A patient developed a haemothorax due to left innominate vein injury. This occurred during insertion of a veno-venous (VV) bypass line in the right internal jugular vein during adult liver transplantation surgery. The injury was identified whilst attempting to place the patient on VV bypass. There was a drop in blood pressure, the bypass machine would not run and the patient went into cardiac arrest. CPR and advanced life support (adrenaline and fluid boluses using a rapid infuser) were given and the major haemorrhage protocol activated. Output was restored after thoracotomy and clamping of the left hilum. The line was retracted and the vessel repaired. After bilateral intercostal drains were inserted, the chest was closed and liver transplantation surgery proceeded.

Commentary

Complications of insertion of catheters for veno-venous (VV) bypass although rare may be associated with severe morbidity and even mortality. This is partly due to the size of catheter (typically 18 Fr, 6mm), twice the size of a multi-lumen central line (9 Fr, 3mm). In the context of liver transplantation surgery, coagulopathy may be a contributory factor.¹ As with any central venous cannulation, ultrasound visualisation should be used for insertion. The smallest bore catheter possible should be used, and minimal force exerted for insertion. There should be a low threshold for abandoning an insertion attempt should difficulties be encountered. The position must be confirmed before use.

1. Jackson P, Jankovic Z. Veno-venous bypass catheters for hepatic transplant risk unique complications. AnaesI Intensive Care. 2007 Oct; 35(5):805-6