Accidental arterial puncture is a well-recognized complication of CVC placement. The incidence of this complication in published reports ranges from 0% to 15%.8–10 Complications arising from accidental arterial puncture include mediastinal hematoma formation, hemothorax, tracheal compression and possible asphyxiation, and retroperitoneal hemorrhage. A recent meta-analysis comparing internal jugular versus subclavian catheter placement noted a higher incidence of arterial puncture with internal jugular catheter attempts.10 Although arterial puncture occurs more frequently with internal jugular attempts, the carotid artery is more readily compressible compared with the subclavian artery, which makes this approach more attractive in patients with coagulation disturbances. Most complications of accidental arterial puncture occur with dilation and subsequent placement of large-bore catheters into an artery. Several case reports and small series have acknowledged this important complication.11–13 Traditional means of confirming arterial versus venous puncture of a blood vessel (e.g., bright red color, pulsatile blood return) may be unreliable in hypotensive, hypoxemic patients frequently encountered in the ICU. Transduction of the pressure waveform with intravenous extension tubing before dilation and placement of a large-bore catheter may reduce the occurrence of this complication. One may use tubing filled with sterile saline and attached to a three-way stopcock. After a vessel is entered, this tubing is connected to the needle while it is in the vessel, the tubing is elevated, and movement of the column of saline is analyzed to reflect either a venous or arterial waveform. Alternatively, the guidewire can be placed through the needle into the vessel using the modified Seldinger technique. Subsequently, a small, short catheter (e.g., 18- or 20-gauge 2-in intravenous catheter) can be placed over the wire into the vessel and the wire removed. The saline-filled, intravenous extension tubing can be attached to the catheter in the vessel to confirm a venous or arterial waveform. After confirmation of a venous waveform, the guidewire is replaced through this small intravenous catheter, the catheter is removed, and the procedure is finished. If unintentional arterial cannulation occurs, the small catheter is removed from the artery, and pressure is held at the site. Such a small catheter is much less likely to cause serious complications compared with a dilator and large-bore catheter. In our teaching hospital, we stress the importance of placing sterile intravenous extension tubing on the sterile field before the procedure is started so that a venous waveform can be confirmed prior to dilation and insertion of the catheter.
Bleeding complications from both arterial and venous punctures are exacerbated dramatically in patients who are thrombocytopenic or in those with coagulation disturbances. Unfortunately, such problems are common in critically ill patients. Those with platelet counts below 50,000/μL or those with an international normalized ratio (INR) above 2 probably should have catheters placed at a site with compressible vessels (e.g., internal jugular or femoral vein) unless the clotting problem can be corrected. The external jugular vein is an alternative that should be considered in those with clotting disturbances because it is a superficial vein that is easily compressible.