A 64-year-old woman is brought to the emergency department due to fever, chills, flank pain, and lethargy for the past 2 days. Temperature is 38.9 C (102 F), blood pressure is 100/60 mm Hg, and pulse is 120/min. The patient has right costovertebral angle tenderness. Leukocytes are 16,000/mm³ and urinalysis shows pyuria, many bacteria, and positive nitrites. ECG shows sinus tachycardia. A central venous catheter placement is planned for intravenous therapy and hemodynamic monitoring. After the patient's chest is appropriately prepared and draped, a needle is inserted just lateral to the angle of the left clavicle and a triple lumen catheter is placed into the left subclavian vein. Each lumen is flushed with sterile saline after obtaining blood return. The catheter is sutured in place to the skin and a sterile dressing is applied. Which of the following is the best next step in management of this patient?

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A central venous catheter (CVC) is commonly used for the administration of critical care medications (eg, pressors, hypertonic saline) and in the setting of difficult vascular access or need for long-term medication (eg, chemotherapy). The preferred points of central venous access are the internal jugular vein (typically by ultrasound guidance) or the subclavian vein (typically by anatomic landmark guidance). CVC complications occur in up to 15% of cases, and many are due to inappropriate catheter placement. The ideal placement of a CVC tip is in the lower superior vena cava. Tip placement in smaller veins (eg, subclavian, jugular, azygous) predisposes to venous perforation. In addition, inappropriately placed catheter tips may cause lung puncture, leading to pneumothorax, or myocardial perforation, leading to pericardial tamponade. Arterial (eg, subclavian) puncture is also a risk, particularly in the absence of ultrasound guidance. Confirmatory chest x-ray may be omitted in the setting of an uncomplicated (eg, first needle insertion, no resistance to catheter advancement) ultrasound-guided CVC placement. Otherwise, a portable chest x-ray should be performed immediately following CVC placement to facilitate timely recognition of a misplaced catheter tip, identify possible injury (eg, pneumothorax), and prevent exacerbation of injury (eg, infusion of fluid into the pericardial space). Visualization of the catheter tip just proximal to the angle between the trachea and right mainstem bronchus confirms appropriate placement. (Choices A and C) In this patient, catheter tip location should be confirmed prior to the administration of medications (eg, antibiotics) or fluids. (Choice B) Bedside echocardiography may determine the position of a CVC tip and detect a pneumothorax but only if performed by an experienced operator. Chest x-ray is the standard of care as it is more practical and reliable. (Choice E) A CVC may trigger cardiac arrhythmias if inserted too far into the right atrium. Patients in critical care settings are typically on continuous telemetry that will detect cardiac arrhythmia. In the absence of continuous telemetry, patients should be monitored for hemodynamic instability (eg, tachycardia, hypotension) during and after catheter placement, but routine ECG is not indicated. Educational objective: Complications due to inappropriate central venous catheter placement are common. With the exception of select cases, appropriate catheter tip placement should be confirmed by chest x-ray prior to catheter use. References: Aberrant locations and complications in initial placement of subclavian vein catheters. (http://www.ncbi.nlm.nih.gov/pubmed/6696623) Incidence of mechanical complications of central venous catheterization using landmark technique: do not try more than 3 times. (http://www.ncbi.nlm.nih.gov/pubmed/24988896)

A 64-Year-Old Woman Is Brought to the Emergency Department Due