Adult Male With Bloody Diarrhea

Article Outline

• Diagnosis
  • Improper placement of the central venous catheter
• References
• Copyright

[Ann Emerg Med. 2008;52:765.]

A 41-year-old man with a history of distal ulcerative colitis was admitted to a public hospital in southern Italy with persistent bloody diarrhea. A right internal jugular central venous catheter was placed for management of parenteral nutrition. During placement of the catheter, the guidewire was advanced approximately 30 cm. Despite a gradual improvement of gastrointestinal symptoms, the patient died 2 weeks later from a ventricular fibrillation cardiac arrest.

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Diagnosis 

Improper placement of the central venous catheter 

Radiographs demonstrate the improper placement of the central venous catheter, which abuts the right ventricular wall (Figure, Panel A, red arrows). Autopsy demonstrated ventricular perforation with 4 cm of the catheter tip lying outside the myocardium (Figure, Panel B). Histologic analysis showed a chronic fibrotic and inflammatory reaction. This reaction suggests that the incorrect positioning of the catheter may have caused the progressive cardiac perforation, perhaps because of endocardial damage from repeated contacts of the catheter tip with the myocardial wall. To avoid this type of complication, advancement of the guidewire should be limited to approximately 15 cm before threading of the catheter.¹, ², ³

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• Figure. 

  A, Chest radiograph that shows the positioning of the catheter. Used with permission of Biagio Lettieri, MD, Department of Anesthesiology and Emergency, Second University of Naples, Naples, Italy. B, Autopsy shows the catheter extending for about 4 cm. Used with permission of Paola Capodanno, MD, Department of Anaesthesiology and Emergency, Second University of Naples, Naples, Italy.

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References 

1. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348:1123–1133
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2. Graham CA. Central venous catheterization—subclavian vein. N Engl J Med. 2008;358:1759
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3. Mills CN, Liebmann O, Stone MB, et al. Ultrasonographically guided insertion of a 15-cm catheter into the deep brachial or basilic vein in patients with difficult intravenous access. Ann Emerg Med. 2007;50:68–72
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