Tag Archives: Central Line

Trauma Devices

February 27, 2018

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Trauma Lines

This patient has four devices.

  1. There is an endotracheal tube that is malpositioned into the right mainstem bronchi.
  2. A right subclavian central line can be seen positioned in the right atrium
  3. A right sided chest tube is in good position
  4. Coursing up from the femoral area is a REBOA catheter.

What is a REBOA catheter?  REBOA = Resuscitative Endovascular Balloon Occlusion of the Aorta.  It is relatively new technology in which a specialized catheter is used with a balloon that occludes the aorta.  It is predominantly used in lieu of cross-clamping the aorta for severely ill trauma patients with uncontrolled abdominal hemorrhage as a temporizing device to allow time for transport to the OR and definitive control.

The patient’s lungs also appear with contusions and possibly a posterior hemothorax (patient is supine) on the left.

For a detailed discussion of REBOA including radiologic placement please refer to Life in the Fast Lane:

https://lifeinthefastlane.com/ccc/resuscitative-endovascular-balloon-occlusion-aorta-reboa/

Author:  Russell Jones, MD

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Further images of interesting central line complication…

April 19, 2014

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Last post was concerning an uncommon central line complication with the line passing into the mediastinum through the inferior brachiocephalic vein.  One astute observer asked for more information about the case, see the comments posted (very interesting fluoro experience with this type of  complication).  Here are some further images of the traversing the mediastinum very close to the aorta and the tip ends up near a pleural effusion on that side. 

Abberrent central line Aberrent Central line 1

Interestingly this patient had a vascular surgery consult.  The line actually passed through the IJ near the line insertion, tracked down the neck near the IJ and brachiocephalic,  and into the mediastinum.  The pleural effusion was from another process.  Fortunately the line was removed and no further problems were encountered. 

Unfortunately this was another team that placed the line so I don’t have information on the actual difficulty in placing the line, confirmation of venous flow once placed, etc. 

Thanks for the comments.

Author:  Russell Jones, MD

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Central line complication…

April 14, 2014

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Central line mishap 1

Central line mishap 2 Central line mishap 3 Central line mishap 4

Central lines are often necessary and performed quite frequently.  With frequent procedures sometimes we get comfortable performing them and we minimize possible dangers.  This case demonstrates, however, that there are real complications that can occur from our invasive procedures.  Thus it is important to weigh the risks and benefits.

This central line decided to go through the caudal portion of the brachiocephalic vein and into the mediastinum.  The first xray shows the end of the catheter kinked near the aortic root.  CT of the chest shows the distal tip of the catheter puncturing through the vein and into the mediastinum.  Obviously this is a very rare complication!

Image Contributor:  Aaron Hougham, MD

Author:  Russell Jones, MD

 

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PORT placement revisited…

October 20, 2012

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A couple days ago I posted a case of a guy with chest wall pain after PORT placement.  I posed the question:  “With a recent PORT placement, what complications can occur and specifically which problems are we looking for when we order a chest Xray?”

A PORT, or a Port-A-Cath (Smith’s Medical) is a long-term central line placed subcutaneously into a central vein to allow for frequent access.  Usually they are placed for chemotherapy administration, as was the case with the man I saw with the chest Xray shown several days ago.  As with any indwelling device or procedure, there are possible complication:

1. Thrombosis:  PORTs can be associated with venous clots and are a risk factor for SVC (Superior Vena Cava) Syndrome

2.  Infection:  infection of the line can cause life-threatening sepsis

3.  Bleeding:  can occur into the chest cavity as well as hematomas around the catheter.  Can be from subclavian vein or artery

4.  Pneumothorax:  the catheter is placed most-often in the left upper chest wall and, as with other central lines, pneumothorax can occur

5.  Mechanical failure:  breaking of the line or migration of the line can rarely occur

PORT-A-Catheters are generally safe and well tolerated.  It is important to know what you are looking for however if you are assessing them in the postoperative time period.  In our case, the chest Xray was obtained mainly to rule out #4 and #5 above.  There are subtle signs of #2 that can occur on chest Xray (such as multiple septic emboli or signs of heart failure from cardiac valvular infection) but generally line infections are a clinical diagnosis in conjunction with cultures from the line.  #1 is best worked up with a CT of the chest in the right clinical situation.  #3 is clinically rare outside of the immediately post-operative time period but if the man had a large pleural effusion on the side of the PORT this could indicate bleeding from the subclavian vein (or less likely artery).

I’ve included the picture again for your reference with the knowledge that it is normal, no findings suggestive of PORT complications.  Note the proper placement of the distal portion of the catheter in the SVC (red arrow):

The gentleman showed no signs of SVC syndrome and the pain was very reproducible.  It was attributed to post-operative pain and he was discharged in good condition.

If you are wondering, the patient does NOT have free air under the diaphragm.  This is his colon as demonstrated by the haustra visible and can sometimes be confused with free air.  This is referred to as Chilaiditi syndrome and occurs because of a transposition of the colon between the liver and the diaphragm.  His was unchanged from prior and is an incidental, non-clinically significant finding (1).

Author:  Russell Jones, MD

References

1.  Saber AA, Boros MJ.  Chilaiditi’s Syndrome:  what should every surgeon know?  Am Surg.  2005 Mar; 71 (3): 261-3.

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Chest wall pain…

October 9, 2012

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This gentleman presented to the ED today with chest wall pain anterior L sided.  Pertinent history included a PORT placement 1 week ago.  Here’s his Chest Xray:

This is an example of a normal PORT (portacath) placement.  With a recent PORT placement, what complications can occur and specifically which problems are we looking for when we order a chest Xray?

To be continued later…

Comments are appreciated if appropriate!

Author:  Russell Jones, M.D.

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