8/12/2023 0 Comments Triple lumen central lineThe medical community appears to be adopting these guidelines, albeit slowly. Identified concerns include: (i) improper insertion technique (real-time ultrasound not utilized) (ii) improper decision to use the line, despite inability to withdraw blood from it and (iii) poor handoff communication between the different treatment teams.īest practice for CVC placement mandates the use of ultrasound as a critical element for safety.( 4,5) In fact, the Agency for Healthcare Research and Quality (AHRQ) has been recommending the use of ultrasound guidance (UG) for more than 10 years.( 6) In addition, the 2011 Centers for Disease Control and Prevention (CDC) guidelines recommend using UG to place CVCs to reduce the number of cannulation attempts and mechanical complications (Category 1B). Highlighted in this case is an example of a three-faceted CVC error resulting in significant iatrogenic harm to an already critically ill patient. There is controversy over which vein is "best." The subclavian vein is recommended by the Institute for Healthcare Improvement due to the presumed lower infection rates associated with this positioning however, procedural complications may be more common with this vein because of its anatomic proximity to the chest cavity and lungs.( 2,3) The exact opposite may be true for femoral veins. The possibilities for harm are numerous and include accidental trauma to non-venous structures (arteries, lung, nerve, visceral organs) bleeding (hematoma, hemothorax, or hemorrhage) operator injury (needle stick or splash) and catheter-related issues (retained wire, bloodstream infections, sheared catheter, dysrhythmias, thrombosis, through-and-through vessel trauma, or, as in this case, malpositioning). Nearly 5 million CVCs are routinely placed each year for infusion, phlebotomy, and/or hemodynamic monitoring.( 1) Although overall complication rates for CVC insertion should be exceedingly low, published complication rates vary considerably and have been reported as high as 19% ( Table). The CommentaryĬentral venous catheter (CVC) placement is one of the most common medical procedures performed in health care today. Fortunately, the patient made a full recovery. Approximately 1400 cc of fluid was then removed from her pleural space via thoracentesis. This radiograph showed whiteout of the right lung, and ultimately the clinicians realized that the tip of the subclavian line was actually within the lung. Several hours later, a repeat chest radiograph was ordered after the patient began to vomit. Reassured, the line was used by the cardiology team to deliver medications and fluids during pacemaker insertion. However, the radiology attending physician concluded the line was in good position. The initial reading noted that the line might have been in the right atrium (which is to say, inserted too far). A chest radiograph was obtained when the patient arrived in the intensive care unit (ICU). The ED team thought this was likely due to severe hypotension (her systolic blood pressure was around 50 mm Hg), but there was some concern that the line was not in the proper position. No blood return was obtained from any of the lines. A right subclavian central line was placed during resuscitation. When found unresponsive by her partner on the bathroom floor, she was brought by ambulance to the emergency department (ED). A 48-year-old woman with a history of hypertension, psychiatric illness, and a previous suicide attempt overdosed on her blood pressure medication (calcium channel blocker).
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