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This previously healthy 49-year-old woman underwent a cholecystectomy and repair of a perforated duodenum. On post-operative dayseven, her complaints of cough and shortness of breath prompted the radiographs shown above. Despite diuretic therapy, her condition deteriorated, and she diedthree days later, severely hypoxic and undiagnosed.
On close inspection of the lateral radiograph (image below), a central venous catheter (arrows) is visible behind the sternum,with the tip far from its intended position near the right atrium. With the catheter tip clearly extravascular, the infusate presumably dripped directlyinto the chest cavity rather than into the right atrium. Autopsy disclosed large amounts of serous fluid in each pleural space, but the heart, lungs, pulmonaryarteries, and other body organs were unremarkable.
This case teaches several important lessons:
1) when a patient with an indwelling central venous catheter develops new or progressive cardiorespiratory distress, vascularerosion or perforation deserves immediate consideration;
2) a lateral radiograph of the chest can be the best way to verify a malpositioned central venous catheter;
3) failure to recognize this complication can prove fatal.
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