A 66 year old man with underlying chronic kidney disease, presumed secondary to hypertension, presented to the emergency room with one-week history of weakness, fatigue and poor oral intake. The patient was hypotensive (systolic blood pressure of 60 mmHg) and had severe azotemia (serum creatinine of 4.9 mg/dl form baseline of 1.7 mg/dl). Septic shock, methicillin-sensitive Staphylococcus aureus bacteremia and oliguric acute kidney injury were diagnosed. The patient was adequately resuscitated with intravenous fluids, vasopressors and broad-spectrum antibiotics, later narrowed to cefazolin. The source of infection was unclear after broad investigation of body fluids and imaging studies. Despite an initial transient clinical improvement, the patient remained in shock with high vasopressor requirements, became anuric and developed acute mental status changes. As a consequence, the decision to start the patient on CRRT was made. We inserted a 13.5 French diameter temporary dual-lumen Quinton-Mahurkar catheter (Covidien, Inc.) into the left IJV under US guidance. Although the right IJ is preferred, the intensive care unit team had already inserted a triple-lumen central venous catheter in this site for hemodynamic monitoring and fluid and medication administration. The initial puncture with an 18-gauge needle into the left IJV using real-time US guidance was successful with non-pulsatile back-flow and venous (dark red) blood appearance. Subsequently, after removal of the ultrasound transducer, the rest of the procedure was performed without any resistance to advancing the guidewire and catheter by the Seldinger technique []. Good flow of dark red blood was obtained from both catheter lumens. However, the routine post-cannulation chest X-ray (Figure ) showed that the tip of the catheter was not crossing the midline to the right side and the tip appeared to be lying over the aortic arch suggesting inadvertent carotid artery cannulation. We then obtained blood gas analysis from the catheter which showed: pH of 7.34, partial pressure of oxygen (PO2) of 140 mmHg and partial pressure of carbon dioxide (PCO2) of 22 mmHg, also suggestive of arterial cannulation. The vascular surgery team was emergently consulted. A pressure transducer was attached to the catheter and showed venous wave forms. To definitively determine the location of the catheter, a Computed Tomography Angiography (CTA) of the head and neck was obtained. The CTA showed the Quinton-Mahurkar catheter extending into the left IJV and subsequently descending to terminate in an anomalous left upper lobe pulmonary vein, just inferior to its anomalous insertion in the left brachiocephalic (innominate) vein (Figures A and B). Interestingly, manipulation of the catheter under fluoroscopy by interventional radiology showed that the left brachiocephalic (innominate) vein failed to cross the midline to empty into the right atrium, confirming the venous anomaly. The catheter was therefore removed and a new similar catheter was placed in the right IJV. CRRT was then initiated and continued uneventfully until the patient’s critical condition improved.
A 56-year-old woman with a medical history of multiple sclerosis, quadriplegia, sacral decubitus ulcer, chronic osteomyelitis, chronic deep vein thrombosis (DVT), chronic steroids use, and chronic Foley catheter use presented to the emergency department with severe sepsis due to multiple potential sources including urinary tract infection, soft tissue infection, or osteomyelitis. Vital signs were significant for blood pressure of 85/59 mmHg, heart rate of 63 beats per minute, respiratory rate of 33 breaths per minute, and oxygen saturation of 83% on room air. At the beginning, patient declined intubation so she was placed on 100% oxygen via nonrebreather mask. Arterial blood gas (ABG) on 100% oxygen was 7.29/49/55. Initial chest X-ray (CXR) showed small bilateral pleural effusions with suspected left lower lobe infiltrate. Despite intravenous (IV) fluid resuscitation, broad spectrum IV antibiotics, and stress dose steroids, patient became more hypotensive and IV norepinephrine was started through a right femoral CVL that was placed in the emergency department. Patient was started on heparin drip for suspected pulmonary embolism that was stopped later due to large bleeding from femoral line site and consideration of pneumonia as the cause of hypoxemia. Patient agreed later to be intubated and decision was made to remove femoral line and place a 7.0 Fr triple-lumen CVL through the left internal jugular vein (IJ) over a guidewire and under full ultrasound (U/S) guidance, which was placed easily with no complications. A CXR was obtained to confirm placement which showed that the catheter tip did not cross the midline; instead, it was extending towards the left of the aortic arch probably into an anomalous vein as read by the radiologists (). Ultrasound examination of the neck showed proper catheter placement in the left IJ. A pressure transducer was connected which showed a venous wave form with a pressure of 10 mmHg. ABG obtained from the catheter on continuous mechanical ventilation (FiO2 = 50%, positive end expiratory pressure = 5 CM H2O) showed PaO2 of 102 mmHg compared to 79 mmHg from radial arterial site. A transthoracic echocardiography, which was done to evaluate cardiac function, did not show evidence of atrial septal defect or any other cardiac malformation. Fluoroscopy study was used to place a left peripherally inserted central catheter (PICC) and to confirm the location of the left IJ CVL which demonstrated contrast injection in an anomalous pulmonary vein (). We concluded that the patient has partial anomalous pulmonary venous return (PAPVR) and the left IJ CVL was removed. The PICC line was used instead for central access.