Challenges Associated with Central Venous Catheter Placement and Central Venous Oxygen Saturation Monitoring

Challenges Associated With Central Venous Catheter Placement and Central Venous Oxygen Saturation Monitoring Matthew Wemple MD and Andrew M Luks MD Introduction mellitus, and hypertension presented to the emergency department with shortness of breath and hypotension. Soon Patients with septic shock and respiratory failure often after arrival he became drowsy and was placed on nonin- require hemodynamic monitoring in order to guide bed- vasive mechanical ventilation. Labs drawn in the emer- side management. This is particularly true of patients with gency department revealed white-blood-cell count dialysis-dependent chronic kidney disease, who may be 22,000 cells/␮L, with 90% neutrophils and 1% bands, blood less tolerant of large volume resuscitation than individuals urea nitrogen 67 mg/dL, creatinine 8.1 mg/dL, hematocrit with normal renal function. With the declining use of pul- 34%, and venous lactate 1.2 mmol/L. His Acute Physiol- monary artery catheters and the introduction of early goal- ogy and Chronic Health Evaluation II score at this time, directed therapy as a means for resuscitating patients with calculated retrospectively, was 29. Following admission to septic shock,1 central venous catheters (CVCs) are increas- the ICU, a venous blood gas analysis revealed pH 7.10, ingly being used for this purpose. These catheters allow P 82 mm Hg, and P 52 mm Hg. The patient was CO2 O2 continuous monitoring of central venous pressure to guide subsequently intubated with a 7.5-mm endotracheal tube, fluid administration, as well as point measurement or con- using a rapid sequence protocol with etomidate for seda- tinuous monitoring of central venous oxygen saturation tion and rocuronium for neuromuscular blockade. He was (S ), a surrogate measure of mixed venous oxygen sat- cvO2 placed on mechanical ventilation with the following set- uration (S ) that provides information about the balance vO2 tings: volume assist control, respiratory rate 24 breaths/ between oxygen delivery and consumption at the tissue min, tidal volume 510 mL (8 mL/kg ideal body weight), level. In order to use the central venous pressure and S cvO2 F 1.0, and PEEP 5 cm H O. Peak inspiratory pressure at IO2 2 to guide sepsis resuscitation or other aspects of patient the time was 53 cm H O, while mean airway pressure was management, the clinician must verify that the line is in 2 13 cm H2O. Sedation and analgesia for ventilator tolerance the appropriate position and ensure there are no sources of were provided with intravenous boluses of fentanyl and error in the generated data. We present a case of a patient midazolam, administered according to a nurse-driven pro- with chronic kidney disease who presented with sepsis and tocol. His vital signs following intubation were: tempera- respiratory failure, which demonstrates some of the chal- ture 36.7°C, heart rate 111 beats/min, blood pressure 87/ lenges that can arise in these regards and how to approach 39 mm Hg, and S 100%. On examination, the patient pO2 these situations. had breath sounds bilaterally, without crackles or wheezes. He demonstrated an irregular tachycardic rhythm, with no Case Summary murmurs, rubs, S3, S4, or loud P2. His abdomen and skin A 54-year-old man with a past medical history notable were unremarkable, and bilateral lower extremities showed for dialysis-dependent chronic kidney disease, diabetes symmetric 1ϩ pitting edema. The patient had bilateral upper extremity dialysis fistulae, both of which demonstrated a palpable thrill. Patient records available at this The authors are affiliated with the Division of Pulmonary and Critical time indicated that the left upper extremity fistula had a Care Medicine, Department of Medicine, Harborview Medical Center, pseudoaneurysm. University of Washington, Seattle, Washington. A triple lumen CVC capable of continuously monitoring S (Presep, Edwards Lifescience, Irvine, California) The authors have disclosed no conflicts of interest. cvO2 was placed in the left internal jugular vein without diffi- Correspondence: Andrew M Luks MD, Division of Pulmonary and Crit- culty, using ultrasound guidance. The left internal jugular ical Care Medicine, Harborview Medical Center, 325 Ninth Avenue, Box 359762, Seattle WA, 98104. E-mail: [email protected]. was chosen because the physician performing the proce- dure, aware of the pseudoaneurysm of the left-sided fis- DOI: 10.4187/respcare.01762 tula, assumed the patient received hemodialysis via the RESPIRATORY CARE • DECEMBER 2012 VOL 57 NO 12 2119 CHALLENGES ASSOCIATED WITH CENTRAL VENOUS CATHETER PLACEMENT biotic coverage was narrowed to penicillin on hospital day 3. Beginning on hospital day 1, the patient underwent intermittent hemodialysis, with minimal hemodynamic in- stability on the norepinephrine infusion. He was dialyzed using his left upper extremity fistula after the nephrologist ascertained that this was his usable fistula. With intermittent