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Sir,

Central venous catheter placement is a common procedure performed in children for long-term intravenous access and resuscitation. Immediate venous congestion following central venous catheter insertion has not been previously reported.

A 100-day-old, 4.5-kg male with biliary atresia underwent an uneventful Kasai’s portoenterostomy with heart rate 120/min and blood pressure 70/30 mmHg, postprocedure. Anticipating a difficult intravenous access postoperatively, a femoral central venous catheter (22G) was placed percutaneously on the right side. Within 15 min of insertion, there was a dramatic change in color of the right lower limb accompanied by prolonged capillary time [Figure 1a and b]. Femoral pulses were well felt bilaterally and no temperature difference was detected between the limbs. Blood gas drawn from the catheter confirmed a venous sample with metabolic acidosis. Fluids were administered through the peripheral line, and the color of the limb returned to normal within 30 min of removing the catheter. A similar phenomenon and course [Figure 1c and d] was observed when a 22G single-lumen venous catheter was placed via saphenofemoral cut down in a 36-day-old, 3.4-kgs, male child, admitted with septic shock in the pediatric intensive care unit with deranged coagulation parameters.

We suspect that this occurs in infants and young children due to a combination of two reasons: (1) The average preexisting peripheral vasoconstriction and (2) catheter-induced venous spasm.[1] The diameter of the femoral vein in a 3-month-old infant (such as the patient described in Case 1) is approximately 2.5 mm,[2] which may be significantly reduced due to volume depletion following a major surgical procedure. Ultrasound measurements of femoral vein diameter have shown that a nearly 75% reduction in diameter can be observed with a 5–6 mmHg drop in central venous pressure.[3] A similar reduction coupled with venous spasm could have resulted in inadequate venous drainage around a catheter of 22G having an outer diameter of 0.7 mm, ultimately causing obstruction of venous drainage. A similar hypothesis holds good for the second case of a 3.4-kg baby in septic shock.

We conclude that acute venous occlusion may occur after inserting a central venous catheter, due to venous spasm or a relatively oversized catheter in a hypovolemic state, and thus, a Doppler evaluation of the relevant vessels should ideally be done before insertion in a volume-depleted child.

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