Septic emboli from a radial artery catheter with local manifestations of subacute bacterial endocarditis Amihai Shinfeld, M D , Amos Ofer, M D , I. Engleberg, M D , and Isam Rabi, M D , Tel Hashomer, Israel Septicemboli, giving rise to physical signs similar to those of subacute bacterial endocarditis, are extremely rare complications of radial artery catheterization. A case is reported with splinter hemorrhages and Janeway lesions, resulting from an infected radial ~rtery catheter. Five other cases with these signs are collected from among 21 patients with localized septic complications described in the literature. The duration of radial artery catheterization was 4 days or longer in all cases, and Staphylococcus aureus was the offending agent in all. We conclude that arterial lines should be removed as early as possible, and in any case they should be pulled out at the earliest sign of a local complication. In the presence of signs of local infection, antistaphylococcal treatment should be given until results of cultures are available. (l VASc SURG 1992;16:293-6.)
Radial arterial fines are used extensively and routinely in intensive care units for monitoring the progress of severely ill patients. The practice is, however, not free of complications, the most common of which is thrombosis, reported in 15% to 38% of patients. 1,2 Local infection is less common, occurring in 0.4% to 4%, a-s and septicemia is the rarest at 0% tO 0.6% 3"7.
We report an unusual case of septic emboli from a radial artery catheter (RAC), with physical findings similar to those found in subacute bacterial endocarditis (SBE), and we review the literature on the
subject. CASE R E P O R T
A 40-year-old man was admitted after falling from a height of 7 meters, sustaining head and chest injuries. ACT scan revealed inttacranial hemorrhage and edema, and he was transferred to the intensive care unit, where a 21-gauge RAC was inserted percutaneously for monitoring of blood pressure and gases. On the third day the patient became febrile to 38.2 ° C, and 24 hours later cellulitis became evident at the site of entry of the RAC. The catheter was removed and cloxacillin was given intravenously. Three days later the vascular service was consulted because of the appearance of a localized abscess with punctate subcutaneous and linear From the Department of General and Vascular Surgery and the Department of Pathology (Dr. Engleberg), The Chaim Sheba Medical Center, Tel Hashomer, Israel. Reprint requests: Isam RaN, MD, Department of Surgery A, Sheba Medical Center, Tel Hashomer 52621, Israel. 24/4/37162
subungual hemorrhages in the area of distribution of the distal radial artery (Fig. 1, A and B). The other fingers appeared normal. The abscess was drained, and the infected arterial segment was excised. The pus grew Staphylococcus aureus, and the histologic appearance of the excised artery was consistent with arteritis and thrombosis (Fig. 2). On continued doxacillin therapy the local signs cleared, without any residual ischemic damage to the thumb. The patient, however, died of his head injury 23 days after admission. DISCUSSION The classic cutaneous manifestations of SBE are the following: Ossler nodes = tender reddend nodtries on the finger pads, 8 Janeway lesions = small nontender hemorrhages in the palms, 9 and splinter hemorrhages in the nail beds. l°,n During the past 20 years sporadic case reports have described these signs, appearing in patients with an RAC, a probable result of septic emboli from the infected artery. A recent textbook on iatrogenic vascular complications fails to even mention this complication. 12 The literature reviewed revealed 21 patients with septic complications of RAC. Twelve of these were reported by Swanson et al) s who followed 2900 patients with RACs during a 2-year period. Only two of the 12 patients in this series had the SBE-like signs. Table I summarizes the clinical data pertaining to aU 21 patients, including three short series and four case reports including our own. s,6a3q7 Only six of these patients had SBE-like signs in the hand. 293
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Fig. 1. A, Linear subungual splinter hemorrhages in the thumb. B, Janeway lesions (small subcutaneous hemorrhages) in thenar area.
