|LETTER TO EDITOR
|Year : 2015 | Volume
| Issue : 2 | Page : 173-174
Wrongly placed central venous catheter
Monish S Raut, Arun Maheshwari
Department of Cardiac Anesthesia, Dharam Vira Heart Center, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi, India
|Date of Web Publication||16-Mar-2015|
Monish S Raut
Department of Cardiac Anesthesia, Dharam Vira Heart Center, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Raut MS, Maheshwari A. Wrongly placed central venous catheter. CHRISMED J Health Res 2015;2:173-4
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].
The reported incidences of malpositioning of CVC ranges from <1% to >60%.  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. ,, 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. 
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.  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  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.  Keeping the J-tip of the guidewire directed downwards can decrease the incidence of misplacement of CVC.  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.
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