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Images of Memorable Cases: Case 149
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Order the print version of Images of Memorable CasesExercise 1
This previously healthy 49-year-old woman underwent a cholecystectomy and repair of a perforated duodenum. On post-operative day seven, her complaints of cough and shortness of breath prompted the radiographs shown above. Despite diuretic therapy, her condition deteriorated, and she died three days later, severely hypoxic and undiagnosed.
Solution 1: 149. Vascular erosion by a central venous catheter
On close inspection of the lateral radiograph (image below), a central venous catheter (arrows) is visible behind the sternum, with the tip far from its intended position near the right atrium. With the catheter tip clearly extravascular, the infusate presumably dripped directly into the chest cavity rather than into the right atrium. Autopsy disclosed large amounts of serous fluid in each pleural space, but the heart, lungs, pulmonary arteries, and other body organs were unremarkable.
This case teaches several important lessons:
1) when a patient with an indwelling central venous catheter develops new or progressive cardiorespiratory distress, vascular erosion or perforation deserves immediate consideration;
2) a lateral radiograph of the chest can be the best way to verify a malpositioned central venous catheter;
3) failure to recognize this complication can prove fatal.
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This work is licensed by Herbert L. Fred, MD and Hendrik A. van Dijk under a Creative Commons Attribution License (CC-BY 2.0).
Last edited by Frederick Moody on Oct 12, 2007 1:14 pm GMT-5.
"This book is available in full color in three different formats, published by Rice University Press. It presents a series of interesting medical cases and the eventual diagnosis of each one. "