The patients, aged 38 to 75 years, were hospitalized mostly in intensive care units, with a variety of severe illnesses. As far as is ascertainable all catheters except one were in place 5 days or more before the appearance of the septic emboli. 13-17 .' In eight of nine cases where the physical findings were described there were local signs of infection, 4'1s17 and all except two had positive blood cultures as well. As a result of reporting practices, it was not possible to identify the source of the sepsis or the infecting agent. Nine out of 10 positive blood cultures grew S. aureus, and one grew Proteus mirabilis. Thirteen of 16 cultures from the site of the local infection also were ofS. aureus, the other three were ofPr0teus, Enterococcus, and Diphtheroides species.
All patients except one were treated with antibiotics after the RAC infection became manifest. Nine patients required surgical attention, in seven a septic false aneurysm was resected, and one infected radial artery ruptured and was urgently ligated. No patient developed ischemic necrosis in the thumb or thenar region. Except for two patients who, like ours, died of their basic disease, all others recovered completely. The histologic findings in three cases are similar to those in our case, 15-17 that is, thrombosis and infection of the arterial wall. Gardner et al. 3 reviewed 536 RACs in 530 patients and found the average length of catheterization to be between 3 and 4 days in patients without infection. In 200 of these patients the catheter tip was
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295
Fig. 2. Wall ofatherosclerotic raadialartery,shows a murad thrombus with signs of organization. (HematoxTlin = eosin stain; original magnification × 40.)
Table I. Clinical data on 21 patients with localized septic complications of ILa.C Local signs Ref. no.
No. of patients
14 15 17 17 17 16
1 1 1 1 3 1
13 Present
12 1
No. of days 4 5 5 5 >5 5 5.2 (Avg.) 5
Celiulitis
Abscess
False anegrysm
Rupture
+
+ + +
+ + +
Surgical treatment
Os Sp,Os,~n + + + 5/12
+
SBE4ike signs
+
Os 2/12 Sp, Os,Jn Sp,ln
+ 5/12 +
O60ssler nodes; Sp, splinter hemorrhages; Jn, laneway lesions.
sent for culture, which was positive in eight patients (4%). None of the cultures were orS. aureus, and none had any signs beyond local infection at the entry site of the RAC. The average length of catheterization for the infected catheters was 5.9 days. Bond and M a k i 6 reported on 130 arterial lines (most of them RACs) in 95 patients, with an average length of catheterization of 4.4 days. In 23 patients (18%) there were signs of a local infection, and four of these had cultures positive for S. aureus. Five other patients had septicemia but not from S. aureus. In this series insertion of the arterial catheter by cutdown, as opposed to percutaneously, was associated with a ninefold increase of bacteremia and a 12-fold increase of local infection. Bond and Maki also noted that antibiotic treatment of any kind administered at the
time of catheter insertion did not influence the rate of infectious complications; however, this observation is not based on a randomized clinical study. In this series, none of the patients developed SBE-like lesions. CONCLUSION Subacute bacterial endocarditis-like signs are a rare manifestation of RAC sepsis. All six cases described to date were caused by S. aureus infection. In all these patients, as well as in most patients with positive blood cultures from RACs, the catheter was in. place for more than 4 days. Antistaphylococcal antibiotic therapy, combined with the necessary local surgical measures, resulted in complete recoveDr without residual ischemic damage. This rare complication, as well as other more
296
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Shinfeld et al.
common ones, is better avoided than treated. Lines should be removed as soon as they are not absolutely essential to patient care. They should certainly be removed at the earliest sign of any local or systemic complication. Because the limited experience with severe local infectious complications suggests a predominant role for S. aureus, it appears that intravenous antistaphylococcal antibiotic treatment should be promptly administered until the results of cultures become available. REFERENCES 1. Bedford R_F, Wollman H. Complications of percutaneous radial artery cannulation: an objective prospective study in man. Anesthesiology 1973;38:228. 2. Wilkins RG. Radial artery cannulation and ischemicdamage. A review. Anaesthesia 1985;40:896-9. 3. Gardner RM, Schwartz R, Wong HC, Burke JP. Percutaneous indwelling radial artery catheters for monitoring cardiovascularfunction: prospective study of the risk of thrombosis and infection. N Engl J Med 1974;290:1227-31. 4. Thomas F, Burke JP, Parker J, et al. The risk of infection related to radial vs femoral sites for arterial catheterization. Crit Care Med 1983;11:807-12: 5. RussellJA, Joel M, Hudson RJ, Mangano DT, Schlobohm RM. Prospective evaluation of radial and femoral artery catheterization sites in critically ill adults. Crit Care Med 1983;11:936-9. 6. Band JD, Maki DG. Infections caused by arterial catheters used for hemodynamic monitoring. Am J Med 1979;67:73541.
