Case study examines vascular access choice prior to ICU admission

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The decision is made to initiate central venous access and admit the patient to the intensive care unit (ICU). He has one 18-gauge peripheral intravenous catheter in place, with other good peripheral targets available. What is the best choice of central venous access for this patient?” Govindan and Simpson (2019).

Extract:

A 60-year-old man with a history of diabetes, hyperlipidemia, and prostate cancer is seen in the emergency department for 5 days of fever and purulent sputum. Vital signs are temperature 39.1o C, heart rate 110 beats/min, respiratory rate 22 breaths/min, SpO2 91% on 3 L/min of oxygen, and blood pressure 70/30 mm Hg. Serum lactate is 5 mmol/L. A chest radiograph shows a right lower lobe infiltrate. Bedside ultrasonography finds a hyperdynamic left ventricle and inferior vena cava variation. Cultures are obtained, antibiotics are initiated, and the patient receives 30 mL/kg of intravenous fluids. His heart rate subsequently decreases to 100 beats/min, and SpO2 is 96% on 3 L/min of oxygen; however, blood pressure remains low at 80/40 mm Hg. Repeated measurement of serum lactate is 4 mmol/L. The decision is made to initiate central venous access and admit the patient to the intensive care unit (ICU). He has one 18-gauge peripheral intravenous catheter in place, with other good peripheral targets available. What is the best choice of central venous access for this patient?

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Reference:

Govindan, S. and Simpson, S.Q. (2019) Annals for Hospitalists Inpatient Notes – Choosing a Central Line in the ICU—What’s New and What’s True? Annals of Internal Medicine. 170(6), p.HO2-HO3. DOI: 10.7326/M19-0447.

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