A 64-year-old man, weighing 47 kg and having a height of 154 cm, was scheduled for a pericardiectomy for treatment of constrictive pericarditis. When he was hospitalized with a two-week history of aggravating dyspnea, he had been placed on outpatient follow-up for pulmonary tuberculosis, previously diagnosed with dyspnea on exertion and pleural effusion. His past medical history included diabetes mellitus diagnosed 20 years ago and stent insertion in the left anterior descending (LAD) coronary artery eight years ago. Preoperative ECG revealed left atrial enlargement, and ST depression and flat T-wave on lead II, III and V4-6. Chest radiograph showed pulmonary edema and bilateral pleural effusion. Coronary computerized tomography demonstrated that the LAD stent was intact, but there was >50% narrowing of the left circumflex coronary artery, and pericardial thickening with adhesion to the right atrial and left ventricular lateral walls. Echocardiography showed a left ventricular ejection fraction of 73%, and mild pulmonary hypertension with a systolic right ventricular pressure of 38 mmHg.\nAn hour before surgery, premedication was done with IM morphine 3 mg. On arrival, continuous monitoring of ECG lead II and V5 was initiated, and the radial artery cannulation was done under local anesthesia for pressure monitoring. Vital signs before induction of anesthesia were HR 85/min, ABP 108/68 mmHg, and SpO2 98%. Anesthesia was induced with IV midazolam 3 mg and ketamine 20 mg. Rocuronium 50 mg was administered to facilitate endobronchial intubation with a 35 Fr left-sided double-lumen tube. After intubation, lungs were ventilated with a tidal volume of 8-10 ml/kg, adjusted to maintain end-tidal CO2 within 33-38 mmHg. Anesthesia was maintained with 1.0-1.5% sevoflurane in 60% oxygen in air and continuous infusion of remifentanil at 0.1-0.3µg/kg/min.\nAfter induction of anesthesia, the patient was turned to the head-down position with the head rotated leftward by approximately 60° to facilitate internal jugular catheterization. An 18-G puncture needle was inserted at the conjoined site of both bellies of the SCM, and was advanced toward the ipsilateral nipple until free regurgitation of venous, non-pulsatile blood flow was observed. During the first attempt, the puncture needle had to be withdrawn, as the J-tipped guide wire could be advanced <10 cm. After 5 min of manual compression, jugular venous puncture was retried in the same manner, and non-pulsatile, free-regurgitant blood flow was again obtained. In the second attempt, the J-tipped guide wire was inserted into the vessel without significant resistance, even though it was initially difficult to advance the wire and the puncture needle had to be withdrawn a few millimeters to obtain free regurgitant blood flow. Then, a 7-Fr double-lumen central venous catheter (Arrow Gard Blue, Arrow International, Inc., USA) was inserted using the Seldinger method and was suture-fixed at 16 cm in the skin after confirming free inflow of fluid. At the end of procedure, the guide wire withdrawn showed no deformations. Central venous pressure (CVP) was measured to be 20 mmHg with the patient in a supine position and thereafter was maintained within 30-40 mmHg in the right semi-lateral decubitus position at approximately 30° during one-lung ventilation for surgery. Such a high CVP was considered to be related to the constrictive pericarditis, as the pressure measurement was less than the mean arterial pressure of the radial artery (80-85 mmHg) and the waveform was flat without pulsations, being affected by right-side one-ling ventilation and surgical manipulation of the heart. During the catheterization, vital signs were stable with HR 83/min, BP 90-100/65-68 mmHg, and SpO2 99-100%. Arterial blood gas analysis was done after induction of anesthesia and revealed pH 7.486, PaO2 331 mmHg, and PaCO2 36.2 mmHg with FiO2 0.6.\nApproximately 50 minutes after the surgery began, the pressure waveform from the central venous catheter changed abruptly into what was seemingly an arterial waveform, with a mean pressure of 61 mmHg, almost same to the mean arterial pressure of 62 mmHg (). Simultaneously, blood regurgitated through the fluid line connected to the central venous catheter. Even though about 300 ml of fluid had already been administered, no hematoma or edema was shown in the puncture site. Arterial blood gas measurement was done on blood withdrawn from the central venous catheter, indicating a PaO2 of 438.7 mmHg with a FiO2 of 0.6, confirming that it was arterial blood. Furthermore, the catheter was apparent in the aortic arch on TEE (). Fluid infusion was immediately stopped, and the catheter was removed when the surgery was completed. After confirming that there was no bleeding or developing hematoma in the puncture site with >15 min of compression, the double-lumen tube was replaced with a single-lumen endotracheal tube. Thereafter, the patient was transferred to the intensive care unit with the endotracheal tube in situ. Extubation was done after seven days of mechanical ventilatory care for tachypnea and CO2 retention, and the patient was transferred to the general ward without central venous catheter-related complications on the 10th postoperative day.
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.