P017: NAVIGATING CENTRAL LINE PLACEMENT CHALLENGES IN A SEVERE BURN PATIENT WITH HIGH BMI AND UNSTABLE CERVICAL SPINE INJURY
Shayla McMahon, DO; Tyler Chonis, MD
HCA Kendall Hospital
Introduction: Central venous access is critical for the management of critically ill burn patients, facilitating fluid resuscitation, medication administration, and hemodynamic monitoring. However, patients with severe burns, morbid obesity, and an unstable cervical spine present significant challenges for central line placement. This case highlights the technical difficulties encountered and the strategies employed to successfully obtain central venous access in a patient with extensive burns, a nonfunctional PICC catheter, and restricted positioning due to cervical spine fractures.
Methods: The patient was a middle-aged male with extensive burns, a BMI of 60, and an unstable cervical spine injury requiring central venous access. The right internal jugular (IJ) vein was identified as the most viable option due to severe burns limiting alternative access sites and venous thrombosis restricting femoral access. However, initial ultrasound visualization revealed anatomic challenges, including the carotid artery directly in line with the IJ vein, compounded by the patient’s body habitus and inability to reposition the neck due to spinal precautions. Improved visualization was achieved with manual displacement of the neck’s adipose tissue by a surgical resident.
During the procedure, difficulty arose in threading the guidewire despite successful needle cannulation under ultrasound guidance. Further ultrasound assessment revealed that the pre-existing, partially removed PICC catheter was obstructing the passage of the wire. To resolve this, the PICC catheter was removed under real-time ultrasound guidance, allowing for successful advancement of the guidewire and placement of the central line.
Results: By optimizing ultrasound techniques, including adjusting probe positioning and depth settings, the right IJ vein was successfully accessed despite anatomic and technical difficulties. The use of real-time ultrasound guidance facilitated the safe removal of the obstructing PICC catheter, ultimately enabling successful central line placement. Procedural sedation was administered to prevent movement, and spinal precautions were maintained with a sterile cervical collar. The line was placed without complications such as arterial puncture, hematoma, or pneumothorax, and post-procedural imaging confirmed appropriate catheter positioning.
Discussion: This case illustrates the complex interplay of anatomic, technical, and procedural challenges encountered in central line placement for patients with severe burns, morbid obesity, and cervical spine instability. Key strategies for success included advanced ultrasound techniques, collaborative efforts from a multidisciplinary team, and intra-procedural problem-solving to address unexpected obstacles. The identification of the PICC catheter as a mechanical barrier to guidewire passage underscores the importance of dynamic ultrasound assessment throughout the procedure. Alternative access sites were considered but carried higher risks given the patient’s condition. This case highlights the need for adaptability, procedural expertise, and a team-based approach in managing difficult vascular access scenarios.