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Case 327

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A 2 year-old male patient with short bowel syndrome is in the late postoperative period (7 weeks) of a extensive enterectomy. After several unsuccessful peripheral venous access insertions attempts and previous venous thrombosis, he went under a central venous access puncture (right femoral vein), guided by ultrasonography (US), in which great difficulty in the guidewire navigation was observed. After 48 hours, the patient was tearful, feverish (38,7°C) and with abdominal distension, without nausea or vomiting. Plain abdominal radiography and abdominal computed tomography were requested.

Considering the clinical history of the patient and the provided images, what is the most likely diagnosis?

a) Bowel obstruction

25%

b) Anomalous position of central venous catheter

25%

c) Abdominal-wall abscess

25%

d) Encysted ascites

25%
   

Image analysis

Image 1 - Analysis: Plain abdominal radiography, anteroposterior view, in a supine position. Presence of central venous catheter in the right inguinofemoral region's projection (yellow arrow), coursing through the right hemiabdomen. Hypertranslucent area with poorly-defined limits and irregular contours in the projection of the end of the catheter, consistent with gas accumulation (red circle). (Obs: additional lateral view radiography can be useful in locating the distal end of the venous catheter).

 

Image 2: Non-contrast-enhanced abdominal computed tomography, axial view, at the sacroiliac joints level. End of the central venous catheter in an anterior position, close to the abdominal wall (red arrow), in intimate relationship with the gas accumulation (yellow arrows). Few intestinal loops are visualized due to the previous enterectomy with the removal of the jejunum, ileum, cecum, ascending and transverse colon.

 

Image 3: Non-contrast-enhanced abdominal computed tomography, coronal reconstruction of the right hemiabdomen. End of central venous catheter in anomalous position, close to the abdominal wall (red arrow), in intimate relationship with the gas accumulation (yellow arrow). Few intestinal loops are visualized due to the previous enterectomy with the removal of the jejunum, ileum, cecum, ascending and transverse colon.

 

Highlights

- Central venous access is defined as placement of a catheter with the extremity of the superior vena cava or inferior vena cava, regardless its insertion site;

- The puncture site depends on the clinical aspects, the context of the assistance and, mainly, the doctor's experience;

- There is no absolute contraindication. Coagulopathies and thrombocytopenias are relative contraindications;

- Central venous access guided by dynamic US increases the success rates and decreases the probability of complications, especially in pediatric patients;

- Loss of central venous catheters before the end of the proposed therapy is common, being up to the care team to know how to manage it the right way.

 

References

- Netter. Atlas of Human Anatomy, Sixth Edition. Elsevier; 2014.

- Ullman A, Marsh N, Mihala G, Cooke M, Rickard C. Complications of Central Venous Access Devices: A Systematic Review. PEDIATRICS. 2015;136(5):e1331-e1344.

- C Heffner A, P Androes M. UpToDate [Internet]. Uptodate.com. 2018 [cited 19 April 2018]. Available from: https://www.uptodate.com/contents/overview-of-central-venous-access/contributors

- Arvaniti K, Lathyris D, Blot S, Apostolidou-Kiouti F, Koulenti D, Haidich A. Cumulative Evidence of Randomized Controlled and Observational Studies on Catheter-Related Infection Risk of Central Venous Catheter Insertion Site in ICU Patients. Critical Care Medicine. 2017;45(4):e437-e448.

 

Authors

Bernardo Bahia Finotti, 6th year medical student at Universidade Federal de Minas Gerais

E-mail: bernardofinotti[at]gmail.com

 

Ariádna Andrade Saldanha da Silva, 6th year medical student at Universidade Federal de Minas Gerais

E-mail: ariadna.andrade[at]hotmail.com

 

Izabella Barreto, Pediatric Surgery resident at HC-UFMG

E-mail: Izabellabarreto[at]gmail.com

 

Supervisors

Fabio Mendes Botelho Filho, pediatric surgeon at HC-UFMG

E-mail: mendesbotelho[at]hotmail.com

 

Túlio Cezar S. Bernardino, Professor at the Departament of Anatomy and Image at Medical School of Universidade Federal de Minas Gerais

E-mail: ituliob[at]gmail.com

 

Reviewers

André Naback, Lucas Bruno Rezende, Luísa Bernardino, Gabriella Yuka Shiomatsu, Vinícius R. Avelar, Prof. José Nelson Mendes Vieira, Profa. Viviane Santuari Parisotto Marino.

 

Translated by

Gabriella Yuka Shiomatsu, 4th year medical student at Universidade Federal de Minas Gerais

E-mail: gabriellashiomatsu[at]gmail.com

Test question

(SUS – PE 2015. Direct Access)
Comparing the central venous puncture sites used in the clinical practice, it is CORRECT to affirm that

a) The infection rate related to the catheter is similar in the puncture of the subclavian vein or the femoral vein. Therefore, the choice between both puncture sites is indifferent.

25%

b) In general, the complications rate is similar between the puncture of the subclavian and the internal jugular veins. While in the subclavian there is a higher risk of pneumothorax or hemothorax, in the internal jugular there is a higher risk of arterial puncture and hematoma

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c) The accidental arterial puncture rate, the hematomas and the venous thrombosis associated to the catheter are lower in the femoral accesses.

25%

d) The central venous access in the subclavian vein must be avoided due to the higher rate of mechanical and infectious complications among all the central accesses.

25%

e) All the central puncture sites have reasonable rate of infection after a few of days. Therefore, catheters and puncture sites must be exchanged routinely, every 10-14 days, if there is still a need for central venous access.

25%
   

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