Death following removal of a misplaced central venous catheter

Abstract

We report the case of a misplaced central venous catheter into the pleural cavity despite the use of ultrasound to aid insertion into the left internal jugular vein. The patient was taking dabigatran for management of embolic complications secondary to atrial fibrillation. Misplacement was undiagnosed despite imaging, and eventually led to severe intrapleural haemorrhage on removal of the line, subsequently leading to death.