PDF(Pubmed)
Abstract：
BACKGROUND: Central venous catheters (CVCs) often cause life-threatening complications, especially CVC-related bloodstream infection (CVC-BSI) and catheter-related thrombosis (CRT). Here, we report an unusual case of misplaced CVC-induced emphysematous thrombophlebitis, a rare but potentially lethal form of CRT and CVC-BSI characterized by both thrombosis and gas formation.
METHODS: A 48-year-old male presented to the emergency room of a local hospital with sudden-onset headache and coma for 4 h. Computed tomography (CT) revealed right basal ganglia hemorrhage, so emergency decompressive craniotomy was performed and a CVC was inserted through the right subclavian vein for fluid resuscitation during anesthesia. Two days later, the patient was transferred to the intensive care unit of our hospital for further critical care. On day 9 after CVC insertion, the patient suddenly developed fever and hypotension. Point-of-care ultrasound (POCUS) demonstrated thrombosis and dilatation of the right internal jugular vein (IJV) filled with thrombosis. Ultrasonography also revealed that the CVC tip had been misplaced into the IJV and was surrounded by gas bubbles, which manifested as hyperechoic lines with dirty shadowing and comet-tail artifacts. Further CT scan confirmed air bubbles surrounding the CVC in the right neck. The final diagnosis was septic emphysematous thrombophlebitis induced by a misplaced CVC and ensuing septic shock. The responsible CVC was removed immediately. The patient received fluid resuscitation, intravenous noradrenaline, and a 10-d ultra-broad spectrum antibiotic treatment to combat septic shock. Both CVC and peripheral venous blood cultures yielded methicillin-resistant Staphylococcus cohnii. The patient was gradually weaned off vasopressors and the symptoms of redness and swelling in the right neck subsided within 7 d.
CONCLUSIONS: Emphysematous thrombophlebitis is a fulminant and life-threatening CVC-BSI associated with thrombosis and gas formation in the vein. A misplaced CVC may facilitate the development of emphysematous thrombophlebitis. POCUS can easily identify the artifacts produced by gas and thrombosis, facilitating rapid diagnosis at the bedside.
METHODS: A 48-year-old male presented to the emergency room of a local hospital with sudden-onset headache and coma for 4 h. Computed tomography (CT) revealed right basal ganglia hemorrhage, so emergency decompressive craniotomy was performed and a CVC was inserted through the right subclavian vein for fluid resuscitation during anesthesia. Two days later, the patient was transferred to the intensive care unit of our hospital for further critical care. On day 9 after CVC insertion, the patient suddenly developed fever and hypotension. Point-of-care ultrasound (POCUS) demonstrated thrombosis and dilatation of the right internal jugular vein (IJV) filled with thrombosis. Ultrasonography also revealed that the CVC tip had been misplaced into the IJV and was surrounded by gas bubbles, which manifested as hyperechoic lines with dirty shadowing and comet-tail artifacts. Further CT scan confirmed air bubbles surrounding the CVC in the right neck. The final diagnosis was septic emphysematous thrombophlebitis induced by a misplaced CVC and ensuing septic shock. The responsible CVC was removed immediately. The patient received fluid resuscitation, intravenous noradrenaline, and a 10-d ultra-broad spectrum antibiotic treatment to combat septic shock. Both CVC and peripheral venous blood cultures yielded methicillin-resistant Staphylococcus cohnii. The patient was gradually weaned off vasopressors and the symptoms of redness and swelling in the right neck subsided within 7 d.
CONCLUSIONS: Emphysematous thrombophlebitis is a fulminant and life-threatening CVC-BSI associated with thrombosis and gas formation in the vein. A misplaced CVC may facilitate the development of emphysematous thrombophlebitis. POCUS can easily identify the artifacts produced by gas and thrombosis, facilitating rapid diagnosis at the bedside.
摘要：
背景：中心静脉导管（CVC）通常会引起危及生命的并发症，尤其是CVC相关性血流感染（CVC-BSI）和导管相关性血栓形成（CRT）。这里,我们报告了一例CVC引起的气肿性血栓性静脉炎，一种罕见但可能致命的CRT和CVC-BSI形式，其特征是血栓形成和气体形成。
方法：一名48岁男性因突发性头痛昏迷4小时到当地医院急诊室就诊。计算机断层扫描（CT）显示右侧基底节出血，因此，在麻醉期间进行了紧急减压开颅手术，并通过右锁骨下静脉插入CVC进行液体复苏。两天后,患者被转移到我们医院的重症监护室接受进一步的重症监护。CVC插入后第9天,患者突然出现发热和低血压。护理点超声（POCUS）显示右颈内静脉（IJV）充满血栓形成和扩张。超声检查还显示，CVC尖端被误置到IJV中，并被气泡包围，表现为高回声线，带有肮脏的阴影和彗星尾伪影。进一步的CT扫描证实右侧颈部的CVC周围有气泡。最终诊断为由错位的CVC引起的脓毒性气肿性血栓性静脉炎，并随后发生脓毒性休克。立即移除负责的CVC。病人接受了液体复苏,静脉注射去甲肾上腺素,和10天的超广谱抗生素治疗以对抗感染性休克。CVC和外周静脉血培养均产生耐甲氧西林的cohnii葡萄球菌。患者逐渐脱离血管加压药，右侧颈部红肿症状在7d内消退。
结论：气肿性血栓性静脉炎是一种与静脉血栓形成和气体形成相关的暴发性和危及生命的CVC-BSI。错位的CVC可能会促进肺气肿性血栓性静脉炎的发展。POCUS可以很容易地识别气体和血栓形成产生的伪影，有利于在床边快速诊断。
方法：一名48岁男性因突发性头痛昏迷4小时到当地医院急诊室就诊。计算机断层扫描（CT）显示右侧基底节出血，因此，在麻醉期间进行了紧急减压开颅手术，并通过右锁骨下静脉插入CVC进行液体复苏。两天后,患者被转移到我们医院的重症监护室接受进一步的重症监护。CVC插入后第9天,患者突然出现发热和低血压。护理点超声（POCUS）显示右颈内静脉（IJV）充满血栓形成和扩张。超声检查还显示，CVC尖端被误置到IJV中，并被气泡包围，表现为高回声线，带有肮脏的阴影和彗星尾伪影。进一步的CT扫描证实右侧颈部的CVC周围有气泡。最终诊断为由错位的CVC引起的脓毒性气肿性血栓性静脉炎，并随后发生脓毒性休克。立即移除负责的CVC。病人接受了液体复苏,静脉注射去甲肾上腺素,和10天的超广谱抗生素治疗以对抗感染性休克。CVC和外周静脉血培养均产生耐甲氧西林的cohnii葡萄球菌。患者逐渐脱离血管加压药，右侧颈部红肿症状在7d内消退。
结论：气肿性血栓性静脉炎是一种与静脉血栓形成和气体形成相关的暴发性和危及生命的CVC-BSI。错位的CVC可能会促进肺气肿性血栓性静脉炎的发展。POCUS可以很容易地识别气体和血栓形成产生的伪影，有利于在床边快速诊断。