7. Pinilla JC, Ross DF, Martin T, Crump H. Study of the incidence of intravascular catheter infection and associated septicemia in critically ill patients. Crit Care Med 1983;11: 21-5. 8. Osier W. The chronic intermittent fever of endocarditis. Practitioner 1893;1:181-90. 9. Janeway E. Certain clinical observations upon heart disease. Med News !899;75:257-62. 10. Horder T. Discussion on clinical significanceand course of subacute bacterial endocarditis. Br, Med J 1920;2:301. 11. Blumer G. The digital manifestations of subacute bacterial endocarditis. Am Heart J 1926;1:257-61. 12. Bergentz SE, Bergqvist D, eds. Iatrogenic vascular complications. Berlin, Heidelberg, New York: Springer Verlag, 1989. 13. Swanson E, Freiberg A, Salter DR. Radial artery infections and aneurysms after catheterization. J Hand Surg 1990;15A: 166-71. 14. Michaelson ED, Walsh RE. Osler's node-a complication of prolonged arterial cannulation. N Engl J Med 1970;283: 472-3. 15. Fanning WL, Aronson M. Osier node, Janeway lesions and Splinter hemorrhages: occurence with an infected arterial catheter. Arch Dermatol 1977;113:648-9. 16. Cohen A, Reyes R, Kirk M, Fulks RM. Osler's nodes, pseudoaneurysm formation, and sepsis complicating percutaneous radial artery cannulation. Crit Care Med 1984;12: 1078-9. 17. Arnow PM, Costas CO. Delayed rupture of the radial artery caused by catheter-related sepsis. Rcv Infect Dis 1988;10: 1035-7.
Submitted Nov. 21, 1991; accepted Feb. 13, 1992.
Radial arterial fines are used extensively and routinely in intensive care units for monitoring the progress of severely ill patients. The practice is, however, not free of complications, the most common of which is thrombosis, reported in 15% to 38% of patients. 1,2 Local infection is less common, occurring in 0.4% to 4%, a-s and septicemia is the rarest at 0% tO 0.6% 3"7.
We report an unusual case of septic emboli from a radial artery catheter (RAC), with physical findings similar to those found in subacute bacterial endocarditis (SBE), and we review the literature on the
subject. CASE R E P O R T
A 40-year-old man was admitted after falling from a height of 7 meters, sustaining head and chest injuries. ACT scan revealed inttacranial hemorrhage and edema, and he was transferred to the intensive care unit, where a 21-gauge RAC was inserted percutaneously for monitoring of blood pressure and gases. On the third day the patient became febrile to 38.2 ° C, and 24 hours later cellulitis became evident at the site of entry of the RAC. The catheter was removed and cloxacillin was given intravenously. Three days later the vascular service was consulted because of the appearance of a localized abscess with punctate subcutaneous and linear From the Department of General and Vascular Surgery and the Department of Pathology (Dr. Engleberg), The Chaim Sheba Medical Center, Tel Hashomer, Israel. Reprint requests: Isam RaN, MD, Department of Surgery A, Sheba Medical Center, Tel Hashomer 52621, Israel. 24/4/37162
subungual hemorrhages in the area of distribution of the distal radial artery (Fig. 1, A and B). The other fingers appeared normal. The abscess was drained, and the infected arterial segment was excised. The pus grew Staphylococcus aureus, and the histologic appearance of the excised artery was consistent with arteritis and thrombosis (Fig. 2). On continued doxacillin therapy the local signs cleared, without any residual ischemic damage to the thumb. The patient, however, died of his head injury 23 days after admission. DISCUSSION The classic cutaneous manifestations of SBE are the following: Ossler nodes = tender reddend nodtries on the finger pads, 8 Janeway lesions = small nontender hemorrhages in the palms, 9 and splinter hemorrhages in the nail beds. l°,n During the past 20 years sporadic case reports have described these signs, appearing in patients with an RAC, a probable result of septic emboli from the infected artery. A recent textbook on iatrogenic vascular complications fails to even mention this complication. 12 The literature reviewed revealed 21 patients with septic complications of RAC. Twelve of these were reported by Swanson et al) s who followed 2900 patients with RACs during a 2-year period. Only two of the 12 patients in this series had the SBE-like signs. Table I summarizes the clinical data pertaining to aU 21 patients, including three short series and four case reports including our own. s,6a3q7 Only six of these patients had SBE-like signs in the hand. 293
294
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Shinfeld et al.
