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 During the first attempt, the puncture needle had to be withdrawn, as the J-tipped guide wire could be advanced 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 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.