THE NEW ZEALAND MEDICAL JOURNAL Vol 118 No 1215 ISSN 1175 8716 NZMJ 20 May 2005, Vol 118 No 1215 Page 1 of 2 URL: http://www.nzma.org.nz/journal/118-1215/1470/ © NZMA Horner’s syndrome after central venous catheterisation John Jarvis, Angus Watson, Greg Robertson Case report A 19-year-old female patient presented for surgery with indeterminate colitis refractory to medical therapy. She had severe diarrhoea despite being on maximal medical therapy. Colonoscopic examination of the lower bowel demonstrated a confluent colitis with granular mucosa and a mucopurulent exudate throughout the colon. The patient underwent a subtotal colectomy with preservation of the rectum and formation of end ileostomy. The patient initially had an uncomplicated recovery and was discharged home. However she became unwell and was readmitted acutely with peritonitis the following day. An abdominal radiograph suggested there was free gas in the abdomen, and the clinical impression was either that of a rectal stump staple line dehiscence or a perforated peptic ulcer. The patient was taken back to theatre for an exploratory laparotomy, which revealed an infected fluid collection without evidence of a perforated viscus. An internal jugular central venous line was placed using the Seldinger technique without the aid of ultrasound. Central line placement was checked with a chest radiograph and the position was thought to be satisfactory. The patient progressed well on the first postoperative day, however the central line was difficult to flush and back-filled with blood. A blood sample was taken for blood gas analysis and was found to be arterial. After discussion, the central line was removed and pressure applied locally to the puncture site for 20 minutes. On the third postoperative day, the patient complained of a drooping eyelid and slightly blurred vision on the right side. Her pupils were also unequal. An ophthalmology opinion confirmed the presence of a right-sided Horner’s syndrome and normal visual acuity. Three months after surgery, the Horner’s syndrome had largely resolved. Discussion Horner’s syndrome is a recognised complication of internal jugular venous catheterisation. 1 Risk factors for development of the syndrome appear to include: insertion of large bore haemodialysis 2 or Swan-Ganz 3 catheters, difficult catheterisation with repeated needling attempts, and accidental carotid artery puncture. All of these share the likely aetiology of carotid sheath haematoma with damage to the second-order sympathetic fibres in and around the cervical ganglia. As in this case, most Horner’s syndromes develop from a neuropraxia caused by a carotid sheath haematoma—often seen after internal carotid artery stenting. 4 Debate about the use of ultrasound to increase the rate of successful central venous catheterisation (CVC) continues, 5 but there is now increasing evidence that the use of a two-dimensional (2-D) ultrasound guidance increases the likelihood of success, thus decreasing the incidence of complications and the time spent on the procedure. 6,7