Left-sided superior vena cava and venous hyperoxia masquerading as inadvertent carotid artery catheterization.

BACKGROUND: A persistent left-sided superior vena cava (PLSVC) is a rare, often asymptomatic, venous anomaly that may be first diagnosed during central venous catheterization. During chest radiograph interpretation, a PLSVC can be confused with inadvertent arterial catheterization. CASE REPORT: We describe the presentation of a 45-year-old man with end-stage liver disease who required central venous catheterization for treatment of septic shock. An aberrantly placed catheter noted on chest radiograph and an elevated central venous oxygen saturation gave the appearance of inadvertent carotid artery catheterization. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: A persistent left-sided superior vena cava can masquerade as an inadvertent cannulation of the carotid artery during central line placement. It is important for emergency physicians to be aware of this possibility when evaluating a chest radiograph with an aberrantly placed catheter. Venous hyperoxia may further complicate attempts to differentiate between arterial and venous catheterization in patients with septic shock. After confirmatory tests, the emergency physician should consider removal of the catheter due to potential complications.

Resource utilization and end-of-life care in a US hospital following medical emergency team-implemented do not resuscitate orders.

BACKGROUND: Medical emergency teams frequently implement do not resuscitate orders, but little is known about end-of-life care in this population. OBJECTIVE: To examine resource utilization and end-of-life care following medical emergency team-implemented do not resuscitate orders. DESIGN: Retrospective review. SETTING: Single, tertiary care center. PATIENTS: Consecutive adult inpatients requiring a medical emergency team activation over 1 year. MEASUREMENTS: Changes to code status, time spent on medical emergency team activations, frequency of palliative care consultation, discharges with hospice care. INTERVENTIONS: None. RESULTS: We observed 1156 medical emergency team activations in 998 patients. Five percent (58/1156) resulted in do not resuscitate orders. The median time spent on activations with a change in code status was longer than activations without a change (66 vs 60 minutes, P = 0.05). Patients with a medical emergency team-implemented do not resuscitate order had a higher inpatient mortality (43 vs 27%, P = 0.04) and were less likely to be discharged with hospice at the end of life than patients with a preexisting do not resuscitate order (4 vs 29%, P = 0.01). There was no difference in palliative care consultation in patients with a preexisting do not resuscitate versus medical emergency team-implemented do not resuscitate order (20% vs 12%, P = 0.39). CONCLUSIONS: Despite high mortality, patients with medical emergency team-implemented do not resuscitate orders had a relatively low utilization of end-of-life resources, including palliative care consultation and home hospice services. Coordinated care between medical emergency teams and inpatient palliative care services may help to improve end-of-life care.