hemodialysis and treatment of his in- fection, the patient’s oxygenation improved, such that his F was 0.4 on hospital day 1, and 0.3 on hospital day 2. IO2 The patient received spontaneous breathing trials (CPAP 5cmH2O with no pressure support) starting on hospital day 1, but failed on this and the following day due to a rapid shallow breathing pattern. On hospital day 3 he main- tained a respiratory rate of 25 breaths/min and a tidal volume of 330 mL during his spontaneous breathing trial, and was subsequently extubated to oxygen by nasal can- nula. The central line was removed following extubation, Figure. Portable chest radiograph taken after insertion of the central venous catheter in the left in internal jugular vein. The black and the patient was transferred to the medicine ward on arrow points to the tip of the catheter. hospital day 4. He was subsequently discharged from the hospital on hospital day 5 with plans to complete a 14-day course of intravenous cefazolin, dosed with hemodialysis. right upper extremity dialysis fistula and wanted to avoid cannulation on that side. After the portable chest radio- Discussion graph obtained to confirm catheter tip position (Figure) raised concern about possible intra-arterial placement, a CVCs play a key role in the management of patients pressure transducer was attached to the catheter (Ultra- with septic shock and respiratory failure. Our case dem- view, Spacelabs Healthcare, Issaquah, Washington) and onstrates some of the challenges that can arise with place- revealed a central venous pressure waveform with a pres- ment of these devices and interpretation of some of the sure of 17 mm Hg. The CVC was then connected to the data provided by them. continuous S monitoring system (Vigilance II, Edwards The first challenge associated with the CVC is safe and cvO2 Lifescience, Irvine, California), and the initial reading was correct placement of the device. The most important step 94%. A blood gas analysis sample was obtained from the in this regard is to ensure that the introducer needle and central line to calibrate the device and revealed pH 7.39, guide wire are in the central vein, rather than an artery, P 33 mm Hg, P 96 mm Hg, and oxygen saturation prior to insertion of the CVC. This is done using portable CO2 O2 96%. ultrasound to identify the vein prior to needle puncture, to Based on the results of pressure transduction and chest observe the needle entering the appropriate vessel, and to radiography, it was felt that the catheter tip was likely in confirm venous placement of the guide wire prior to in- a persistent left superior vena cava, proximal to the right serting the catheter. Before advancing the guide wire atrium. The S was felt to be elevated due to the pres- through the needle, clinicians can also use pressure trans- cvO2 ence of a dialysis fistula on the same side as the catheter, duction via the 18-gauge needle to verify the presence of through which arterialized blood entered the venous sys- a central venous pressure waveform. In our case we used tem and traveled past the catheter tip. S monitoring ultrasound guidance, as described above, but did not use cvO2 was discontinued, and the central line was used only for pressure transduction prior to guide wire insertion. Cath- infusion of vasopressors and other medications. eter placement proceeded without apparent complication. The patient required a continuous infusion of norepi- Once the CVC has been secured in place, chest radiog- nephrine to achieve a goal mean arterial pressure of raphy is performed to confirm that the tip of the CVC is in Ͼ 65 mm Hg. The infusion rate varied between 6 and the appropriate position at the junction of the superior 10 ␮g/min before it was discontinued on hospital day 2, as vena cava and the right atrium. In our patient the chest his hemodynamic compromise resolved (the day of pre- radiograph and the initial, uncalibrated S reading were cvO2 sentation is treated as day zero). Following admission, the both concerning for a possible intra-arterial placement. In patient had been started on vancomycin, ceftriaxone, and such situations, providers can employ several tactics to azithromycin pending culture results. Blood cultures drawn verify that the CVC is in a central vein. Pressure trans- in the emergency department subsequently grew group B duction can be used at this point to identify either an ␤-hemolytic streptococci on hospital day 2, and his anti- arterial or venous waveform, although, as noted above, 2120 RESPIRATORY CARE • DECEMBER 2012 VOL 57 NO 12 CHALLENGES ASSOCIATED WITH CENTRAL VENOUS CATHETER PLACEMENT this measurement is more appropriately performed prior to ing. Cardiac catheterization with oximetry can also be insertion of the guide wire and CVC. Second, comparisons performed to evaluate the degree of shunt volume. We did can be made between simultaneous blood gases drawn not consider this diagnosis at the time of the patient’s ad- from the CVC and a known arterial site.

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