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A Man in His 60s With Renal Failure and Shock Refractory to VasopressorsRenal Failure and Shock Refractory to Vasopressors FREE TO VIEW

Kerry M. Hena, MD; Lewis A. Eisen, MD, FCCP; Ariel L. Shiloh, MD
Author and Funding Information

From the Division of Critical Care Medicine, Department of Medicine, Albert Einstein College of Medicine, The Jay B. Langner Critical Care Service, Montefiore Medical Center, Bronx, NY.

CORRESPONDENCE TO: Ariel L. Shiloh, MD, Division of Critical Care Medicine, Albert Einstein College of Medicine, Critical Care Administration, Montefiore Medical Center, 111 E 210th St, Bronx, NY 10467; e-mail: arielshiloh@gmail.com


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(6):e171-e174. doi:10.1378/chest.15-0160
Text Size: A A A
Published online

A 64-year-old man with coronary artery disease, chronic systolic heart failure, and bioprosthetic mitral valve replacement presented to the ED with diffuse body pain and weakness. Initial workup revealed acute renal failure and hypotension. The patient received 2 L of normal saline but remained hypotensive, and a left internal jugular central venous catheter was placed by the ED team. A critical care medicine consult was called for further assistance with renal failure, severe acidemia, and shock state.

On initial evaluation, vital signs were BP, 77/42 mm Hg; pulse rate, 87/min; respiratory rate, 14/min; saturation, 99% on room air; and temperature, 36.5°C. Lungs were clear to auscultation bilaterally. Cardiac examination revealed a grade 2 holosystolic murmur. The abdomen was unremarkable, and there was mild pitting edema. Laboratory test results were significant for acute renal failure (BUN, 106 mg/dL; creatinine, 7.6 mg/dL) with severe hyperkalemia (potassium, 9.3 mEq/L) and metabolic acidosis (bicarbonate, 11 mEq/L). Venous blood gas values were pH, 7.191; Pco2, 34.4 mm Hg; and lactate, 1.3 mM. ECG demonstrated a wide complex QRS pattern (Fig 1). An echocardiogram showed moderately reduced left ventricular function that was unchanged from previous examinations and interval development of mild right ventricular hypokinesis. Chest radiography was interpreted by the radiologist as having no focal pulmonary consolidation and a left internal jugular catheter coursing to the left of the sternum with catheter tip presumed to be in a left-sided superior vena cava or left internal mammary vein (Fig 2). The ED team reported using ultrasound guidance for vascular access.

Figure Jump LinkFigure 1 –  ECG on presentation to the ED.Grahic Jump Location

Figure Jump LinkFigure 2 –  Chest radiograph after the placement of a central venous catheter.Grahic Jump Location

The patient required emergent hemodialysis for hyperkalemia. Norepinephrine was initiated for hemodynamic support during hemodialysis. Escalating doses of norepinephrine, up to 40 μg/min, were required to maintain a mean arterial pressure of 65 mm Hg. An additional 2 L of normal saline were bolused via the central access.

After dialysis, the patient was transferred to the medical ICU. He was newly dyspneic, tachypneic, and tachycardic. There were decreased breath sounds on auscultation and dullness to percussion over the left chest. The nurse transduced the distal port of the triple lumen catheter (Fig 3), and amber-colored fluid was drawn from the distal port. The intensivist team performed bedside ultrasonography to determine the cause of respiratory insufficiency and tachycardia (Video 1, Video 2, Video 3, Video 4).

Figure Jump LinkFigure 3 –  Catheter pressure transduction tracing.Grahic Jump Location

Video 1

Left pleural effusion.

Video 2

Demonstration of the catheter within the pleural space.

Video 3

Bubble study confirming the catheter within the pleural space.

Video 4

Demonstration of the extravascular placement of the catheter within the soft tissue.

Question: Based on the interpretation of these videos and the patient’s clinical presentation, what is the most likely diagnosis?
Diagnosis: Misplacement of a central venous catheter within the pleural space

Based on the ultrasound findings, chest radiography, the pressure tracing, and the return of thin yellow fluid from the catheter, extravascular catheter deployment was presumed (Video 5). Evaluation of the catheter insertion site failed to reveal a catheter entering the left internal jugular vein. A small echogenic focus with shadowing artifact represented part of the catheter in the soft tissue of the neck. Bedside thoracic ultrasonography of the left hemithorax identified a large left-sided pleural effusion, demarcated by an echo free space and dynamic lung findings, bordered by the diaphragm and chest wall. An apical cardiac view demonstrated a hyperechoic linear structure with comet-tail artifact abutted up against the heart, most likely in the left pleural space.

Video 5

Discussion video.

Running Time: 3:14

On further imaging, the tip of the catheter was confirmed in the pleural space with a bubble study. Instillation of agitated saline via the catheter resulted in small echogenic bubbles within the pleural effusion. A 14F percutaneous chest tube was placed via ultrasound guidance with 2 L of serosanguinous output and resolution of the patient’s impending respiratory failure. A right internal jugular central venous catheter was inserted, and the left-sided catheter was removed after consultation with cardiothoracic surgery. ​Ultimately, the patient improved to his baseline and was discharged without the need for further dialysis.

Central venous catheters remain an essential component of current critical care practice, allowing for volume resuscitation, hemodynamic monitoring, vasopressor administration, medication delivery, parenteral nutrition, and hemodialysis. The use of ultrasound guidance has led to considerable reductions in mechanical complications when compared with landmark techniques. However, even with ultrasound guidance, mechanical complications are possible.

