Central venous catheter placement is a common procedure performed in the intensive care unit with common and uncommon complications. Standard post-procedure practices such as chest radiography, free venous blood return, and pressure transduction may fail to detect catheter malposition in rare cases. The following case illustrates a patient who underwent left internal jugular central venous dialysis catheter placement and suffered acute cardiac tamponade as a consequence of a misplaced dialysis catheter into the pericardial space.
A 69 year-old male physician was admitted to the intensive care unit for severe community acquired pneumonia and sepsis that was found to be due to methicillin-resistant Staphylococcus aureus. Despite aggressive antibiotic therapy, fluid resusitation, drotrecogin alfa infusion, hydrocortisone infusion, and vasopressor therapy, his sepsis progressed and he developed oliguric renal failure with metabolic and respiratory acidosis. The renal team was consulted for evaluation for slow low effective dialysis (SLED). The drotrecogin alfa infusion was held as a left internal jugular dialysis catheter was placed utilizing bedside ultrasound guidance. A post-procedure chest radiograph revealed an unusual position of the catheter consistent with either a persistent left superior vena cava (SVC) or arterial cannulation. Blood gas analysis revealed a pH of 7.04, pCO2 58, pO2 34, HCO3 15, and a measured saturation of 63% consistent with venous blood. Transduction of central venous pressure (CVP) via the left internal jugular dialysis catheter distal port was 20cmH2O pressure and was equal to the CVP transduced by a previously placed right internal jugular catheter. The patient was therefore presumed to have a dialysis catheter located in a persistent left SVC. An echocardiogram obtained prior to initiation of SLED revealed a small pericardial effusion without evidence of tamponade. SLED was initiated with transfusion of packed red blood cells. The dialysis nurse reported some difficulty with flow through the catheter and the renal team attempted to adjust SLED by pulling from the distal port and reinfusing through the proximal port. However, effective SLED could not be achieved and the critical care team elected to remove the patient from SLED and place a new dialysis catheter at another site. Upon flushing the SLED circuit and removing the patient from the SLED unit, he acutely became hypotensive, bradycardic, and progressed to asystole that was refractory to advanced cardiac life support protocol. He subsequently underwent post-mortem examination which revealed 500ml of bloody fluid upon opening the pericardial sac, with the final position of the dialysis catheter in the pericardial space.
Cardiac tamponade is a rare, but lethal complication of misplaced central venous catheters. Standard bedside practices to determine catheter placement may fail to disclose the true location of the catheter. The possibility of pericardial placement must be considered in order to avoid lethal cardiac tamponade. In this case, as the SLED circuit was flushed and the patient was removed from the dialysis unit, 500ml of fluid filled the pericardial space resulting in acute cardiac tamponade and cardiac arrest. A definitive study such a contrast venography may be required to confirm catheter location in special circumstances. A persistent left SVC may have a radiograph identical to the radiograph in this case, however, as illustrated here, simple measurements such as blood gas analysis and pressure transduction may fail to confirm the true location of the catheter.
In order to avoid potentially lethal complications of central venous catheter placement, we must be aware of the potential pitfalls of simple bedside tests such as venous blood return, blood gas analysis, and pressure transduction to determine catheter location. When there is suspicion of aberrant catheter placement, contrast venography should be considered to verify the true catheter location.
Susan Rohr, None.