AB223. SOH21AS253. The misguided catheter: a case report
Anaesthesia Poster Session

AB223. SOH21AS253. The misguided catheter: a case report

Sean Noel Rooney, Catherine Nix, Hugh O’Callaghan

Department of Critical Care and Anaesthesiology, University Hospital Limerick, Limerick, Ireland

Abstract: Critically ill patients in an intensive care unit (ICU) require venous catheters to maintain and monitor their physiology. Peripherally inserted central catheter (PICC) and central venous catheters (CVC) are placed by experienced physicians using a standardised Seldinger technique in an aseptic environment, they are also associated with a myriad of complications. It is standard practice to confirm the position of catheters and assess for complications on a chest x-ray (CXR) before use. Here we present a case where the position of a previously sited right sided PICC was altered by the insertion of a left internal jugular CVC. A 64-year-old gentleman 3 days post laparoscopic Hartmann’s procedure for perforated diverticular disease developed type 1 respiratory failure requiring ICU admission. His respiratory deterioration resulted from a combination of post-operative ileus, hospital acquired pneumonia, para-pneumonic effusion and PCR confirmed COVID-19 infection (Image1). He required intubation and placement of a left sided CVC. A post-procedural CXR revealed drastic displacement of his right sided PICC, the tip now residing in the left brachiocephalic vein. We hypothesised that while a standardised approach and sequence was followed: the blunted, ‘hook-like’ guidewire was the culprit in the dislodgement of the previously sited PICC. Curiously the PICC spontaneously returned to its optimal position in the SVC without intervention. This case illustrates an unusual and interesting complication of CVC insertion despite standardised technique and safety precautions.

Keywords: Catheter; central; malposition; complication


Funding: None.


Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/map-21-ab223). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

doi: 10.21037/map-21-ab223
Cite this abstract as: Rooney SN, Nix C, O’Callaghan H. AB223. SOH21AS253. The misguided catheter: a case report. Mesentery Peritoneum 2021;5:AB223.