Atrial fibrillation (AFib) with rapid ventricular response (RVR) due to central line placement

Author: V. Dimov, M.D.
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 African American female (AAF) with past medical history (PMH) of diabetes mellitus type 1 (DM1) was admitted to the hospital with an infected right diabetic foot ulcer. She needed intravenous access (IV) access for Unasyn (ampicillin and sulbactam) and laboratory work, and failed several peripheral line attempts.

Past medical history (PMH)

Diabetes mellitus type 1 (DM1), hypertension (HTN).

Medications

Insulin, lisinopril.

Physical examination

Vital signs stable (VSS).
Well-developed and well-nourished in non-apparent distress (WD/WN in NAD).
Chest: Clear to auscultation bilaterally (CTA (B).
Cardiovascular system (CVS): Clear S1S2.
Abdomen: Soft, non-tender and non-distended (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 bpm and irregular. Is it due to PVCs (premature ventricular complexes)?

What tests would you order?

The best option would be to withdraw the line. An alternative approach is described below.

The treatment team ordered a STAT EKG and chest X-ray (CXR).

The EKG showed atrial fibrillation (AFib) with rapid ventricular response (RVR).

The 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 (click to enlarge the images).


Atrial fibrillation (AFib) with rapid ventricular response (RVR) due to a TLC at the right atrio-ventricular (AV) junction (click to enlarge the images).

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The TLC was withdrawn 5 cm.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 (click to enlarge the images).


Conversion to normal sinus rhythm (NSR) after the central line was repositioned (click to enlarge the images).

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: 06/14/2010

15 comments:

  1. 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.

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  2. really good...learned a lot...keep it up

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  3. I think I have learned something useful from this blog.

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  4. Is there a less problematic long term regimine
    than coumadin and sotalol? Coumadin seems to have many negatives.

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  5. This patient will not require Coumadin (warfarin) or sotalol.

    Long-term anticoagualtion is done with warfarin.

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  6. 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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  7. Re: "withdrawing the catheter few centimeters out could have been one of the diagnostic approaches."

    Probably the best approach. I agree. Does not sound like this patient was on telemetry from the start though - there was no need to be on. She may have been placed on tele after she developed the arrhythmia.

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  8. please explain me the symbols used in physucal examination. because as a student of 1st year mbbs i m unable to undersrand them

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  9. It is now explained in the text above and also listed below. Thank you for your comment.

    Vital signs stable (VSS).
    Well-developed and well-nourished in non-apparent distress (WD/WN in NAD).
    Chest: Clear to auscultation bilaterally (CTA (B).
    Cardiovascular system (CVS): Clear S1S2.
    Abdomen: Soft, non-tender and non-distended (NT, ND).
    Extremities: right diabetic foot ulcer with signs of infection.

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  10. thanks alot for your kind response

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  11. thax for your kind response

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  12. Very interesting case. Sorry for my not good english. What is the necessity of central line placement in this case? In my opinion, their was enough to have a access in a peripheral vein. And no AF.

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    Replies
    1. Note the first paragraph. Several failed peripheral IV attempts

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  13. Very informative cases..nice job !

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  14. good teaching case...beware the dangers of iatrogenesis!! personally, I would have placed a subclavian line!!

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