title: Missed carotid artery cannulation: a line crossed and lessons learnt.
abstract: We report a case of an infusion of intra-aortic propofol after the missed inadvertent placement of a central venous catheter into the right common carotid artery. Radiological imaging revealed bilateral ischaemic infarcts in the posterior fossa and right cerebral artery territories consistent with an embolic source. The potential causes of the neurological injuries sustained in this case are explored. Discussion focuses on the sequelae, management and prevention of an iatrogenic carotid artery injury from a central venous catheter insertion. Finally, we propose an algorithm for management of iatrogenic carotid artery cannulation.
authors.affiliation: Department of Anaesthesia, Austin Health, Heidelberg, Victoria.
authors.forename: L
authors.initials: L
authors.lastname: Ho
authors.affiliation: Department of Radiology, Box Hill Hospital, Box Hill, Victoria.
authors.forename: M
authors.initials: M
authors.lastname: Spanger
authors.affiliation: Department of Cardiac Surgery, Austin Health, Heidelberg, Victoria.
authors.forename: P
authors.initials: P
authors.lastname: Hayward
authors.affiliation: Department of Anaesthesia, Austin Health, Heidelberg, Victoria.
authors.forename: L
authors.initials: L
authors.lastname: McNicol
authors.affiliation: Department of Anaesthesia, Austin Health, Heidelberg, Victoria.
authors.forename: L
authors.initials: L
authors.lastname: Weinberg
mesh_terms: D000369:Aged, 80 and over; D018686:Anesthetics, Intravenous / Q000008:administration & dosage; D002545:Brain Ischemia / Q000209:etiology; D002339:Carotid Arteries / Q000000981:diagnostic imaging; D020212:Carotid Artery Injuries / Q000209:etiology* / Q000517:prevention & control; D002404:Catheterization / Q000009:adverse effects*; D005260:Female; D006801:Humans; D007049:Iatrogenic Disease / Q000517:prevention & control; D010291:Paresis / Q000209:etiology; D015742:Propofol / Q000008:administration & dosage; D018084:Ultrasonography, Interventional / Q000379:methods
chemical_list: D018686:Anesthetics, Intravenous; D015742:Propofol
keywords: central venous catheter; propofol; ultrasound; vascular injury