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A 34-year-old woman with HIV/AIDS and chronic kidney disease presented to the emergency department with fever and vomiting. We were unable to obtain peripheral IV access; therefore, a left internal jugular central venous catheter was placed with ultrasound (US) guidance. During the procedure, the needle and guidewire were both visualized entering the left internal jugular vein by US using a short-axis view. Furthermore, blood return through the needle immediately after vessel puncture was dark and nonpulsatile. Figure 1 shows the chest radiograph obtained to confirm line placement. The catheter projects over the left paramediastinum with an unusual acute bend in the distal portion, raising concern for malposition (including intra-arterial placement). To rapidly confirm catheter location, we performed bedside echocardiography using a subcostal view while rapidly injecting 10 mL of normal saline into the distal lumen of the catheter (Video Clip 1). The nearly immediate opacification of the right atrium followed by the right ventricle confirmed the venous position of the central line.

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Figure 1.  Chest radiograph.

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Other methods of verifying intravenous catheter position include computed tomography (CT) imaging, blood gas analysis on a specimen drawn from the line, or invasive monitoring (evaluating for a typical central venous pressure and waveform). All three are associated with unnecessary cost and a significant time delay. The bedside “bubble test” presented here has been described in a previous report1 in association with an aberrantly positioned central line on chest x-ray due to a persistent left superior vena cava. Our patient had undergone prior CT imaging of her chest with contrast, ruling out this anomaly. In addition, we did not agitate the saline to create microbubbles before injection as described in the previous report, yet still obtained unambiguous venous opacification.

Ultrasound guidance has replaced the landmark technique as the standard of care in placing an internal jugular central venous catheter, with a reduction in failed attempts and complications.2 However, the risk of carotid artery puncture or cannulation is present even when proper technique is followed.3 The bubble test reported here can also be performed before using the guidewire or vessel dilator by injecting the saline flush directly into the needle if there are doubts about its location, thus obviating the morbidity and mortality associated with accidental arterial cannulation.

References

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  2. References
  3. Supporting Information
  • 1
    Ghadiali N, Teo LM, Sheah K. Bedside confirmation of a persistent left superior vena cava based on aberrantly positioned central venous catheter on chest radiograph. Br J Anaesth. 2006; 96:536.
  • 2
    Leung J, Duffy M, Finckh A. Real-time ultrasonographically-guided internal jugular vein catheterization in the emergency department increases success rates and reduces complications: a randomized, prospective study. Ann Emerg Med. 2006; 48:5407.
  • 3
    Blaivas M. Video analysis of accidental arterial cannulation with dynamic ultrasound guidance for central venous access. J Ultrasound Med. 2009; 28:123944.

Supporting Information

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Video Clip S1. Bedside echocardiography.

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ACEM_785_sm_VideoClipS1.mov5458KSupporting info item

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