The Case of the Central Arterial Line

Yesterday, I had another central line disaster. A 52 year old Hispanic patient was admitted to the ICU Monday for respiratory failure secondary to terminal interstitial lung disease. Her blood pressures began to drop later that night, so yesterday we decided to place a central line in her. I attempted the first few sticks in trying to find the subclavian vein, and my senior took over soon after. Because this lady was volume depleted and she had significant scarring attributable to her pulmonary fibrosis, she was a difficult patient to get a central line in. My senior poked around several times, but when we got a flush of blood back we noticed that it was bright red and pulsating very vigorously. We had entered into the subclavian artery! After several tries and a new central line kit, we finally got a central line in place. The blood looked a darker red, and it was not pulsating with each heartbeat, so we assumed we were in the correct place. We sutured in the line, and got a STAT portable chest x-ray.

About 15 minutes later, I took a look at the x-ray, and from my limited experience I thought the line was in the right spot. I called the on-call senior just to make sure, and he confirmed that the position of the line was fine. I wrote the order, “OK to use central line.” But then suddenly the nurse handed me the phone and stated that a radiologist wanted to speak with me. He asked, “Are you taking care of a patient named >>>? Did you see any arterial pulsations when you put in the line?” He proceeded to tell me that he thought the central line was in the artery and not the vein. “Unless this is an anomaly to the venous structure, I think you are in the artery.” So we got an arterial blood gas on the blood from the central line just to confirm, and the respiratory therapist said he thought the blood was indeed arterial. By that time, it was already 8 pm, and I was supposed to go home by 7 pm. Unfortunately I had to punt the task of removing the central arterial line and placing another central venous line to the poor team on call. They ended up putting in another central venous line. Today when I asked my senior about it he told me that the first line had been in the right place after all and that the anatomy looked different simply because the patient was all scarred down from her pulmonary fibrotic disease!

*sigh* That’s two for two in disastrous events in placing a central line. Hopefully I will have more luck in the future. =)

For more information on placing central venous lines, visit these websites:

http://www.emedu.org/invas/subc.htm
http://note3.blogspot.com/2004/02/central-line-placement-procedure-guide.html
http://apps.med.buffalo.edu/procedures/centralvenous.asp?p=6
http://en.wikipedia.org/wiki/Central_venous_catheter
http://clinicalcases.blogspot.com/2004/02/complications-of-central-line.html

Quick update on my Code Blue patient. On Monday (7/17/06) I had the opportunity to catch the tail end of the autopsy on my patient who passed away three days ago. The pathologist who was performing the autopsy said he was disappointed to find that there was nothing discovered grossly during the autopsy – no tumors or obvious masses, no significant lymphadenopathy, no organ anomalies. All he found was the cervical lymph nodes that had already been biopsied, an enlarged, soft spleen and hemorrhagic bowel. Everything else was unremarkable. So this case is still a big mystery. Why exactly did the patient pass away? What triggered her to go into DIC? Did she have cancer or an infection? Perhaps no one will really know. I suppose we will just have to wait and see what the final biopsy and pathology reports show.

I will keep you updated.