When Your Central Line Decides to Go for a Stroll

Abstract

SESSION TITLE: Procedures SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Central venous catheters (CVCs) are fastened at the skin, but their free, intra-vascular end has a tendency to become malposition. CASE PRESENTATION: A 76-year-old woman was intubated for worsening hypoxemia, and a pigtail catheter was placed into the left lower pleural space to drain an effusion. 700 cc of serous exudative fluid was drained. A 16 cm, 7 F left subclavian triple-lumen CVC was placed on the 1st attempt for vasopressor administration, with blood being easily aspirated from all ports. A follow-up CXR demonstrated a left apical pneumothorax for which another pigtail catheter was placed in the left anterior 2nd intercostal space, resulting in lung re-expansion. Over the next 2 days there was a dramatic increase in pigtail drainage and vasopressor requirements. Repeat pleural fluid analysis revealed a glucose level of 734 mg/dL. A norepinephrine drip with a dextrose carrier was being infused though the CVC. Later that day, the fluid turned milky after propofol was started through the CVC. Chest CT done concurrently for worsening hypoxemia revealed the CVC traversing the left lung apex before entering the left brachiocephalic vein. These findings were consistent with an extravascular catheter, with the proximal ports in the pleural space. Now we could aspirate blood only from the distal port. The CVC was replaced resulting in resolution of the pleural drainage and decrease in norepinephrine requirements. DISCUSSION: Late migration of CVCs often occurs inadvertently due to arm/neck movements, increase in intra-thoracic pressure due to PEEP, PPV or the patient coughing, and due to a ‘jet effect’ of drug infusions (1). These factors can cause CVC migration up to 2-4 cm. Another factor that may have caused this migration in our patient is trans-fixation of the lung apex during CVC insertion and its subsequent outward drag by the re-expanding lung. An intrapleural CVC can cause an effusion with a pleural fluid to serum glucose ratio > 1. The fluid is usually transudative with protein < 1 g/dL, but varies depending on the infusate, degree of pleural inflammation or hemorrhage, and fluid osmolality (2). CONCLUSIONS: Malpositioned CVCs should be replaced. Intra-pleural position causes an increase in pleural effusion with fluid analysis revealing similarities to infusing drugs. Reference #1: Ahuja V, Bhaga H. Late migration of subclavian venous catheter after initial correct placement. J Anesth. 2009;23(2):310-1 Reference #2: Sahn SA. Pleural effusions of extravascular origin. Clin Chest Med. 2006;27(2):285-308 DISCLOSURE: The following authors have nothing to disclose: Udit Chaddha, Jamie Kaghihara, Kavitha Bagavathy, Ashley Prosper, Ami Oren No Product/Research Disclosure Information