just when you think you know all....

We had this 60+ y/o uremic patient few days ago...He had been hemodialysed for a few years. He was also a known case of Diabtes mellitus and recieving control with insulin. Few weeks ago, a small wound over his left hand was noted and he had been doing routine dressing in our hosptial. His wound had worsen and he was admitted later. On D2 of admission, his BP crushed and gangrenous change was noted over his left hand extending toward his forearm. I was just about to go off by 11:50am, and the orthopedic surgeon called me and asked me if I could put in a central line for him... I tried and failed over 2 site - the rt int jug and rt femoral. As he was going to OT urgently for an amputation - he was sent into OT stat after 2 trial. I got the vein but was unable to introduce the guide wire during my trial. The guidewire went in half way and could not advanced. I seldom came across such condition - femoral vein and internal jugular vein are both big vessel - I cant explain such condition.... The patient went into arrest in the OT while waiting for his amputation, he was intubated and resuscitated after few minutes of CPR. He recieved an Below elbow amputation and sent into ICU for care. The CVP was inserted by the anesthesiologist.... The next day, he was planned for hemodialysis and as his AV shunt was done over his left upperarm, he was unable to used his AV shunt - a double lumen catheter was needed. Our nephrologist needed to put in a double lumen catheter - he had chosen the rt femoral vein approach which I had failed 1 days ago. He tried and met the same problem. Twice he had got the vein but just unable to introduce the guide wire. He than requested a heparin + NS in an 20cc syringe and flushed the venocath before he introduce the guide wire for the 3rd time - well, he succeeded - he told me the vein is ok but due to coagulopathy, sometimes the clot will formed instantly when the guide wire was introduced...so heparin would do the trick.... Although I had done so many central line - I learnt something that day...