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• W1584662195 abstract "A 71-year-old Chinese woman with a history of ischaemic heart disease, atrial fibrillation and non-insulin-dependent diabetes mellitus was admitted with necrotizing fasciitis of her right leg. On admission, she was septic with signs␣of diabetic ketoacidosis. A central venous catheter was inserted via the right subclavian vein to aid fluid resuscitation. A chest radiograph showed that the catheter tip was in the ipsilateral internal jugular vein, and was therefore removed. After induction of general anaesthesia, another central venous catheter was inserted via the left internal jugular (LIJ) vein. As the pressure waveform and readings were consistent with that of a central vein, and there was good blood flow on aspiration of the ports, this catheter was used for monitoring and infusion purposes during surgery. Following surgery, she was transferred to the surgical intensive care unit where the admission chest radiograph revealed that the central venous catheter was projected along the left lateral border of the heart. As the location of this catheter was unclear, another catheter was inserted via the right internal jugular (RIJ) vein with no complications. On closer inspection, the pressure waveforms from the two catheters were morphologically different with the pressure recorded via the LIJ catheter 5 mmHg higher than that from the RIJ catheter. Blood aspirated from the LIJ catheter showed a Pao2 of 212 mmHg, whilst that from the radial arterial cannula was 196 mmHg. Blood aspirated from the RIJ catheter had a Pao2 of 52 mmHg. These blood samples were taken simultaneously while the patient's lungs were being ventilated with an inspired oxygen concentration of 40%. Doppler ultrasound studies confirmed that the LIJ catheter was lying within a vein in the neck. Venograms were then performed with the injection of contrast medium through both catheters. The tip of the LIJ catheter was located within a vessel inferior to the confluence of the left internal jugular and subclavian veins (Fig. 13). As blood was flowing towards the catheter from this anomalous channel, manual injection of the contrast medium could not reveal the origin of this anomaly. Contrast medium injected through the RIJ catheter was seen to enter the right side of the heart and the pulmonary circulation, followed rapidly by the anomalous channel. The LIJ catheter was removed, though on another occasion it was used for central venous access, when the catheter tip went into the brachiocephalic vein. Digital subtraction venography with the injection of contrast medium through the LIJ catheter showing the anomalous venous connection at the point where the internal jugular vein continues into the left brachiocephalic vein. Anomalous pulmonary venous connections occur when at least one pulmonary vein is connected to the right atrium either directly or indirectly via a venous tributary. A partial anomalous pulmonary venous connection (PAPVC) occurs when one or more, but not all, the pulmonary veins connect to the right atrium. These may be found in association with atrial septal defects. There are a number of potential variants, but the variants with anomalous right pulmonary veins are said to be twice as common as those involving the left side. PAPVCs are usually asymptomatic, remain undiagnosed during life and are incidental post mortem findings [1]. The incidence ranges from 0.4 to 0.7% in different series. Although they are associated with cardiopulmonary malformations, there are no known risk factors for the development of this abnormality. The haemodynamic consequence is a left-to-right shunt and the consequent volume overload to the right heart with dilatation of the right atrium, right ventricle and pulmonary artery. The left heart chambers tend to be unaffected and the cardiac output remains normal. Pulmonary hypertension is not a recognised complication. Surgical correction is not required in the absence of other cardio-pulmonary malformations. The slightly different pressure waveform morphology that we observed is in contrast to previous reports [2, 3] of PAPVC catheterisation, in which an early sign was a markedly abnormal waveform with pulsatile flow of bright red blood. The explanation for these was wedging of the catheter in the pulmonary vein, resulting in the transmission of the pulmonary arterial pressure waveform. Such waveform anomalies, if recognised early, may indicate misplacement of the central venous catheter. This case illustrates the value of check chest radiographs in the correct identification of central venous catheter position. Congenital vascular abnormalities are rarely diagnosed in this way unless catheterisation of either a left superior vena cava or a partial anomalous pulmonary venous channel occurs. If the left superior vena cava is catheterised, the catheter will be seen to travel in a left paramediastinal path initially, then cross the mediastinum deeper within the thorax. In such a situation, the pressure waveforms would conform to that of a normal central vein. Digital subtraction angiography has been used to define PAPVCs without subjecting patients to the risks of conventional angiography [4]. Non-radiological methods of diagnosing the presence of partial anomalous pulmonary venous channels include transthoracic [5] or trans-oesophageal [6] echo cardiography. Transthoracic echocardiography done on this patient a few years previously had merely revealed bi-atrial enlargement and did not suggest the presence of an atrial septal defect. We felt it was unnecessary to subject her to trans-oesophageal echocardiography when there was little doubt about the diagnosis after the radiological studies." @default.
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• W1584662195 date "2002-02-01" @default.
• W1584662195 modified "2023-10-14" @default.
• W1584662195 title "Inadvertent catheterisation of a partial anomalous pulmonary venous channel during central venous cannulation" @default.
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• W1584662195 doi "https://doi.org/10.1046/j.1365-2044.2002.2470_29.x" @default.
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