Fig. 1. A, Linear subungual splinter hemorrhages in the thumb. B, Janeway lesions (small subcutaneous hemorrhages) in thenar area.
The patients, aged 38 to 75 years, were hospitalized mostly in intensive care units, with a variety of severe illnesses. As far as is ascertainable all catheters except one were in place 5 days or more before the appearance of the septic emboli. 13-17 .' In eight of nine cases where the physical findings were described there were local signs of infection, 4'1s17 and all except two had positive blood cultures as well. As a result of reporting practices, it was not possible to identify the source of the sepsis or the infecting agent. Nine out of 10 positive blood cultures grew S. aureus, and one grew Proteus mirabilis. Thirteen of 16 cultures from the site of the local infection also were ofS. aureus, the other three were ofPr0teus, Enterococcus, and Diphtheroides species.
All patients except one were treated with antibiotics after the RAC infection became manifest. Nine patients required surgical attention, in seven a septic false aneurysm was resected, and one infected radial artery ruptured and was urgently ligated. No patient developed ischemic necrosis in the thumb or thenar region. Except for two patients who, like ours, died of their basic disease, all others recovered completely. The histologic findings in three cases are similar to those in our case, 15-17 that is, thrombosis and infection of the arterial wall. Gardner et al. 3 reviewed 536 RACs in 530 patients and found the average length of catheterization to be between 3 and 4 days in patients without infection. In 200 of these patients the catheter tip was
Volume 16 Number 2 August 1992
Septic emboli fcom radial catheters
295
Fig. 2. Wall ofatherosclerotic raadialartery,shows a murad thrombus with signs of organization. (HematoxTlin = eosin stain; original magnification × 40.)
Table I. Clinical data on 21 patients with localized septic complications of ILa.C Local signs Ref. no.
No. of patients
14 15 17 17 17 16
1 1 1 1 3 1
13 Present
12 1
No. of days 4 5 5 5 >5 5 5.2 (Avg.) 5
Celiulitis
Abscess
False anegrysm
Rupture
+
+ + +
+ + +
Surgical treatment
Os Sp,Os,~n + + + 5/12
+
SBE4ike signs
+
Os 2/12 Sp, Os,Jn Sp,ln
+ 5/12 +
O60ssler nodes; Sp, splinter hemorrhages; Jn, laneway lesions.
