An unusual position of a Swan-Ganz catheter

Pericardial placement of a pulmonary artery catheter

Extravascular placement of a pulmonary artery catheter occurred when it was passed down an in situ sheath, the side arm of which had already been used for administration of fluids without any problems. The case emphasises that complications occur with the use of invasive monitoring and a correctly placed line may become extravascular even in a short time.