A 2-year-old girl with acute myelogenous leukemia and thrombocytopenia (platelet count 26,000 per microliter) with marked generalized petechiae and bruising was scheduled for implantation of a central venous catheter with a subcutaneous port. After reviewing the patient’s electronic health records but without seeing the patient, who was in another hospital, the anesthetist asked the surgeon to order a platelet transfusion to increase the child’s platelet count to above 50,000 per microliter. The patient was transported to the operating room while still receiving the platelet transfusion, so a follow-up platelet count had not yet been obtained.

After induction of general anesthesia, the assistant surgeon tried 10 times to cannulate either subclavian vein without using ultrasound guidance. He finally succeeded in cannulating the left subclavian vein and, after fluoroscopically confirming that the tip of the catheter was in the lower half of the superior vena cava, he closed the wound. The patient...

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