• Users Online: 383
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
  Navigate here 
 Resource links
 »  Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 »  Article in PDF (547 KB)
 »  Citation Manager
 »  Access Statistics
 »  Reader Comments
 »  Email Alert *
 »  Add to My List *
* Registration required (free)  

  In this article
Article Figures

 Article Access Statistics
    PDF Downloaded15    
    Comments [Add]    

Recommend this journal


  Table of Contents 
Year : 2023  |  Volume : 24  |  Issue : 1  |  Page : 84-85

Curious case of central venous catheter leak

1 Department of Forensic Medicine and Toxicology, ESIC Medical College and Hospital, Faridabad, Haryana, India
2 Department of Anaesthesiology, Pain Medicine and Critical Care, JPNATC, AIIMS, New Delhi, India

Date of Submission19-Jan-2023
Date of Decision07-Mar-2023
Date of Acceptance07-Mar-2023
Date of Web Publication24-May-2023

Correspondence Address:
Dr. Sharmishtha Pathak
Department of Anaesthesiology, Pain Medicine and Critical Care (JPNATC), AIIMS, Delhi
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/TheIAForum.TheIAForum_7_23

Rights and Permissions

How to cite this article:
Sharma M, Pathak S. Curious case of central venous catheter leak. Indian Anaesth Forum 2023;24:84-5

How to cite this URL:
Sharma M, Pathak S. Curious case of central venous catheter leak. Indian Anaesth Forum [serial online] 2023 [cited 2023 Jun 7];24:84-5. Available from: http://www.theiaforum.org/text.asp?2023/24/1/84/377555


We would like to report a case of inadequate fluid management of the patient due to a leakage in the proximal port of the central venous catheter. A 36-year-old male who suffered extensive pelvic injuries following a road traffic accident was brought to the emergency department of our trauma center and was immediately transfused with packed red blood cell, fresh frozen plasma, and platelets (4:4:4). The patient did not respond to the above management and hence was shifted to operation theater (OT) immediately for exploration due to his nonresponder status. Intraoperatively, the patient required vasopressor support, which was initiated through the broad gauge peripheral venous access (16G). Since the vasopressor requirement was increasing, a central venous line placement was desired. Cervical spine injury could not be ruled out before shifting to OT; hence, we decided against the removal of the cervical collar and placed a subclavian line. Once the line was placed, we shifted the vasopressors to the central line. The patient was stabilized and was shifted to the intensive care unit (ICU) after internal iliac artery ligation. Once the requirement of vasopressor decreased, the patient was again taken to OT for the removal of abdominal packs and the creation of stoma. Intraoperatively, once the packs were removed, the patient started bleeding and required fluid resuscitation, which was being provided through the central line. However, even after starting fluids the patient was not responding and hence, we started looking for all the possible causes and found that the fluid was leaking under the sheets next to the patient. On close examination, we found that the proximal port was broken [Figure 1] and the fluid had been partially leaking from there, thus adequate resuscitation was not taking place. Once this port was blocked and fluidly connected to the medial port, the patient stabilized hemodynamically and the vasopressor requirement decreased. The remainder of the surgery was uneventful, and the patient was shifted to ICU for further monitoring and management.
Figure 1: Injection of saline leaking out as a stream as shown by the red arrow

Click here to view

Various complications have been reported with the use of central venous catheters. These complications range from those related to catheter insertion, immediate access related as well as long-term complications.[1] Most observed complications include bleeding, arterial puncture, arrhythmia, air embolism, catheter malposition, and pneumothorax or hemothorax.[2] Catheter-related complications include catheter malfunction and migration.[3] Mechanical issues with the catheter are reported rarely. In our case, there was a mechanical issue with the catheter which resulted in leakage of fluid. This compels us to realize the importance of checking and cross-checking the intravenous fluid connections, again and again, to avoid such defective devices from affecting patient care. This case highlights the importance of continuous monitoring of the patient and lines intraoperatively, thus helping in catching any defects early and providing timely correction.[4],[5] With increased production of medical devices, there is a high chance of deterioration in quality. Although the products pass various quality checks, there can be errors in one or two of the thousands manufactured and we may end up with that one faulty product, thus reiterating the need for a vigilant anesthesiologist.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kornbau C, Lee KC, Hughes GD, Firstenberg MS. Central line complications. Int J Crit Illn Inj Sci 2015;5:170-8.  Back to cited text no. 1
[PUBMED]  [Full text]  
Pathak S, Kaushal A, Gupta P, Singh S. From subclavian vein to contralateral internal jugular vein: Central venous catheter malposition is still not uncommon. Int J Health Allied Sci 2021;10:177.  Back to cited text no. 2
McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33.  Back to cited text no. 3
Aronson S, Cook R. Vigilance – A main component of clinical quality. Anesthesiology 1998;88:1122-3.  Back to cited text no. 4
Verma R, Mohan B, Attri JP, Chatrath V, Bala A, Singh M. Anesthesiologist: The silent force behind the scene. Anesth Essays Res 2015;9:293-7.  Back to cited text no. 5
[PUBMED]  [Full text]  


  [Figure 1]


Print this article  Email this article