sent for culture, which was positive in eight patients (4%). None of the cultures were orS. aureus, and none had any signs beyond local infection at the entry site of the RAC. The average length of catheterization for the infected catheters was 5.9 days. Bond and M a k i 6 reported on 130 arterial lines (most of them RACs) in 95 patients, with an average length of catheterization of 4.4 days. In 23 patients (18%) there were signs of a local infection, and four of these had cultures positive for S. aureus. Five other patients had septicemia but not from S. aureus. In this series insertion of the arterial catheter by cutdown, as opposed to percutaneously, was associated with a ninefold increase of bacteremia and a 12-fold increase of local infection. Bond and Maki also noted that antibiotic treatment of any kind administered at the
time of catheter insertion did not influence the rate of infectious complications; however, this observation is not based on a randomized clinical study. In this series, none of the patients developed SBE-like lesions. CONCLUSION Subacute bacterial endocarditis-like signs are a rare manifestation of RAC sepsis. All six cases described to date were caused by S. aureus infection. In all these patients, as well as in most patients with positive blood cultures from RACs, the catheter was in. place for more than 4 days. Antistaphylococcal antibiotic therapy, combined with the necessary local surgical measures, resulted in complete recoveDr without residual ischemic damage. This rare complication, as well as other more
296
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Shinfeld et al.
common ones, is better avoided than treated. Lines should be removed as soon as they are not absolutely essential to patient care. They should certainly be removed at the earliest sign of any local or systemic complication. Because the limited experience with severe local infectious complications suggests a predominant role for S. aureus, it appears that intravenous antistaphylococcal antibiotic treatment should be promptly administered until the results of cultures become available. REFERENCES 1. Bedford R_F, Wollman H. Complications of percutaneous radial artery cannulation: an objective prospective study in man. Anesthesiology 1973;38:228. 2. Wilkins RG. Radial artery cannulation and ischemicdamage. A review. Anaesthesia 1985;40:896-9. 3. Gardner RM, Schwartz R, Wong HC, Burke JP. Percutaneous indwelling radial artery catheters for monitoring cardiovascularfunction: prospective study of the risk of thrombosis and infection. N Engl J Med 1974;290:1227-31. 4. Thomas F, Burke JP, Parker J, et al. The risk of infection related to radial vs femoral sites for arterial catheterization. Crit Care Med 1983;11:807-12: 5. RussellJA, Joel M, Hudson RJ, Mangano DT, Schlobohm RM. Prospective evaluation of radial and femoral artery catheterization sites in critically ill adults. Crit Care Med 1983;11:936-9. 6. Band JD, Maki DG. Infections caused by arterial catheters used for hemodynamic monitoring. Am J Med 1979;67:73541.
7. Pinilla JC, Ross DF, Martin T, Crump H. Study of the incidence of intravascular catheter infection and associated septicemia in critically ill patients. Crit Care Med 1983;11: 21-5. 8. Osier W. The chronic intermittent fever of endocarditis. Practitioner 1893;1:181-90. 9. Janeway E. Certain clinical observations upon heart disease. Med News !899;75:257-62. 10. Horder T. Discussion on clinical significanceand course of subacute bacterial endocarditis. Br, Med J 1920;2:301. 11. Blumer G. The digital manifestations of subacute bacterial endocarditis. Am Heart J 1926;1:257-61. 12. Bergentz SE, Bergqvist D, eds. Iatrogenic vascular complications. Berlin, Heidelberg, New York: Springer Verlag, 1989. 13. Swanson E, Freiberg A, Salter DR. Radial artery infections and aneurysms after catheterization. J Hand Surg 1990;15A: 166-71. 14. Michaelson ED, Walsh RE. Osler's node-a complication of prolonged arterial cannulation. N Engl J Med 1970;283: 472-3. 15. Fanning WL, Aronson M. Osier node, Janeway lesions and Splinter hemorrhages: occurence with an infected arterial catheter. Arch Dermatol 1977;113:648-9. 16. Cohen A, Reyes R, Kirk M, Fulks RM. Osler's nodes, pseudoaneurysm formation, and sepsis complicating percutaneous radial artery cannulation. Crit Care Med 1984;12: 1078-9. 17. Arnow PM, Costas CO. Delayed rupture of the radial artery caused by catheter-related sepsis. Rcv Infect Dis 1988;10: 1035-7.
Submitted Nov. 21, 1991; accepted Feb. 13, 1992.
