Abstract The use of central venous catheters as access for hemodialysis has become common in children with end-stage renal disease. Phrenic nerve palsy is an unusu- al complication of this procedure. We report a case of delayed right diaphragmatic palsy due to phrenic nerve damage resulting from an indwelling right subclavian catheter in a 3-year-old child. Key words Hemodialysis · Subclavian catheter · Phrenic nerve Introduction Central venous catheters are inserted in the subclavian and the internal jugular veins for administration of flu- ids, hyperalimentation, infusions of chemotherapeutic agents for malignancies, hemodynamic measurements, and hemodialysis in uremic patients. Venipuncture of these veins is also performed for insertion of temporary endocardial pacemaker catheters. Well-recognized complications of central venous catheter insertion include pneumothorax, hemothorax, mediastinal hematoma, air embolism, erosion of catheter and sepsis [1–3]. Although rare, injury to the phrenic nerve has been described as an immediate as well as a late complication of indwelling central venous pressure catheter [4–8]. We report a case of phrenic nerve damage with de- layed right diaphragmatic palsy following an indwelling subclavian catheter used for hemodialysis. Case report A 3-year-old child was admitted to our hospital with end-stage re- nal disease due to focal segmental glomerulosclerosis. He was started on maintenance hemodialysis through an indwelling dou- ble lumen right subclavian catheter in October 1997. The catheter was inserted using the Seldinger technique. There were no proce- dure-related complications and the post insertion chest roentgeno- gram confirmed the catheter to be in proper position and the dia- phragm position to be normal (Fig. 1). The catheter was removed about 3 months later due to catheter thrombosis. While waiting for renal transplantation, the child underwent a detailed preoperative work-up. During the course of investigations, the chest roentgenogram done in February 1998 revealed markedly raised right hemidiaphragm (Fig. 2). Subsequent ultrasound and fluoroscopy confirmed the paralysis of right hemidiaphragm. The child was asymptomatic with respect to this problem. He under- went a successful live-related renal transplantation in March 1998. There were no postoperative respiratory complications. A follow- up chest roentgenogram done 3 months after renal transplantation revealed persistence of raised right hemidiaphragm (Fig. 3). Discussion The phrenic nerve is the motor nerve to the diaphragm. It arises from the third, fourth, and fifth cervical nerves. In the neck, it lies on the scalenus anterior muscle. It de- scends posterolateral to the internal jugular vein and passes behind the junction of the internal jugular and the subclavian veins into the mediastinum. Hence, it is in close proximity to the veins usually cannulated for cen- tral venous catheter insertion. Phrenic nerve palsy following central venous catheter- ization is a rare complication and is not well recognized. Although, most of the reported cases are those following subclavian vein cannulation [4, 6–8], it can also occur af- ter internal jugular vein catheterization [5]. Usually, it has been described as an immediate complication of the pro- cedure [4, 5, 7]. Only recently has its occurrence as a late complication been recognized [8]. In a report of five cases of colonic malignancy receiving protracted chemotherapy infusion through indwelling subclavian catheters, eleva- tion of right hemidiaphragm occurred 55–134 days (mean 93 days) after the Hickman line insertion [8]. According S. Aggarwal · S.N. Mehta Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India P. Hari ( ✉ ) · A. Bagga Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India e-mail: pankajhari@hotmail.com Fax: +91-11-6862663 Pediatr Nephrol (2000) 14:203–204 © IPNA 2000 BRIEF REPORT Sandeep Aggarwal · Pankaj Hari · Arvind Bagga S.N. Mehta Phrenic nerve palsy: a rare complication of indwelling subclavian vein catheter Received: 29 March 1999 / Revised: 16 July 1999 / Accepted: 17 July 1999