부산대학교 도서관

Introduction: Most often, cannulation of the right internal jugular vein (IJV) is preferred over the left IJV. However, in situations where the right IJV cannot be utilized for accessing the central circulation, as in our case, the left IJV is used. Cannulation of left IJV has additional risks due to the anatomical variations. Despite the use of ultrasound guidance, anatomical variations and tortuous course of the left IJV make cannulation of the left IJV more prone to the failure of cannulation or malposition of the cannula leading to catastrophic complications. Case Report: A 63-year-old female with multiple comorbidities presented with progressive shortness of breath and mild respiratory distress due to bibasilar pneumonia. Despite aggressive management of her pneumonia, she continued to deteriorate and became increasingly hypoxemic, hypotensive with abnormal renal functions necessitating medical intensive care treatment and continuous hemodialysis. As she had a chemo-port in her right subclavian vein, it was determined to avoid insertion of the dialysis catheter in her right IJV. An attempt was made to insert the catheter in her left IJV under ultrasound guidance. The catheter was inserted without any perceived resistance. Blood withdrawn from the ports was however, bright red, and gas analysis revealed arterial blood values. A bed side X-ray revealed that the catheter was in the heart. Conclusion: This is the first reported case where the tip of the cannula was in the left atrium. Despite the use of ultrasound guidance, the anatomical variations and the tortuous course of the left internal jugular vein make its cannulation more prone to failure or malposition of the cannula leading sometimes to catastrophic complications. This case reinforces studies which have shown that even with ultrasound guidance, left internal jugular vein cannulation is fraught with higher risk of complications.