Unpredictable Location of Central Catheter

Abstract

A man in his mid-50s presented to the hospital with malaise, fevers, hypotension, and altered mental status. Three months prior, he had an episode of native aortic valve endocarditis, necessitating aortic valve replacement with a pericardial bioprosthesis. He developed postoperative acute renal failure, which progressed to chronic renal failure requiring dialysis via tunneled catheter. On this admission, he was found to have methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Transesophageal echocardiography demonstrated a vegetation on his prosthetic aortic valve. He was diagnosed as having MRSA prosthetic valve endocarditis and admitted to the cardiovascular surgical intensive care unit prior to surgical intervention.In the setting of MRSA bacteremia, his tunneled dialysis catheter had been removed. Owing to his dialysis needs, a temporary dialysis catheter was placed in the right internal jugular vein. As intravenous access was required for vasoactive medications and intravenous antibiotics, a triple-lumen central catheter was placed in the left internal jugular vein under ultrasonographic guidance. The catheter went in easily without resistance, was drop tested to confirm venous placement, and flushed and drew easily, and venous waveforms and pressures were transduced. However, on postprocedure radiography, the tip of the triple-lumen catheter was not in the expected location (Figure 1). The catheter was removed, and a new-stick insertion of a new catheter was attempted under ultrasonographic guidance.Quiz at jamasurgery.com