Potassium Chloride-Induced Phlebitis via a Malpositioned Central Venous Catheter

We present a case of potassium chloride-induced phlebitis with severe, burning, left-sided chest pain when infused via a malpositioned central venous catheter. Using a malpositioned central venous catheter requires careful consideration, but this novel case prompts the need for additional review before its use for the infusion of potentially irritating medications. We present a case of potassium chloride-induced phlebitis with severe, burning, left-sided chest pain when infused via a malpositioned central venous catheter. Using a malpositioned central venous catheter requires careful consideration, but this novel case prompts the need for additional review before its use for the infusion of potentially irritating medications. It is known that IV potassium chloride (KCl) can lead to burning, irritation, or phlebitis at the site of injection. The risk of these adverse events is largely considered to be mitigated when the drug is infused via a central venous catheter (CVC), rather than a peripheral IV line. This case report may identify an exception to this principle. A risk for these injection site reactions to occur may still exist if the CVC is malpositioned where the tip of the catheter lies within a smaller vessel. A 69-year-old man with a past medical history of COPD, hypertension, hyperlipidemia, heart failure with reduced ejection fraction, and coronary artery disease with coronary artery bypass grafting was admitted for acute respiratory failure and non-ST-segment elevation myocardial infarction with a peak troponin of 60.700 ng/mL. The patient was intubated and received mechanical ventilation shortly after arrival. A heparin infusion was started, but the patient was considered too unstable for left heart catheterization. Within a few hours of intubation, he became hypotensive; norepinephrine and vasopressin were started. A 14-French triple-lumen CVC was inserted via the left internal jugular. To confirm placement, chest radiography was performed that demonstrated that the CVC terminated over the aortic knob (Fig 1). The CVC was connected for central venous pressure, which was 15 mm Hg with absence of arterial wave form, confirming venous placement. The CVC was presumed to be in the azygos vein system via the accessory hemiazygos vein. BP normalized soon after, and vasopressors were stopped later that day; however, the CVC remained in place. On day 3 of hospitalization, the patient was extubated. On day 4, the patient's serum potassium was low at 3.3 mEq/L. A dose of IV KCl 40 mEq/100 mL was ordered. The medication was infused via the CVC at a rate of 10 mEq/h. Minutes later, the patient began reporting severe, burning, left-sided chest pain that radiated between his shoulders and worsened on palpation. The patient described it as the worst pain he has ever felt. The patient was administered two doses of sublingual nitroglycerin 0.4 mg 5 min apart that offered only mild improvement. The consulted cardiologist was notified, and a nitroglycerin drip was ordered. When the KCl infusion was paused to set up the nitroglycerin drip, the pain resolved immediately. The nitroglycerin drip was started at 5 μg/min and the potassium chloride infusion was restarted, at which time the severe chest pain returned. The IV KCl was stopped again, which alleviated the chest pain once more. Despite being infused via a CVC, this incident likely was caused by KCl-induced phlebitis because the malpositioned CVC terminated in a smaller vessel. The nitroglycerin drip was stopped and the KCl infusion was switched to a peripheral line. The patient did not report any further chest pain, either during peripheral infusion or afterward. The CVC was removed later that day without incident. To our knowledge, this is the first documented case of KCl-induced central vein phlebitis. On the Naranjo's adverse drug reaction probability scale, the adverse event was calculated to be a 7, indicating a probable reaction to IV KCl.1Naranjo C.A. Busto U. Sellers E.M. et al.A method for estimating the probability of adverse drug reactions.Clin Pharmacol Ther. 1981; 30: 239-245Crossref PubMed Scopus (8709) Google Scholar The main strength of this case was its cause-and-effect nature, in which the pain came and went as the KCl infusion was started and stopped. A major limitation we faced was not having additional imaging to confirm the exact placement of the malpositioned CVC. Malpositioning of CVCs in the azygos system occurs in approximately 0.7% to 1.2% of cases. In terms of anatomic course and drainage pattern, the azygos system is quite variable.2Wang L. Liu Z.S. Wang C.A. Malposition of central venous catheter: presentation and management.Chin Med J (Engl). 2016; 129: 227-234Crossref PubMed Scopus (22) Google Scholar,3Burney K. Young H. Barnard S.A. McCoubrie P. Darby M. CT appearances of congenital and acquired abnormalities of the superior vena cava.Clin Radiol. 2007; 62: 837-842Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar The accessory hemiazygos vein drains the superior left hemithorax. Normally, a small connection to the left superior intercostal vein is present, but in approximately 1% to 2% of patients, the accessory hemiazygos vein drains into the brachiocephalic vein directly (Fig 2).4Blackmon J.M. Franco A. Normal variants of the accessory hemiazygos vein.Br J Radiol. 2011; 84: 659-660Crossref PubMed Scopus (12) Google Scholar,5Galwa R.P. Prakash M. Khandelwal N. 16-MDCT depiction of accessory hemiazygos vein draining into the left brachiocephalic vein.Indian J Radiol Imaging. 2007; 17: 50-51Crossref Scopus (9) Google Scholar If this rare variation in the azygos system is present, then a risk for a unique CVC malpositioning exists, particularly if inserted into the left internal jugular. Because of the thin wall and small lumen of the azygos veins, prompt recognition with removal or repositioning of the CVC is recommended to prevent complications such as vein perforation and thrombosis. When such malpositioned catheters are used for medication administration, caution should be exercised while infusing hyperosmolar and irritant solutions because of concern for increased pain during infusion that, in extreme cases, theoretically could lead to extravasation or erosion of the vein into the pleural space. None declared. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met. The authors thank the patient for consenting to publication of his case and their colleagues who assisted in managing this patient.