Authors: Karakosta P. MD, Aslanidis Th. MD, PhD
Intensive Care Unit, St. Paul General Hospital, Thessaloniki, Greece
Central venous catheters (CVC) are an extremely usefull tool in clinical medicine. Yet, its placement and use is not without complication. In the present paper, a case report of Central venous catheter malposition is presented.
Insertion of a (central venous catheter) CVC using the Seldinger technique has revolutionized medicine1. However, numerous complications are associated with central venous catheter placement: from failure to place the catheter to arrhythmia and cardiac arrest2. We present a case report of CVC malposition in a critically ill patient.
A 35 year old male with history of drug abuse, Chronic Hepatitis C infection, Chronic Mycobacterium tuberculosis infection, Epilepsy was admitted intubated in the Intensive Care Unit for acute respiratory failure following a respiratory infection. A CVC is inserted in right subclavian vein on his admission. In his 9th day of hospitalisation , a programmed change of CVC was performed. Posterior approach to left jugular vein without imaging guidance was used for venous access without problems. Before removing the old CVC an coaxial X-Ray (CXR) exam was conducted , which reveal malposition of the new CVC into left axillary vein (Figure 1a and 1b). Eventhough the new CVC was functioning, a new change was performed a day after without problems.
Rate utilisation of CVCs in ICU patients range from 13 to 91%3. Reported frequency of misplacement during insertion without image guidance ranges from 3.3% to 6.2%4. Methodological innaccuracy, anatomical variation and inter-operator avriability. Insertion via left jugular vein is reported to have the highest frequency (12%), followed by right subclavian (9.3%), left subclavian (7.3%) and right internal jugular (4.3%)5. Frequency of accidental azygos vein cannulation during venous access through internal jugular vein is 0.7-1.2%6, yet in general data about the miplsplacement site frequency are scarce. With very few exceptions, the recommendation cases of intravascular CVC misplacement is to remove and relocate the catheter. Leaving the catheter in situ is related to high frequency of complications such as vesel perforation or thrombosis7.Proper selection of the vessel, insertion technique (preferably with ultrasound guidance) and control postprocedural imaging is essential for minizing the possibilty of misplacement.
- Higgs ZC, Macafee DA, Braithwaite BD, Maxwell-Armstrong CA. The Seldinger technique: 50 years on. Lancet 2005; 366:1407.
- Eisen LA, Narasimhan M, Berger JS, et al. Mechanical complications of central venous catheters. J Intensive Care Med 2006; 21:40.
- Gershengorn HB, Garland A, Kramer A, Scales DC, Rubenfeld G, Wunsch H. Variation of arterial and central venous catheter use in United States intensive care units. Anesthesiology. 2014; 120(3):650-664.
- Poldermann KJ, Girbes AJ. Central venous catheter use Part 1: mechanical complication. Intensive Care Med 20002;28:1-7
- Schummer W, Schummer C, Rose N, Niesen WD, Sakka SG. Mechanical complications and malpositions of central venous cannulations by experienced operators. A prospective study of 1794 catheterisation in critically ill patients. Intensive Care Med 2007;33:1055-1059
- Wang L, Liou ZS, Wang CA. Malposition of Central venous catheter: Presentation and management. Chin Med J 2016;129:227-234.
- Roldan CJ, Paniagua L.Central Venous Catheter Intravascular malpositioning: Causes. Prevention and Correction. West J Emerg Med 2015; 16(5):658-664.
Authors Karakosta P., Aslanidis Th. have no conflicts of interest or financial ties to disclose.
Adress: 3 Viopoulou str , PC 55132, Thessaloniki,Greece.