Refractory Hypotension Despite High Dose Inotropic Support: An Unusual Cause

Central venous cannulation is common invasive procedure that is executed in operating rooms, intensive care unit’s (ICU) and wards. It is usually put in hemodynamically unstable patients or patients undergoing major surgical procedures. It is a secure venous access for infusion of inotropes, vasoactive drugs, electrolytes, fluid, central venous pressure monitoring, temporary hemodialysis, pumlonary artery cannulation or when no peripheral access can be secured. This procedure is associated with many complications including malposition (1). Thus it is important to ensure it’s proper placement. This is a report that shows a rare malpositioning of venous catheter in internal jugular vein (IJV) which resulted into a cause of refractory hypotension despite high dose inotropic support attached to it. This patient was a case of carcinoma ovary, psueudomyxoma with uterine prolapsed and was planned for cytoreductive surgery. Anaesthesia was induced by experienced anesthesiology team with peripheral venous access as per hospital protocol. After intubation, central venous cannulation was done in IJV by ultrasound (USG) guidance, blood flow was checked in all three ports and 7.5 Fr catheter was fixed at 12 cm by suturing. The duration of surgery was seven hours and patient had 3 episodes of hypotension, which was managed with fluid bolus through peripheral venous access. After the surgery, patient was shifted to ICU for further monitoring. In immediate post operative period, patient required inotropic support, but despite giving inotropes, patient’s blood pressure was not able to be maintained. Patient’s chest X-ray was done and central line was found to be turning on to itself and going in upwards direction (Figure 1A). Immediately IJV was recannulated with 7.5 Fr Anahtar Kelimeler: Santral venöz kateter, hipotansiyon, ultrason