Challenges in Central Venous Catheter Placement in a Patient With Recurrent Diabetic Ketoacidosis and Kussmaul Breathing

Document Type

Conference Proceeding

Publication Date

10-2025

Publication Title

Chest

Abstract

INTRODUCTION: Diabetic ketoacidosis (DKA) is a potentially life-threatening condition commonly encountered in patients with insulin-dependent type 1 diabetes. Severe episodes may necessitate invasive management strategies such as central venous catheter (CVC) placement for fluid and electrolyte resuscitation. This case report discusses a 24-year-old female with a history of insulin-dependent type 1 diabetes who presented with severe DKA and recurrent issues related to CVC placement, highlighting the role of respiratory physiology, specifically Kussmaul breathing and its associated increase in intrathoracic pressure, in contributing to CVC malpositioning. CASE PRESENTATION: A 24-year-old female with type 1 diabetes presented to the emergency department with nausea, vomiting, and altered mental status. Initial workup revealed a serum glucose of 619 mg/dL and severe metabolic acidosis, confirming DKA. She was started on the GluCommander DKA protocol and intravenous fluids (IVF). Due to the need for reliable venous access for resuscitation, ultrasound-guided central venous catheter placement was attempted. The first attempt was made in the left internal jugular vein (LIJ) as patient has external Internal Jugular catheter in right internal jugular vein; however, after two unsuccessful attempts due to the catheter advancing into the left axillary vein, the decision was made to place a right femoral vein catheter, which was successful. The patient clinically improved with resolution of his symptoms and was discharged home on an adjusted insulin dosage one week later. This same situation mirrored a previous event during a prior admission one month earlier when an ultrasound-guided CVC was placed in the right internal jugular vein (RIJ) but was found to terminate in the right axillary vein, confirmed by post procedure chest X-ray (CXR). No immediate complications were observed, and the line was promptly removed and repositioned in the RIJ. A follow-up CXR confirmed proper placement. DISCUSSION: This case illustrates the challenges associated with CVC placement in patients with recurrent DKA, particularly when rapid fluctuations in intrathoracic pressure induced by Kussmaul breathing, may contribute to malpositioning. Kussmaul breathing, characterized by deep, rapid respirations, increases central venous pressure, which can distort the venous return and lead to unintended catheter placement into low-pressure veins such as axillary veins instead of the superior vena cava. In this patient, the malpositioning occurred in both the left and right jugular venous access attempts. This suggests that the dynamic changes in venous return during the Kussmaul breathing cycle may significantly influence catheter placement. A technique to minimize this risk involves advancing the guidewire during inspiration, which is associated with increased venous return and reduced intrathoracic pressure. CONCLUSIONS: This case highlights the importance of understanding the physiological changes that accompany DKA, such as Kussmaul breathing, which can affect CVC placement. Proper technique, including advancing the guidewire during inspiration to take advantage of reduced intrathoracic pressure, can help minimize the risk of malpositioning. While anatomical variations may contribute, dynamic changes in venous pressures appear to be a key factor in the recurrent malpositioning of the CVC in this case. Ensuring optimal placement techniques and careful monitoring are essential for reducing complications and improving patient outcomes in DKA management.

Volume

168

Issue

4S

First Page

6058A

Last Page

6059A

Comments

American College of Chest Physicians CHEST Annual Meeting, October 19-22, 2025, Chicago, IL

DOI

10.1016/j.chest.2025.07.3394

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