Jugular central line inserted into the hepatic vein of a COVID-19 patient

1. Discussion

COVID-19 is a new disease that started at the end of 2019 and became a pandemic in 2020. The disease mainly affects the respiratory symptoms, and the patients usually present with fever, cough, and shortness of breath. COVID-19 can lead to respiratory failure which increases intensive care unit (ICU) admissions and requires assistant ventilation.¹

The central venous line (CVL) is a venous catheter with a large bore placed in specific veins. It is commonly used in ICU patients. The indications for insertion of CVL are different. However, it is mainly used for fluid resuscitation, drug infusion, and central venous pressure monitoring. On the other side, multiple conditions are considered a contraindication, and they are divided into absolute and relative. Like other procedures, CVL may lead to different complications such as pain at the cannulation site, local hematoma, infection, and pneumothorax requiring a possible chest tube. The CVL positioning should be confirmed post-insertion. Additionally, a chest x-ray should be done after subclavian and internal jugular vein insertion to confirm the placement and exclude complications like pneumothorax.²

2. Visual case discussion

A 73-year-old patient with a history of multiple comorbidities presented to the emergency department with shortness of breath, fever, cough, and generalized fatigue. He claimed that his breathing became worse over three days. He did a nasopharyngeal swab before two days for SARS-CoV-2, which appeared positive today. The patient's vital signs showed a blood pressure of 110/50 mmHg; a heart rate of 115 beats per minute; a respiratory rate of 42 breaths per minute; a temperature of 38.5 C; and an oxygen saturation of 78% on room air. Thus, the patient was placed on a monitor, and a non-rebreather mask with 10-liter of oxygen was started. Antipyretics, in addition to other supportive measures, were initiated. A set of blood tests and chest computerized tomography in addition to arterial blood gas analysis was arranged. As his condition did not improve, non-invasive ventilation was started in the emergency department, and the intensivist was consulted. The intensivist decided to admit the patient to the ICU for further management. Later on, the patient was intubated and connected to mechanical ventilation due to the lack of improvement in the patient’s condition. Additionally, a right internal jugular central venous catheter was inserted. A portable chest X-ray was arranged to check the catheter position before use. Meanwhile, the patient heart rate increased to range from 140 to 158 beats per minute, and his rhythm showed intermittent atrial fibrillation in the monitor. The chest X-ray confirmed that the catheter reached the right upper abdomen region and was located within the hepatic vein (Fig. 1 ). Thus, the central venous catheter was adjusted and pulled up to be in the correct position. Nevertheless, increased heart rate and intermittent atrial fibrillation were persistent despite treatment with beta-blocker medication. A few hours later, another portable chest X-ray was arranged, which confirmed that the catheter tip is in an abnormally low position (Fig. 2 ). Consequently, the central venous catheter was repositioned and pulled up. The heart rate decreased, and the atrial fibrillation disappeared. Additionally, the arranged echocardiography showed normal chambers of the heart with no structural defects.

Fig. 1.

Portable chest x-ray showed a right jugular central line seen passed the heart and overlying the right upper abdominal region (located with Hepatic vein) (red right arrow). Endotracheal tube (green up arrow) and nasogastric tube (blue left arrow) are seen in place.

Fig. 2.

Portable chest x-ray revealed that the central line is kinked back (right and left red arrow) and in low position (blue right arrow).

3. Questions and answers

Question 1

Please choose one option:

Which of the following is an absolute contraindication to central venous line insertion?

• 1-Coagulopathy.
• 2-Combative patients.
• 3-Hemorrhage from the target vessel.
• 4-Infection overlying the insertion site.
• 5-Suspected proximal vascular injury.

The correct answer is (4-Infection overlying the insertion site)

Explanation:

Contraindications are divided into absolute and relative. Absolute contraindications include distorted local anatomy (such as for trauma), infection overlying the insertion site, or thrombus within the intended vein. Relative contraindications include coagulopathy, hemorrhage from target vessel, suspected proximal vascular injury, or combative patients.²

Question 2

True/ False Question:

Central venous line insertion should only be done with Ultrasound guidance?

• 1-True.
• 2-False.

The correct answer is (2- False.)

Explanation: Ultrasound guidance can be beneficial in all approaches and is the recommended approach. However, when ultrasound guidance is not feasible for various reasons, such as the emergency nature of a procedure, lack of equipment, or a patient's anatomy in a situation where there is limited room for the ultrasound transducer in the subclavian approach while manipulating the needle, CVLs may be placed using anatomical landmarks without ultrasound.²

Declaration of Competing Interest

I have no conflicts of interest to disclose.