Radiographic mislead: apparent arterial placement of subclavian central venous catheter due to mediastinal shift
A 32-year-old lady with leiomyosarcoma of hand, underwent amputation of right forearm. On second postoperative day, her general condition gradually deteriorated. She was shifted to intensive care unit (ICU) in view of tachypnoea and desaturation to 84% on oxygen (60% byVenturi) support. She was haemodynamically unstable with a heart rate of 120/min and blood pressure (BP) of about 85/45 mmHg. Auscultation of chest revealed decreased air entry on the right side of chest. Patient did not co-operate for the noninvasive ventilation. She was intubated with a 7.0 mm internal diameter cuffed Portex© endotracheal tube (ETT) and started on dopamine infusion at 10 μg/kg/min through 18 gauge peripheral intravenous (IV) line. A 15 cm seven French triple lumen CVC was secured in the right subclavian vein in first attempt using the Seldinger technique, and backflow of blood was confirmed in all three lumens. We planned to administer ionotropes through CVC once its placement was confirmed by a chest radiograph. Urgent portable chest radiograph was sought for and it showed CVC crossing the midline with gradual turn leftwards and downwards []. The position of the CVC tip was above and on the right side of carina, but it never in its course crossed the trachea []. The radiograph also revealed right-sided massive pleural effusion and tracheal shift to the left side []. Pressure transducer was not available at that point of time. So, to confirm correct placement of CVC tip, two separate samples for blood gas analysis were sent, one from CVC and another from radial artery, which confirmed that CVC was in subclavian vein. Ionotropes were then administered through the CVC and the patient improved haemodynamically. Malignant pleural effusion was diagnosed provisionally. Right-sided intercostal drain (ICD) was inserted. Plain and contrast computerized tomography (CT) of thorax revealed loculated right-sided pleural effusion with right-sided lung collapse and marked mediastinal shift of the cardia and great vessels to the left. Patient's condition gradually improved in the next three days. She was extubated and finally discharged from ICU on oxygen (35%) by Venturi.