An abnormal post-procedure chest radiograph
BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2359 (Published 29 April 2016) Cite this as: BMJ 2016;353:i2359All rapid responses
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I note the authors do not mention whether they took a blood gas sample at the time of line insertion.
The unit in which I first learned CVC insertion had a safety bundle which, as well as covering sterility and US technique, mandated that a blood gas sample should be taken - ideally from the initial needle prior to dilation of the vessel, or from the line, post insertion, prior to use.
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Dear Editors
I might be an orthopod but I am curious why there was no mention of a left sided pneumothorax or lower lobe collapse. Presumably this was also treated in addition to the fuss over the accidental arterial line? Alternatively it may be a unusually distinctive lingual lobe consolidation, although my old(er) eyes find it hard to see lung markings in the region where the left lower lobe should be.
For clinicians with progressive medical school background (ie anatomy-starvation curriculum), it is important to recall that the first major branch off the ascending aorta is the brachiocephalic trunk (innominate artery) which then travels cephalad to the right for about 2 inches before dividing into right subclavian and common carotid arteries behind the right sternoclavicular joint. Only the left common carotid and subclavian arteries directly and individually arise from the aortic arch.
http://www.scielo.cl/pdf/ijmorphol/v27n2/art46.pdf
It may also be helpful for the authors to explain to readers the rationale for the CVC insertion on top of a pre-existing right subclavian portacath, for rapid fluid resuscitation and venous pressure monitoring perhaps?
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Thank you for a very informative case report and CXR. Was the CVC insertion performed with real-time ultrasound guidance? Was the portacath in situ during this acute deterioration and did you consider infusing vasoactive drugs through this prior to placing a new CVC? A case indeed for us to be aware of potentially fatal complications of a 'routine emergency' procedure. Many thanks.
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Re: An abnormal post-procedure chest radiograph
In our intensive care unit we typically confirm line placement with chest radiograph. However, the suggestion of getting a blood gas for corroborative information is noted and I will consider it in the future.
The patient's portacath was not functioning at the time of ICU admission and hence the central line was inserted. The procedure was done under ultrasound guidance, but due to the low blood pressure, the carotid artery was not pulsatile as usual and hence was difficult to differentiate from the internal jugular vein. The patient was hypoxic and the blood was dark red, which further complicated the situation. That is why we felt this case had important learning points for clinicians.
The patient did not have any pneumothorax or lower lobe collapse. We have provided the same chest radiograph image with very high sharpness preset (figure 1b) for the purpose of clarification.
What appears as the left lower lobe collapse is the lower margin of the left scapula. We have traced the lower margins of the scapulae with white arrows in both the pictures (figure 1a and 1b). Please note in figure 1B how the margins of the scapula are nearly symmetric (white arrows in figure 1b).
On this very high sharpness image pulmonary infiltrates are now visible outside the scapular border (black arrows). Also note the separation of the parietal and visceral pleural (blue arrows) due to layering of pleural effusion. This separation of the pleural linings likely further contributed to the impression of a pneumothorax. Please note the uniform opacity of the bilateral costophrenic angles due to pleural effusion which are obscuring infiltrates in that area.
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