Baylor University Medical Center Proceedings April 2014, Volume 27, Number 2 | Page 62

Where is that hemodialysis catheter (superior vena cava or aorta)? A case of intraarterial catheter placement Valerie Tan, MD, and John C. Schwartz, MD We present a case of a previously unrecognized intraarterial placement of a central venous catheter (CVC)—in this case, a large-bore hemodialysis catheter in an 82-year-old woman. CVC insertions have become a common practice in hospitals due to a variety of indications, and tunneled CVCs still remain an important form of access in patients with end-stage renal disease. Intraarterial puncture is a common complication during CVC insertion, while intraarterial (mis)placement is fairly uncommon and if unrecognized can lead to significant morbidity and mortality. rterial puncture during central venous catheter (CVC) insertion is one of the most common complications related to CVC insertion, with an incidence varying from 1% to 11%. Catheter misplacement outside of the correct position (ideally a large central vein such as the superior or inferior vena cava or the right atrium) has been described with tips lying in aberrant sites in almost every possible anatomical position, including the arterial system, mediastinum, pleura, and pericardium. CVC misplacement depends on several factors such as site and technique of insertion, operator experience, number of needle passes, presence of unknown vascular or anatomic abnormalities, and patient body habitus and positioning (1, 2). A CASE REPORT An 82-year-old black woman with recently diagnosed end-stage renal disease requiring hemodialysis was referred for further evaluation of her kidney disease. Her past medical history was significant for hypertension, hypothyroidism, and pulmonary hypertension. She initially presented to an outside hospital 1 month earlier for progressive edema, nephrotic-range proteinuria, marked hypoalbuminemia, and severe renal failure. Pertinent workup at the outside hospital revealed urinary protein excretion of 10 g/day and a serum albumin level of 0.9 g/dL. Routine serologies and urine and serum protein electrophoreses were normal. The specific cause of her end-stage renal disease was not known, as the patient refused to undergo a kidney biopsy. Her renal function rapidly deteriorated, and hemodialysis was started. She was placed on prophylactic anticoagulation because of her severe nephrotic syndrome. 136 Hemodialysis was performed using a central venous hemodialysis catheter. She was subsequently discharged to continue maintenance hemodialysis at an outpatient hemodialysis unit. Outpatient hemodialysis, however, was not tolerated due to frequent episodes of intradialytic hypotension. She had several catheter exchanges. The patient developed progressive anasarca and dyspnea prompting transfer for management of renal disease and refractory volume overload. Her admission vital signs included a heart rate of 86 beats per minute; blood pressure, 103/57 mm Hg; respiratory rate, 18 breaths/min; and oxygen saturation, 96% on room air. She was in no acute distress at rest. Neck veins were prominent. Lung auscultation revealed decreased breath sounds at the bases. Cardiovascular examination revealed a systolic murmur over the right upper sternal border but no precordial heave. She had overt anasarca with swelling to the level of the hips. A dual-lumen dialysis catheter was located below the right clavicle. Laboratory studies showed a hemoglobin of 12.5 g/dL; hematocrit, 37.7%; white blood cell count, 9200/uL; platelets, 392,000/uL; sodium, 148 mEq/L; potassium, 5.2 mEq/L; chloride, 111 mEq/L; bicarbonate, 27 mEq/L; blood urea nitrogen, 40 mg/dL; creatinine, 5.0 mg/dL; glucose, 106 mg/ dL; albumin, 1.2 g/dL; and calcium, 8.2 mg/dL. Coagulation studies revealed a prothrombin time of 99.4 seconds with an international normalized ratio of 10.6. Urinalysis was significant for 3+ proteinuria, 2+ glucosuria, and 1+ blood with 15 to 30 red blood cells. A 24-hour urine collection revealed a creatinine clearance of 4 mL/min and a urine protein excretion of 18 g/ day. A chest x-ray revealed small bilateral pleural effusions, and the right internal jugular dialysis catheter tip was reported to be in the superior vena cava (Figure 1). As part of the workup of pulmonary hypertension, a CT scan with pulmonary embolus protocol was done, which ruled out a pulmonary embolus. The study, however, revealed the dialysis catheter to actually be in the ascending aorta rather than the superior vena cava (Figure 2). Because of the finding of arterial placement of the dialysis catheter, the vascular surgery service was consulted and From the Division of Nephrology, Department of Internal Medicine, Baylor University Medical Center at Dallas. Corresponding author: Valerie Tan, MD, 3600 Gaston Avenue, Barnett Tower, Suite 904, Dallas, TX 75246 (e-mail: [email protected]). Proc (Bayl Univ Med Cent) 2014;27(2):136–138