A large bore catheter for renal replacement therapy has been accidentally inserted into the carotid artery of a man with multiple organ failure (including a coagulopathy) due to systemic sepsis. The location of the catheter was only discovered after it had been sutured in place. List the potential complications, and outline how you are going to deal with this problem.
Arterial puncture is a well recognised but uncommon complication of central venous catheter insertion. The potential complications include all those associated with venous/arterial puncture, as well as specific ones associated with the large hole in the artery. Damage to associated structures (nerves [eg. vagus], pleura, oesophagus and trachea!) can result in specific problems (either directly or indirectly from compression [eg. haematoma]). A large bore catheter in a blood vessel can result in air embolus (worse if arterial) or even embolus of atheromatous material (stroke risk). Specific problems related to the arterial site include: toxicity of inadvertently administered drugs (before actual position recognised), higher risk of significant haematoma and blood loss (augmented by coagulopathy especially if removed/dislodged). Referral to surgeons
with vascular experience is essential to facilitate definitive management because of the size of the hole in the artery (suture repair, patch repair etc). If surgical repair is not considered indicated, prolonged pressure for haemostasis has associated potential problems (carotid body, distal flow), and haematoma formation likely.
Well, this is embarrassing.
LITFL have a nice page on this topic.
Additonally, the BJMP has an article with a case report of precisely this sort of complication. The author has done a literature search, and presents a list of complications which have been reported in the papers in association with this problem:
Interestingly, having spoken to some of the vascular surgeons about such complications, the general opinion seems to be that if you have already dilated the artery and inserted the vas cath, the best thing you can do is suture it in position and leave it there until they arrive. Apparently that is somehow better than taking it out and then putting pressure on a carotid with a vas-cath-sized hole in it.
How to deal with this problem:
Nair, Sanil, et al. "A case of accidental carotid artery cannulation in a patient for hemofilter: complication and management." British Journal of Medical Practitioners 2.3 (2009): 57-58.