Case study examines vascular access choice prior to ICU admission

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.


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?

Published by IV Team April 15, 2019

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