An Incidental Finding While Placing a Central Line

​BY STEVEN CRUZ; CLAUDIA BORNIA; & ERIC MIZUNO, MDA 68-year-old male nursing home resident with a history of hypertension, cerebrovascular accident, COPD, and chronic respiratory failure with a tracheostomy presented to the ED with a 101°F fever of four days that didn't respond to Tylenol. The patient was alert and oriented x0. His Glasgow Coma Scale score was 5.The patient was tachypneic at 30 bpm, and three systolic blood pressures fell below 100 mm Hg. An initial chest x-ray revealed bilateral pulmonary infiltrates and a left-sided pleural effusion, raising suspicion for pneumonia as the most probable cause of sepsis. His persistent hypotension did not respond to IV fluids, so a left internal jugular central line was placed in anticipation of the need for vasopressors. Ultrasonography was used to aid in line placement, and a non-pulsatile, compressible internal jugular vein was seen. An introducer needle was inserted, and dark venous blood was drawn on the first attempt. Central venous pressure tracings were consistent with venous waveforms.A chest x-ray was ordered to confirm line placement. The line had extended to the left side of the heart, raising concern for arterial cannulation. A contrast CT scan was ordered to better characterize the intrathoracic anatomy and the extent of the pneumonia. It revealed a left-sided pleural effusion and a left-sided superior vena cava draining into the coronary sinus but not a right-sided superior vena cava. (Image 1.) The line...
Source: The Case Files - Category: Emergency Medicine Tags: Blog Posts Source Type: research