![]() It was deemed inappropriate to cannulate either of the femoral veins because of the recent groin incisions made during endograft insertion. The vein was located anteriorly and in close apposition to the internal carotid artery therefore, no attempt was made to access this vein. ![]() Bedside ultrasonography of the left internal jugular vein, which was performed while the patient was in steep Trendelenburg position, showed the fully dilated vein to be only 2 to 3 mm in diameter. The soft tissues covering the upper chest were so swollen that the clavicle and sternal notch could not be palpated to identify safe landmarks for subclavian vein catheterization. There were no suitable veins in the left upper extremity. Access sites for inserting a new venous catheter were limited the right upper extremity was unavailable for large-bore peripheral access because of the length of the arm cast. The patient's overall status and medication requirements, combined with the tenuous peripheral venous access in his left arm, indicated the need for continued central venous or large-bore peripheral venous catheterization. Blood return via the distal port was minimal, and no blood could be aspirated from the proximal port. It is likely that the IJV catheter was malpositioned while the patient was in the radiology suite for a second computed tomography scan of his chest, resulting in fluid extravasation. A chest radiograph showed proximal displacement of the right IJV catheter into the neck and the endoaortic prosthesis, but it was otherwise normal (Figure 1). On hospital day 2, an ICU nurse noticed considerable swelling (noncrepitant) at the base of the patient's neck on the right side and significant swelling that encompassed the entire anterior chest wall from his clavicle to his nipples. Intravenous access was obtained using a 20-gauge, 1¼-inch left forearm catheter and a double-lumen right internal jugular venous (IJV) catheter, which were inserted when the aorta was being surgically repaired. An orthopedic surgeon addressed the extremity fractures, and postoperative hypertension was controlled with an intravenous infusion of esmolol. Examination of the fluid found only a few red blood cells, no significant levels of amylase, and no particulate matter, and it was decided not to perform exploratory laparotomy. Fluid was obtained during diagnostic peritoneal lavage. One femoral artery sustained an iatrogenic intimal injury and required open repair. The aortic injury was repaired using an endograft with access via both femoral arteries. He had no injuries to his central nervous system or vertebral column.įigure 1 - Chest radiograph shows migration of the right IJV catheter into the patient's neck (arrow). He also had minimal bilateral pulmonary contusions moderate hemoperitoneum with no evidence of solid organ injury a closed, comminuted fracture of his right tibia and fibula a fracture of his right elbow and numerous abrasions and contusions. He sustained a contained traumatic tear of his thoracic aorta distal to the origin of the left subclavian artery. ![]() Case reportĪ 19-year-old man, weighing approximately 100 kg, was involved in a high-speed motor vehicle collision. When these devices have to be replaced, it may be necessary to perform the exchange using a guidewire. ![]() Despite the advent of real-time ultrasound imaging at the bedside, satisfactory peripheral and central venous access sites unfortunately tend to disappear over time in ICU patients. Most are used on a short-term basis, but these catheters have become increasingly necessary adjuncts in the management of long-term intensive care unit (ICU) patients. Although other institutions may use the same or similar approaches to guidewire exchange, the author's literature review did not identify other English-language descriptions of the technique detailed in this article.Ĭonclusion: Clinicians should consider using the technique described in this paper for any patient who requires exchange of a centrally or peripherally inserted catheter.Ĭentral venous catheters are routinely inserted in the acute care setting for a variety of monitoring and therapeutic indications. Results and discussion: This paper details a simple technique of catheter preparation and exchange that is designed to minimize the chance of an infectious complication arising from insertion of a replacement catheter. This procedure can be awkward, and great care must be taken to minimize the risk of infection. Introduction: Sometimes only a limited number of sites are available for central venous catheter insertion, and a malfunctioning or infected catheter must be replaced using an exchange over a guidewire. ![]()
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