Lee Allan, Lau Kenneth, Stuckey Stephen
Department of Diagnostic Imaging, Monash Health, Clayton, Victoria, Australia.
BMJ Case Rep. 2014 Apr 10;2014:bcr2014204540. doi: 10.1136/bcr-2014-204540.
A 40-year-old male patient had his right femoral vein catheterised following admission with altered conscious state from polypharmacy overdose. The procedure was documented as successful and uncomplicated. A postprocedural chest radiograph demonstrated a linear metallic opacity projecting over the superior vena cava and inferior vena cava (SVC and IVC, respectively), with superior and inferior ends not visualised. This did not alert the attending radiologist and intensivist who might have assumed such a metallic object to be external to the patient. Only the central line was removed prior to patient discharge 2 days later. The patient died 2 years later from unrelated streptococcal pneumonia complicated by septicaemia and multiorgan failure. The postmortem discovered a central venous guidewire in the IVC across the right atrium into SVC.
一名40岁男性患者因多种药物过量导致意识状态改变入院后，其右股静脉接受了置管。该操作记录为成功且无并发症。术后胸部X光片显示一条线性金属不透光区分别投影在上腔静脉和下腔静脉（分别为SVC和IVC）上，上下两端未显影。这并未引起主治放射科医生和重症监护医生的警觉，他们可能认为这样一个金属物体在患者体外。两天后患者出院前仅拔除了中心静脉导管。患者两年后死于无关的链球菌肺炎，并发败血症和多器官功能衰竭。尸检发现下腔静脉有一根中心静脉导丝穿过右心房进入上腔静脉。
