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 Table of Contents  
LETTER TO EDITOR
Year : 2015  |  Volume : 2  |  Issue : 2  |  Page : 173-174

Wrongly placed central venous catheter


Department of Cardiac Anesthesia, Dharam Vira Heart Center, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi, India

Date of Web Publication16-Mar-2015

Correspondence Address:
Monish S Raut
Department of Cardiac Anesthesia, Dharam Vira Heart Center, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-3334.153270

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How to cite this article:
Raut MS, Maheshwari A. Wrongly placed central venous catheter. CHRISMED J Health Res 2015;2:173-4

How to cite this URL:
Raut MS, Maheshwari A. Wrongly placed central venous catheter. CHRISMED J Health Res [serial online] 2015 [cited 2019 Oct 21];2:173-4. Available from: http://www.cjhr.org/text.asp?2015/2/2/173/153270

Sir,

A 65-year-old woman presented with acute coronary syndrome with left ventricular failure and respiratory distress. Patient was intubated and central venous catheter (CVC) was inserted by right subclavian vein cannulation using anatomical landmarks. After observing free aspiration flow in syringe attached to the puncture needle, guide wire was inserted smoothly and without any resistance. CVC was rolled over the guide wire, guide wire was removed. Back flow in all three lumens was good, however chest X-ray revealed course of CVC from right subclavian vein to right internal jugular vein (IJV) [Figure 1].
Figure 1: Misplaced central venous catheter in internal jugular vein

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The reported incidences of malpositioning of CVC ranges from <1% to >60%. [1] During subclavian vein catheterization, sites of misplacement of the catheter can be into the ipsilateral IJV, azygous vein, left internal mammary vein, lateral thoracic vein, hemiazygos vein, inferior thyroid vein, left superior intercostal vein, thymic vein, pleural cavity, and the jugular foramen. [2],[3],[4] Malposition of the catheter tip raises the risk of clot formation, thrombophlebitis, catheter erosion and erroneous CV pressure (CVP) measurement. CVC placement in a small-caliber vessel can result in an inaccurate readings and not suitable for parenteral nutrition. [5]

Chest radiography confirms the position of CVC tip. Ambesh et al. suggested the IJV occlusion test (applying external pressure on the IJV for approximately 10 s in the supraclavicular area) and observing the changes in the CVP and its waveform pattern can be useful in detecting misplacement of a subclavian vein catheter into the IJV. However, it does not detect any other misplacement. [3] Manual compression of the ipsilateral IJV during subclavian vein cannulation decreased the chances of advancement of the CVC into the ipsilateral IJV. Excessive length of guidewire [4] is considered as risk factor. Tripathi et al. suggested initial orientations of the J-type guidewire tip during the subclavian approach can influence the final position of the catheter tip. [6] Keeping the J-tip of the guidewire directed downwards can decrease the incidence of misplacement of CVC. [7] Insertion with the help of Doppler ultrasound or C-arm imaging will minimize the complication and help in proper placement of catheter. Reinsertion of the catheter is not without potential complication and there is also the possibility of repeating the malposition.

In the present case, J-tip of the guide wire was directed upwards while inserting. This might be the reason for the guide wire entering IJV instead of superior vena cava and CVC followed the course. While doing subclavian cannulation, it is essential to have proper orientation of guidewire for proper placement of CVC. Whenever, possible ultrasound or C-arm imaging would be useful. It is important to confirm correct placement of a CVC by using radiological imaging as CVP reading in such malpositioned catheter can be erroneous and misleading.

 
  References Top

1.
Malatinský J, Kadlic T, Májek M, Sámel M. Misplacement and loop formation of central venous catheters. Acta Anaesthesiol Scand 1976;20:237-47.  Back to cited text no. 1
    
2.
Currarino G. Migration of jugular or subclavian venous catheters into inferior tributaries of the brachiocephalic veins or into the azygos vein, with possible complications. Pediatr Radiol 1996;26:439-49.  Back to cited text no. 2
    
3.
Ambesh SP, Pandey JC, Dubey PK. Internal jugular vein occlusion test for rapid diagnosis of misplaced subclavian vein catheter into the internal jugular vein. Anesthesiology 2001;95:1377-9.  Back to cited text no. 3
    
4.
Tsai YS, Huang JK, Cheng SJ, Fan YK. Malposition of a central venous catheter causing intracranial septic thrombophlebitis. Chin J Radiol 2006;31:109-13.  Back to cited text no. 4
    
5.
Hofmann-Preiss K, Becker A, Sailer S. Radiologic and clinical follow-up of central venous indwelling catheters in home parenteral nutrition. Infusionstherapie 1991;18:292-5.  Back to cited text no. 5
    
6.
Tripathi M, Dubey PK, Ambesh SP. Direction of the J-tip of the guidewire, in seldinger technique, is a significant factor in misplacement of subclavian vein catheter: A randomized, controlled study. Anesth Analg 2005;100:21-4.  Back to cited text no. 6
    
7.
D′souza N, Gupta B, Sawhney C, Chaturvedi A. Misdirected central venous catheter. J Emerg Trauma Shock 2010;3:209-10.  Back to cited text no. 7
    


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