Dr. Nora McNulty (PGY4), Dr. Eldin Pupovic
90-year-old female presented for weakness and altered mental status during hemodialysis therapy. Family reported a productive cough for 5 days and decreased oral intake. Vitals on arrival revealed a blood pressure 66/49, heart rate of 106, respiratory rate of 20 and saturation of 98% on room air. Physical exam was notable for left-sided rhonchi. Laboratory analysis revealed COVID positivity and lactate of 4.2. Emergency Department (ED) course was complicated by hematemesis necessitating emergent intubation for airway protection.
A ultrasound-guided central line was placed in the right internal jugular (RIJ) vein with no immediate procedural complications. Central line was placed at 15cm depth. All ports demonstrated blood return and were flushed easily. Chest x-ray was obtained to confirm placement of both the endotracheal tube and central line. On chest X-Ray, RIJ central line catheter was visualized not lying in the right atrium, but in the subclavian vein terminating in the axillary vein. The associated X-Ray is shown above.
Central venous access is vital in the unstable patient, but placement of a central line comes with well-known risks including (but not limited to) pneumothorax, infection, hematoma, and placement in improper vessels.. Improper positioning of the catheter within the venous system can have multiple resulting complications if not promptly addressed including but not limited to erosion/perforation of vessel walls, venous thrombosis, catheter dysfunction, and cranial retrograde injection (infusate directed peripherally towards the upper trunk and head instead of central circulation). If therapies are improperly initiated through a malpositioned CVC, clinical manifestations may include chest pain if CVC is placed in small tributaries of the SVC, retrosternal pain to the back if in the internal mammary vein, or headache/tinnitus described as “water running” in the internal jugular vein.
To prevent the multitude of resulting complications from improperly positioned lines, confirming placement and ruling out complications via Chest X-Ray is the standard following placement. However, if CXR is not immediately available, another tool for confirmation of proper placement is via ultrasound through flushing the line with agitated saline and directly observing rapid turbulent flow through the right atrium. Ultrasound has been found to detect a majority of catheter malpositions through direct visualization.
Of note, malpositioning is more common if cannulation is attempted into the left IJ due to a more oblique course into the superior vena cava through the long left brachiocephalic vessel. Right-sided catheterization provides a more direct route to the right atrium and, if feasible, access through this route may prevent improper positioning. Other methods to lessen chances of malpositioning when obtaining central venous access through the internal jugular veins include: rotating head in opposite direction of insertion site to stretch and narrow the IJ vein to improve chances of identification and insertion.
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