Case Archive
 
Gastroenterology, Vascular Surgery
Ref. #316301

A 30-year-old woman with a 10-year history of Crohn's disease was admitted to the hospital for rectal bleeding, diarrhea and mid-abdominal pain three weeks post-partum. Stool studies revealed Clostridium dificile infection and a colonoscopy revealed pancolitis. Two days later a central line catheter was placed into the patient's right internal jugular vein for the administration of IV fluids and steroids. She experienced nausea and vomiting during the next four days and underwent upper endoscopy, which revealed gastritis and ulcerations of the stomach and duodenum. During the next 10 days the patient developed headaches and bilateral heel pain, which was more severe in the left foot. Vascular studies were ordered. A repeat upper endoscopy showed esophagitis. The pre-op exam revealed mottled skin of both feet, left more than right. The patient was started on subcutaneous heparin. During the next two days, an echocardiogram was negative for cardiac thrombus and a dermatology consult noted no evidence that skin change was related to infection. An epidural line was placed for anesthesia and possible vasilodilatory effects for the severe left foot progression. The next day a new left subclavian Central Venous Pressure (CVP) line was placed. Rheumatology noted the commencement of antibiotics. A CT scan was noted to have multiple nodular opacities of both lung bases. Two days later blood cultures were positive for gram positive cocci in clusters. Vancomycin and gentamicin are started. A Transesophageal Echocardiogram (TEE) revealed Superior Vena Cava (SVC) thrombus. Infectious Diseases was consulted for the first time the next day and notes sustained coag negative staph bacteremia likely secondary to infected CVC, possible infected SVC. A repeat TEE with "bubble" study was negative for patent foramen ovale or valvular abnormalities. The newer subclavian central line was discontinued. For three more days the patient had no improvement of her lower left extremities and was transferred to a major medical center. She was noted to have dry gangrene of her left foot status post paradoxical emboli. One month later she underwent a transmetatarsal amputation of the left foot. A medQuest gastroenterologist reported the patient's attending gastroenterologist and resident deviated from the standard of care by failing to change the central venous line for 24 days-well beyond the standard. The evidence of an ischemic left foot necessitated pulling the line immediately but when blood cultures were noted to be positive another day passed before the replacement. There was a repeated failure for the second line, which was not replaced for four days. This failure caused the patient's SVC thrombus, which led to the complications including septic emboli to the chest, brain and leg. Furthermore, the patient's relatively immuno-compromised state secondary to treatment with high-dosage steroids and her hypercoaguable state seen in Crohn's disease constituted risk factors that should have called for more diligence regarding the CVP line and a more expeditious search for the thromboembolic and/or septic changes that were noted. A medQuest vascular surgeon also reported the excessively prolonged placement of the right internal jugular central venous catheter constituted negligence and directly resulted in thrombosis of the catheter with secondary infection and also septic bilateral pulmonary emboli. The physicians at the first hospital suspected yet had no evidence of embolic phenomenon in the feet due to a right-to-left communication in the heart. The patient underwent life-threatening complications that were entirely avoidable. She suffers from long-term disabilities, all of which result from her sub-standard care.




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