What is the most common cause of death during central line placement in a pregnant female?

Most Common Cause of Death During Central Line Placement in Pregnant Women

Air embolism is the most common cause of death during central line placement in pregnant women, as it can lead to rapid cardiovascular collapse and mortality.

Pathophysiology and Risk Factors

• Air embolism occurs when air enters the venous system during central line insertion, which can travel to the pulmonary circulation causing obstruction to pulmonary blood flow, right ventricular outflow tract obstruction, and potentially paradoxical embolism through a patent foramen ovale 1
• Pregnant women are at increased risk for air embolism due to:
  • Increased blood volume and cardiac output (30-50% increase) during pregnancy 2
  • Hypercoagulable state of pregnancy which increases risk of thrombotic complications 2
  • Anatomical changes including enlargement of the heart by up to 30% and elevation of the diaphragm 2

Other Significant Causes of Death During Central Line Placement

• Vascular injuries leading to hemorrhage, particularly concerning in pregnant women who already have increased blood volume and cardiac output 1
• Cardiac arrhythmias, particularly ventricular tachycardia (1% incidence), which can be triggered by guidewire contact with the right ventricle 3
• Pneumothorax with tension physiology causing respiratory compromise and hemodynamic collapse 1
• Cardiac tamponade from perforation of central veins or cardiac chambers 1

Complication Rates in Pregnancy

• The overall incidence of central venous catheter complications during pregnancy is approximately 25%, with infectious complications being most common at 12% 3
• Mechanical failures occur in approximately 4% of central line placements in pregnant women 3
• Thrombotic complications (superficial and deep venous thrombosis) occur in approximately 2% of pregnant women with central lines 3

Prevention Strategies

• Use ultrasound guidance for all central line placements to reduce the risk of mechanical complications 1
• Position the patient in slight Trendelenburg position (if not contraindicated) to increase venous pressure and reduce risk of air embolism 1
• Have the patient perform Valsalva maneuver during needle insertion and catheter exchanges 1
• Ensure proper hydration status before the procedure 1
• For pregnant women beyond 20 weeks gestation, utilize left lateral displacement to minimize aortocaval compression 2

Recognition and Management of Air Embolism

• Immediate signs include sudden hypotension, tachycardia, decreased end-tidal CO2, and oxygen desaturation 1
• If air embolism is suspected:
  • Place patient in left lateral decubitus position with head down (Durant position) to trap air in the right atrium 1
  • Administer 100% oxygen 1
  • Consider aspiration of air through the central line if possible 1
  • Initiate cardiopulmonary resuscitation if cardiac arrest occurs 2

Special Considerations for Pregnant Women

• For pregnant women in cardiac arrest during central line placement, high-quality CPR with manual left uterine displacement is essential if the fundus height is at or above the umbilicus 2
• If cardiac arrest occurs and immediate return of spontaneous circulation cannot be achieved, emergency cesarean delivery should be considered within 4-5 minutes of arrest for women in the second half of pregnancy 2
• Cardioversion and defibrillation are considered safe at all stages of pregnancy if needed during resuscitation 2

Interdisciplinary Approach

• High-risk pregnant patients requiring central venous access should be managed by interdisciplinary teams in specialized centers 2
• The team should include obstetric, anesthesia, and critical care specialists with experience in managing pregnant patients 2
• Early identification and aggressive management of complications is crucial to prevent maternal mortality 4