Atrial fibrillation (AFib) with rapid ventricular response (RVR) due to central line placement
Author: V. Dimov, M.D., Fellow, Creighton University Division of Allergy & Immunology
Reviewer: A. Kumar, M.D., Medical Director of IMPACT (Internal Medicine Preoperative) Center and Medical Director, Blood Management, Department of Hospital Medicine at Cleveland Clinic
A 39-year-old AAF with PMH of DM type 1 was admitted to the hospital with an infected right diabetic foot ulcer. She needed IV access for Unasyn (ampicillin and sulbactam) and laboratory work, and failed several peripheral line attempts.
PMH:
DM 1, HTN
Medications:
Insulin, lisinopril
Physical examination:
VSS
WD/WN in NAD
Chest: CTA (B)
CVS: Clear S1S2
Abdomen: Soft, NT, ND
Extremities: right diabetic foot ulcer with signs of infection
What happened?
A right internal jugular (IJ) central line was placed. Immediately after the catheter was placed, she complained of shortness of breath (SOB) and palpitations. Her oxygen saturation (SpO2) was 100% on room air, and breath sounds were equal and clear bilaterally.
What is the most likely diagnosis?
Is it a pneumothorax?
Heart rate (HR) was 140 and irregular. Is it due to PVCs (premature ventricular complexes)?
What tests would you order?
EKG and chest X-ray (CXR).
EKG showed atrial fibrillation (AFib) with rapid ventricular response (RVR).
CXR showed that the triple lumen catheter (TLC) was at the level of the right atrio-ventricular (AV) junction.
Triple lumen catheter (TLC) at the right atrio-ventricular (AV) junction on CXR.
Atrial fibrillation (AFib) with rapid ventricular response (RVR) due to a TLC at the right atrio-ventricular (AV) junction.
What would you do?
Withdraw the central line. Repeat the CXR and EKG.
What happened?
The TLC was withdrawn 5 cm. The conversion to normal sinus rhythm followed immediately and there were no further complaints.
A central line in the superior vena cava (SVC). This is the correct position for an internal jugular (IJ) central line on CXR.
Conversion to normal sinus rhythm (NSR) after the central line was repositioned.
Final diagnosis:
Atrial fibrillation (AFib) with rapid ventricular response (RVR) due to central line malpositioning.
References:
Central Venous Catheterization: Concise Definitive Review. Medscape, Critical Care Medicine, 05/16/2007 (free registration required).
Related reading:
Imaging: Electrocardiograms, X-rays, CT scans
A Systematic Approach to Reading an EKG by Using 2 Mnemonics
After Taser Shot, Fugitive’s Irregular Heartbeat Becomes Normal. WSJ Health Blog, 05/2008.
Published: 04/12/2006
Updated: 11/14/2008
Labels: Cardiology, Critical Care, CXR, Images, Procedures
6 Comments:
Interesting presentation of transient atrial fibrillation with rapid ventricular response due to a rare cause. It is not uncommon to see such atrial arrhythmias during cardiac catheterisation when the catheter is manipulated in the right atrium. The case also illustrates the principle that for sustaining atrial fibrillation once initiated, needs a large atrial mass. Sometimes atrial fibrillation induced by catheter manipulation needs cardioversion for correction, especially when the atria are grossly enlarged and diseased.
really good...learned a lot...keep it up
I think I have learned something useful from this blog.
Is there a less problematic long term regimine
than coumadin and sotalol? Coumadin seems to have many negatives.
This patient will not require Coumadin (warfarin) or sotalol.
Long-term anticoagualtion is done with warfarin.
Interesting case. Often you can tell that the patient is having problem related to the central line placement almost immediately. The patient must have been on telemetry (telemetry leads visible on CXR), so withdrawing the catheter few centimeters out could have been one of the diagnostic approaches.
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