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Arterial Level PO2 Does Not Always Indicate an Arterial Misplacement During Internal Jugular Venous Cannulation FREE TO VIEW

Deepa Kuchelan, MD; Sameh Aziz, MD
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Carilion Clinic - Virginia Tech Carilion School of Medicine, Roanoke, VA

Chest. 2014;146(4_MeetingAbstracts):258A. doi:10.1378/chest.1995265
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SESSION TITLE: Critical Care Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: The rate of misplacement of central venous catheters using the internal jugular vein has been reported between 0.8% and 5.7%. Real time ultrasound guidance is helpful in reducing this complication. Chest radiography, pressure waveform analysis, blood gas analysis are often used to confirm the correct placement, but they are not without pitfalls. Here we describe a case where the blood gas analysis from a central venous catheter was misleading due to a congenital variation and made as concerned for an arterial misplacement.

CASE PRESENTATION: : A 75 year old male was admitted for cervical myelopathy and underwent C3-C7 cervical decompressive laminectomies. Due to hypoxic respiratory failure and shock, he was placed on mechanical ventilation. An emergent left internal jugular central venous line was placed under ultrasound guidance and the vein was noted to be collapsing and overlying the carotid artery. Due to the difficult procedure and as the tip did not cross the midline in the CXR, concern for arterial misplacement was raised. Blood gas analysis from the central line showed PH of 7.49, PCO2 of 35, PO2 of 143 and oxygen saturation of 99% and simultaneously obtained radial arterial blood gas revealed a PaO2 of 197 and oxygen saturation of 100%. The waveform analysis revealed venous waveforms. We decided to leave the line in after checking with US as it confirmed placement in internal jugular vein. A subsequent CTA chest confirmed that our line was ending in the left brachiocephalic vein. On careful review we identified anomalous left upper lobe pulmonary venous drainage into the left brachiocephalic vein contributing to the high oxygen content of the blood gas from the central line.

DISCUSSION: During fetal development some or all of the pulmonary veins may fail to establish connections to the left atrium, draining instead to the right atrium or via the vena cava or one of its branches. It is usually asymptomatic and diagnosed incidentally during imaging or catheter placement. Apart from this the presence of an ipsilateral AV fistula in a hemodilaysis patient had resulted in arterialization of blood obtained from a jugular venous catheter. Current techniques for confirming the central line position are associated with a number of pitfalls

CONCLUSIONS: It is important for the critical care providers to be aware of the congenital anomalies such as partial anomalous pulmonary venous drainage that can complicate CVC placements.

Reference #1: Wylam et al, Chest 1990

DISCLOSURE: The following authors have nothing to disclose: Deepa Kuchelan, Sameh Aziz

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