1. November 18, 2011 Jud Mehl, DO & Nicole Weiss, MD

2.  69 yo female  PMHx: HTN, Pulm HTN, NIDDM, RA, Osteoporosis  PSHx: Cataracts, Hysterectomy, Abdominoplasty  MVA 5 days before presentation; “bruised ribs” but with progressive SOB over next 4 days, prompting call to 911  In ER troponins = 8.8  Possible cardiac contusion, bedside echo done  Severe anteriolateral hypokinesis, EF 25-30

3.  Patient brought emergently to cardiac cath  95% stenosis LAD  80% stenosis LCx  50 % stenosis RCA Fick output 2.6 L/min CI 1.7 L/m/m 2  CCO Swann placed in R IJ  IABP Placed  Primacor infusion

4.  Placed in ICU on Wednesday evening – hemodynamics stable  Scheduled for 3-V CABG on Monday  Patient seen Saturday – looks like a million bucks  Swann and IABP out, PICC placed; A few LGF  Procedure and risks explained to patient with daughter at bedside

5.  Monday morning – CABG canceled for continued and worsening fevers.  Patient on Vanc + Zosyn  Rescheduled for Wednesday  Wednesday AM – Fevers lower, patient looks unwell, hemodynamics remain stable  On Primacor gtts  Decision to continue with CABG

6.  GETA  Left Internal Jugular Cordis placed  Ultrasound utilized  Placed without difficulty, single stick  Swan-Ganz floated with difficulty  Required multiple attempts  CPB initiated  No initial complications

8.  Surgeons note a substantial amount of bleeding at termination of CPB  Laceration of the Left Innominate Vein found  Likely secondary to line placement  Surgically repaired prior to chest closure  Patient transferred to ICU  Low-dose Primacor enroute to ICU

9.  Code called in ICU  Patient unresponsive to initial resuscitation  Patient’s chest opened at bedside  Decreased cardiac blood volume noted  Cardiac massage performed  Rapid transfuser set up  Emergently brought back to the OR  Per surgeons  Innominate Vein Laceration & Torn CABG Anastamosis  PICC line found to be floating through the laceration  Despite repair, patient coded and passed away the following day

10.  Multiple vessels damaged between leaving the OR the first time and returning to the OR the second time  Initial Innominate Vein Tear Re-ruptured  Anastamosis of CABG ripped off  PICC line found in chest  Likely most of the damage was secondary to vigorous cardiac massage  Which came first?  Connective Tissue Abnormality? Vessel friability from PICC?

11.  Well known complication documented in the literature  More frequent on R side because the acute angle between the R IJ and the Innominate Vein puts the vessels at risk  Multiple ways to puncture the vein Wire- The J-tip aims to prevent this complication. The straight end has a higher rate of perforation Dilator- If the dilator is advanced too far, it can cause perforation. This can also happen when the wire threads laterally into the subclavian artery  Swan?

12.  Consistent relationship between experience of the operator and risk of complications  Number of needle passes  Six fold increase in number of complications after three or more venopunctures  History of previous catheterizations  Dehydration  BMI >30 or <20  Large catheter size  Unsuccessful insertion attempts  Coagulopathies do not increase the risk if the proper precautions are taken (transfusing platelets or FFP)

13.  Weighing the risk:benefit ratio before placing a large central line with or without a swan  Utilizing U/S in patients who are at a higher risk for complications  Changing sites or starting over if resistance is met when threading the wire  Ensuring that the dilator is not advanced too far