracheal tube cuff rupture if associated with a decrease in peak airway pressure or loss of tidal volume detected on a ventilator.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rosen M, Latto P, Ng S. Handbook of Percutaneous Central Venous Catheterization. 2nd ed. London: WB: Saunders; 1992.  Back to cited text no. 1
    
2.
Kim WH, Gwak MS, Choi SJ, Song SH, Kim MH. Optimal head rotation and puncture site for internal jugular vein cannulation after laryngeal mask airway insertion. Singapore Med J 2015;56:472-8.  Back to cited text no. 2
    
3.
Konichezky S, Saguib S, Soroker D. Tracheal puncture. A complication of percutaneous internal jugular vein cannulation. Anaesthesia 1983;38:572-4.  Back to cited text no. 3
    
4.
Malik IA, Adams RG. Tracheal cuff puncture: A complication of percutaneous internal jugular vein cannulation. Am J Med 2003;115:590-1.  Back to cited text no. 4
    




 

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