What went wrong??

[jmfkmd]

I had a patient in the ICU last month that needed (non-emergetly) a central line.  So, I took my time... pre-scouted both IJ's with the US, determined that the left was a better IJ to poke due to the larger diameter and lack of vent/extra-lines getting in the way on that side of the patient.  Prepped, positioned, and ultrasounded in the usual, textbook way.  Under live guidance, watched the needle tip enter into the very large around collapsable left IJ... saw the appropriately complementary rush of dark, venous blood fill my syringe... and the rest of the central line went smooth as butter.  No resistance, no PVC's, no bleeding, flushed and drew great.  Sutured the line in and ordered a confirmatory x-ray like we always do.  And here is the X-ray:


As you can imagine, I shit a brick.  I must've gone into the carotid and catheterized into her carotid.  Can anyone guess what I did next?

A)  Called Dr. Effrides (Vascular) and told him I effed up.
B)  Cried to Dr. El-Gamal that I was a failure and should just quit.
C)  Removed the CVC, held pressure, and called surgery to do the line.
D)  Checked an ABG
E)  Checked a CVP
F)  Hooked up an A-line set-up to evaluate the waveform
G)  Pulled the CVC, administered FFP, Bilateral Finger Thoracostomies, performed a bedside open thoracotomy, Cross-clamped the aorta, and then woke up from my dream.


Once you figure out the appropriate thing to do at this point... What do you think explains the findings of this X-Ray?

Thanks, JMFK

[Bjs04f]

I know the answer, it was on a recent other blog post. I will withhold my input. Had I not seen this earlier this month, first step would be panic

[jmfkmd]

You know would've chosen (G), don't lie.

[Bjs04f]

shit I dodnt even see G, yeah I would've yelled "oh no hes hypotensive and unresponsive," pulled off all monitoring, intubated then conitnue with G before they got him back on monitors

[tyson]

maybe a congenital abnormality? if you drew venous blood, flushed, checked and didn't have any complications w/ your line going in, that's the only thing that would make sense. I assume you (and we'd all) notice if you had arterial blood spurting onto the walls.

don't see a pnuemo. but as Spencer Johnson likes to tell me, if you haven't dropped a lung yet, you haven't done enough lines. is he telling me to drop a lung just for a goof?

on another note, a saw a central line end up in the lung pleura during my MICU rotation last year. that was impressive.

[Bjs04f]

At no point in your rambling, incoherent response were you even close to anything that could be considered a rational thought. Everyone in this room is now dumber for having listened to it. I award you no points, and may God have mercy on your soul. Also what sort of congenital abnml are you thinking?

[kemple]

I would check ABG, if it's venous you'll know based on the PO2 and can confirm it's in the SVC. Maybe some sort of dextro svc anomaly?

[Bjs04f]

what if its neither? a mixed venous arterial pattern

[kemple]

what about anomoulus pulmonary vein?

[Bjs04f]

Big fan of this case, crazy john had it the same week I saw it on a forum. But no anomolous pulmonary vein, solid thought

[tyson]

haha, it was fairly incoherent, but i'd still award myself at least 1-2 points for proper spelling and excellent spencer johnson quote.

was thinking of persistent left superior vena cava (cause central line to show up on left side of heart)


anyway, maybe he just put it into internal thoracic vein or some other branching vein.

[Bjs04f]

winner, persistent Left superior vena cava. FOAMEM had a case report of it recently as well

[jmfkmd]

Great discussion! You nailed it Tyson. I actually had no idea this existed, but much to my chagrin it's actually the most common congenital venous anomaly in the chest (albeit less than 0.5% of the general population).

So, what I did first after calming down and throwing away my shit-stained pants was run a blood gas on the line-sample. PO2 was like 55ish. I felt better after that since I knew the guy was on the Vent with 80% FiO2 and otherwise didn't have any DLCO or hemoglobin binding problems. But just to be sure, I bugged the RT to set up an A-Line for me... hooked it up to the line and there was no waveform.

And just to be sure sure... I called the radiologist and he nonchalantly told me, "yeah, this dude's got a left-sided SVC... I see it every once in awhile." I'm thinking every once in awhile? The occurence is <0.5% in the world, bro... are people in Toledo/Maumee more prone to congenital anomalies?? I mean Maumee is even home to 2 of the handful of the world's Progeria kids.... Hmm... Anyways, he confirmed it by looking at a chest CT the dude had on file from a year ago... go figure.

radiopaedia.org/articles/left-sided-superior-vena-cava-1