An analysis of mechanical complications in 385 consecutive central venous catheter attempts demonstrated an overall complication rate of 34%.1 Complications included failure to place the catheter, arterial puncture, improper positioning, hematoma, hemothorax, and asystolic cardiac arrest of unknown etiology. Improper position did not include placement into the pleural space. The complication rate significantly increased to 54% when more than two punctures were required.

When compared with the right internal jugular vein, catheterization of the left internal jugular vein has a higher incidence of malposition. Reasons for malposition include the longer and less straight path to the cavoatrial junction.2 An aberrant left-sided paramediastinal course on chest radiography (as in this case) raises the possibility of anatomic variants (persistent left-sided superior vena cava, hemiazygous vein, anomalous pulmonary vein), catheter tip in a normal venous tributary (internal mammary vein, superior intercostal vein), and inadvertent arterial catheterization.2,3 Incidences of mediastinal and pleural placement have rarely been reported.4-8

A notable 2010 case report describes partial placement of a right internal jugular catheter into the targeted vessel with the distal part entering the right pleural space.5 Like the current patient, this patient accumulated infused fluid in the pleural space. Another case of massive hydrothorax following right subclavian vein catheterization highlighted the importance of recognizing negative aspiration (absence of blood return) and its possible causes: (1) external or internal kinking of the catheter, (2) compression by muscles, and (3) the passage of the catheter through a false lumen.6 Other case reports have demonstrated misplacement of internal jugular central venous catheters in both the right and left mediastinum; the latter via accession of the left superior intercostal vein.7,8

  • 1. While the literature has shown ultrasound guidance to reduce the number of mechanical complications with central venous catheterization, the risk remains present.

  • 2. It is essential to confirm correct positioning of the guidewire in venous vasculature prior to dilatation and threading of the catheter.

  • 3. Once the catheter is in place, correct positioning should again be checked by aspiration of venous blood from all ports. Ultrasound for localization of the tip may be useful in some cases.

Conflict of interest: None declared.

Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Additional information: To analyze this case with the videos, see the online version of this article.

Eisen LA, Narasimhan M, Berger JS, Mayo PH, Rosen MJ, Schneider RF. Mechanical complications of central venous catheters. J Intensive Care Med. 2006;21(1):40-46. [CrossRef] [PubMed]
 
Webb JG, Simmonds SD, Chan-Yan C. Central venous catheter malposition presenting as chest pain. Chest. 1986;89(2):309-312. [CrossRef] [PubMed]
 
Gibson F, Bodenham A. Misplaced central venous catheters: applied anatomy and practical management. Br J Anaesth. 2013;110(3):333-346. [CrossRef] [PubMed]
 
Saseedharan S, Pandit R, Bhargava S. Left internal jugular vein dissection with anterior mediastinal placement following hemodialysis catheter insertion. J Pak Med Stud. 2012;2(4):134-137.
 
Nath MP, Gupta S, Chakrabarty A. Extravasation of catheter tip following central venous catheterisation: a near fatal complication. Indian J Anaesth. 2010;54(6):572-573. [CrossRef] [PubMed]
 
Omar HR, Fathy A, Elghonemy M, et al. Massive hydrothorax following subclavian vein catheterization. Int Arch Med. 2010;3:32. [CrossRef] [PubMed]
 
Tong MK, Siu YP, Ng YY, Kwan TH, Au TC. Misplacement of a right internal jugular vein haemodialysis catheter into the mediastinum. Hong Kong Med J. 2004;10(2):135-138. [PubMed]
 
Moskal TL, Ray CE Jr. Left mediastinal central line malposition—a case report. Angiology. 1999;50(4):349-353. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  ECG on presentation to the ED.Grahic Jump Location
Figure Jump LinkFigure 2 –  Chest radiograph after the placement of a central venous catheter.Grahic Jump Location
Figure Jump LinkFigure 3 –  Catheter pressure transduction tracing.Grahic Jump Location

Tables

Video 1

Left pleural effusion.

Video 2

Demonstration of the catheter within the pleural space.

Video 3

Bubble study confirming the catheter within the pleural space.

Video 4

Demonstration of the extravascular placement of the catheter within the soft tissue.

Video 5

Discussion video.

Running Time: 3:14

References

Eisen LA, Narasimhan M, Berger JS, Mayo PH, Rosen MJ, Schneider RF. Mechanical complications of central venous catheters. J Intensive Care Med. 2006;21(1):40-46. [CrossRef] [PubMed]
 
Webb JG, Simmonds SD, Chan-Yan C. Central venous catheter malposition presenting as chest pain. Chest. 1986;89(2):309-312. [CrossRef] [PubMed]
 
Gibson F, Bodenham A. Misplaced central venous catheters: applied anatomy and practical management. Br J Anaesth. 2013;110(3):333-346. [CrossRef] [PubMed]
 
Saseedharan S, Pandit R, Bhargava S. Left internal jugular vein dissection with anterior mediastinal placement following hemodialysis catheter insertion. J Pak Med Stud. 2012;2(4):134-137.
 
Nath MP, Gupta S, Chakrabarty A. Extravasation of catheter tip following central venous catheterisation: a near fatal complication. Indian J Anaesth. 2010;54(6):572-573. [CrossRef] [PubMed]
 
Omar HR, Fathy A, Elghonemy M, et al. Massive hydrothorax following subclavian vein catheterization. Int Arch Med. 2010;3:32. [CrossRef] [PubMed]
 
Tong MK, Siu YP, Ng YY, Kwan TH, Au TC. Misplacement of a right internal jugular vein haemodialysis catheter into the mediastinum. Hong Kong Med J. 2004;10(2):135-138. [PubMed]
 
Moskal TL, Ray CE Jr. Left mediastinal central line malposition—a case report. Angiology. 1999;50(4):349-353. [CrossRef] [PubMed]
 
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