title: Inadvertent transpericardial insertion of a central venous line with cardiac tamponade failure of preventive practices.
abstract: A 56-year-old man who had undergone cardiac surgery suffered from cardiac tamponade after administration of contrast-medium through a central venous catheter. Pericardiotomy showed the catheter transversing the pericardial sac just beneath an unusual high reflection and then reentering the superior vena cava. Preventive practices including chest radiography, confirming free venous blood return and manometry may fail to detect catheter malposition in rare cases. Knowledge of potential pitfalls in using generally recommended safety practices and continuous vigilance are essential for the anesthesiologist and intensivist in avoiding potentially lethal hazards.
authors.affiliation: Department of Internal Medicine I, Medical School, University of Vienna, Austria. heidrun.losert@akh-wien.ac.at
authors.forename: H
authors.initials: H
authors.lastname: Losert
authors.forename: R
authors.initials: R
authors.lastname: Prokesch
authors.forename: M
authors.initials: M
authors.lastname: Grabenwöger
authors.forename: B
authors.initials: B
authors.lastname: Waltl
authors.forename: R
authors.initials: R
authors.lastname: Apsner
authors.forename: G
authors.initials: G
authors.lastname: Sunder-Plassmann
authors.forename: M
authors.initials: M
authors.lastname: Muhm
mesh_terms: D002305:Cardiac Tamponade / Q000209:etiology*; D002405:Catheterization, Central Venous / Q000009:adverse effects* / Q000379:methods; D006801:Humans; D008297:Male; D008875:Middle Aged; D011859:Radiography; D014683:Vena Cava, Superior; D014950:Wounds, Penetrating / Q000000981:diagnostic imaging / Q000209:etiology*