Case 327 Medical history A 2 year-old male patient with short bowel syndrome is in the late postoperative period (7 weeks) of a extensive enterectomy. After several unsuccessful peripheral venous access insertions attempts and previous venous thrombosis, he went under a central venous access puncture (right femoral vein), guided by ultrasonography (US), in which great difficulty in the guidewire navigation was observed. After 48 hours, the patient was tearful, feverish (38,7°C) and with abdominal distension, without nausea or vomiting. Plain abdominal radiography and abdominal computed tomography were requested. Image 1: Plain abdominal radiography, anteroposterior view, in a supine position.Image 2: Non-contrast-enhanced abdominal computed tomography, axial view, at the sacroiliac joint level.Image 3: Non-contrast-enhanced abdominal computed tomography, coronal reconstruction of the right hemiabdomen. Question:Considering the clinical history of the patient and the provided images, what is the most likely diagnosis? Bowel obstruction. Anomalous position of central venous catheter. Abdominal-wall abscess. Encysted ascites. Test Question (SUS – PE 2015. Direct Access)Comparing the central venous puncture sites used in the clinical practice, it is CORRECT to affirm that The infection rate related to the catheter is similar in the puncture of the subclavian vein or the femoral vein. Therefore, the choice between both puncture sites is indifferent. In general, the complications rate is similar between the puncture of the subclavian and the internal jugular veins. While in the subclavian there is a higher risk of pneumothorax or hemothorax, in the internal jugular there is a higher risk of arterial puncture and hematoma. The accidental arterial puncture rate, the hematomas and the venous thrombosis associated to the catheter are lower in the femoral accesses. The central venous access in the subclavian vein must be avoided due to the higher rate of mechanical and infectious complications among all the central accesses. All the central puncture sites have reasonable rate of infection after a few of days. Therefore, catheters and puncture sites must be exchanged routinely, every 10-14 days, if there is still a need for central venous access. Time is Up! Time's up
