Research Snapshot Theater: Procedures II
1002 1003
A COMPLICATED CASE OF CENTRAL VENOUS
CANNULATION
Shaiva Meka1, Hira Iftikhar1, Vishal Patel1
Learning Objectives: Central venous catheter (CVC) complica-
tions occur with a frequency of 5–29%. This includes bleeding,
pneumothorax, infection and thrombosis. We present a case of
unusual complication.
Methods: A 29 year-old female with cerebral palsy presented with
fever and shortness of breath. She was diagnosed with pneumonia,
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which progressed rapidly to require endotracheal intubation. She
also developed septic shock and large right-sided pleural effusion.
Thoracentesis revealed an exudative fluid suggestive of empyema
(pH 6.8, glucose <10mg/dL). Vasopressor support was initiated
with norepinephrine after fluid resuscitation. A triple-lumen CVC
was placed in the left internal jugular (IJ) vein. Venous oxyhemo-
globin was checked per protocol and was at 57% prior to dilata-
tion of the vein. After insertion, chest x-ray revealed the catheter
looping in the neck, and the tip was overlying the arch of the aorta.
Radiologist was unable to confirm whether CVC was in the venous
or arterial system. By this point, two distal ports did not draw back
blood; the third port drew back darker blood with a point-of-care
oxyhemoglobin value of 70. Point-of-care ultrasound was used
at bedside, which showed the looped catheter within the IJ vein.
Computed tomography (CT) of the neck and chest confirmed this
finding and also showed the catheter tip to be protruding out of
the left subclavian vein into the mediastinal fat. There was no ex-
travasation of blood noted from the vessels and the catheter was
initially left in place, however, patient passed away from worsening
septic shock.
Results: While cases of CVC looping in subcutaneous tissue ex-
ist, looping within the vein is very rarely seen. Our patient, also
had CVC tip in the mediastinum, which is an even more uncom-
mon. Likely looping was created by inability of distal tip of CVC
to advance and as CVC continued to be pushed in the dilated
track it created looping in proximal IJ vein. Literature review only
revealed 2 other cases with mediastinal involvement. In cases of
suspected catheter misplacement, the loss of blood return from
the ports should be a red flag. Bedside ultrasound can be a helpful
tool for rapid evaluation if the problem is suspected in the neck
as in our case. Nevertheless, further imaging such as CT may be
required for further evaluation.
William Beaumont Hospital, Royal Oak, MI
1
Critical Care Medicine • Volume 47 • Number 1 (Supplement) www.ccmjournal.org
Copyright © 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
WHERE ARE WE GOING? COMBINING THREE
EXTRACORPOREAL SUPPORT SYSTEMS IN ONE
CIRCUIT
Yalew Debella1, Alexander Heckman2, Carla Venegas-Borsellino1,
Hassan Baig1
Learning Objectives: Introduction: Technological advances have
dramatically improved critical care management, highlighting
the fine balance required by the intensivist to provide effective
therapies sometimes lacking evidence-based support, trying to
be cost-effective, while still focusing on individualize medicine
and humane care. We describe a case of a hyperacute post-lung
transplant rejection and multiorgan failure supported success-
fully with Extracorporeal Membrane Oxygenation (ECMO),
Continuous Renal Replacement Therapy (CRRT) and Molec-
ular Adsorbent Recirculating System (MARS), with adjunct
Therapeutic Plasma Exchange (TPE), all connected to one cir-
cuit.
Methods: Case: A 60-year-old female who underwent a double
lung transplant for pulmonary fibrosis and severe pulmonary hy-
pertension developed severe respiratory failure from primary graft
dysfunction in less than 24 hours post-surgery. She failed aggres-
sive therapy which included mechanical ventilation, paralysis, in-
haled nitric oxide, and required initiation of Veno-Venous ECMO
and latter conversion to Veno-Arterial ECMO. She progressed to
multi-organ failure and required TPE and initiation of CRRT by
inclusion into the ECMO circuit. After oxygenation and hemo-
dynamics improved, she was switched back to VV-ECMO, but
severe hepatic encephalopathy developed. Considering the high
mortality of post lung transplant patients with hyperammonemia,
MARS therapy was initiated along with other medical measures.
After two MARS treatments, patient’s mental status improved as
her ammonia level normalized. Over a period of three days, pa-
tient had overlapping ECMO, CRRT, and MARS therapy. Patient’s
mental status improved further, and she was subsequently decan-
nulated successfully from ECMO, CRRT and weaned off from me-
chanical ventilation.
Results: As ICU outcomes improve and organ support devices
evolve, managing critically ill patients is more complex, challeng-
ing, and raises many questions. Even though adding other circuits
to ECMO is possible, questions arise about the need for additional
intravenous access, effect on hemodynamics and pharmaco-dis-
tribution of medications, level of required anticoagulation, risk of
air or clot sent to the patient, and others. Introduction of CRRT
and MARS into ECMO circuit appears to be a safe and effective
technique, yet there is a lack of prospective, randomized studies
and more information is necessary.
Mayo Clinic, Jacksonville, FL, 2Mayo Clinic, N/A
1