The incidence and risk of central venous catheter malpositioning: a prospective cohort study in 1619 patients.
Central venous catheters are used in various hospital wards. An anterior posterior chest X-ray is usually obtained soon after cannulation can·nu·la·tion or can·nu·li·za·tion
Insertion of a cannula.
introduction of a cannula into a tubelike organ or body cavity. to assess the location of the catheter tip. This prospective clinical study was designed to determine the radiographic radiographic (rā´dēōgraf´ik),
adj relating to the process of radiography, the finished product, or its use. catheter tip position after central venous cannulation by various routes, to identify clinical problems possibly associated with the use of malpositioned catheters and to make a cost-benefit analysis of routine chest X-ray with respect to catheter malposition malposition /mal·po·si·tion/ (-pah-zish´un) abnormal or anomalous placement.
See dystopia. . A total 1619 central venous cannulations were recorded during a three-year period with respect to patient data, information about the cannulation procedures, the radiographic catheter positions and complications during clinical use. The total incidence of radiographic catheter tip malposition, defined as extrathoracic or ventricular positioning, was 3.3% (confidence interval 2.5 to 4.3%). Cannulation by the right subclavian vein was associated with the highest risk of malposition, 9.1111b, compared with 1.4% by the right internal jugular vein internal jugular vein
A vein that is a continuation of the sigmoid sinus of the dura mater and unites behind the cartilage of the first rib with the subclavian vein to form the brachiocephalic vein. . Six of the 53 malpositioned catheters were removed or adjusted. No case of malposition was associated with vascular perforation per·fo·ra·tion
1. The act of perforating or the state of being perforated.
2. An abnormal opening in a hollow organ or viscus, as one made by rupture or injury.
A hole. , local venous thrombosis or cerebral symptoms. We conclude that the radiographic incidence of central venous catheter central venous catheter
A catheter passed through a peripheral vein and ending in the thoracic vena cava; it is used to measure venous pressure or to infuse concentrated solutions. malpositioning is low and that clinical use of malpositioned catheters is associated with few complications. However, determination of the catheter position by chest X-ray should be considered when mechanical complications cannot be excluded, aspiration of venous blood is not possible, or the catheter is intended for central venous pressure central venous pressure
Abbr. CVP The pressure of the blood within the superior and inferior vena cava, depressed in circulatory shock and deficiencies of circulating blood volume, and increased with cardiac failure and congestion of monitoring, high flow use or infusion of local irritant drugs.
Key Words: catheterisation Noun 1. catheterisation - the operation of introducing a catheter into the body
surgical operation, surgical procedure, surgical process, surgery, operation - a medical procedure involving an incision with instruments; performed to repair , central venous, clinical protocols, costs, cost analysis, diagnostic tests, questionnaires, radiography, unnecessary procedures
Central venous catheters are mainly used for reliable infusion of fluids, for total parenteral nutrition Total Parenteral Nutrition Definition
Total parenteral nutrition (TPN) is a way of supplying all the nutritional needs of the body by bypassing the digestive system and dripping nutrient solution directly into a vein. , for administration of potentially irritant drugs and for assessment of systemic haemodynamics. A standard anterior-posterior chest X-ray is often obtained to assess the location of the catheter tip. The traditionally preferred position of the catheter tip is within the caudal caudal /cau·dal/ (kaw´d'l)
1. pertaining to a cauda.
2. situated more toward the cauda, or tail, than some specified reference point; toward the inferior (in humans) or posterior (in animals) end of the body. third of the superior caval vein (SCV SCV Santa Clarita Valley (California)
SCV Sons of Confederate Veterans
SCV Santa Clara Vanguard
SCV Singapore Cable Vision
SCV Special Category Visa (Australia)
SCV StarHub Cable Vision ). This position is believed to minimise the risk of complications during clinical use such as vascular perforation, local venous thrombosis, catheter dysfunction and cranial cranial /cra·ni·al/ (-al)
1. pertaining to the cranium.
2. toward the head end of the body; a synonym of superior in humans and other bipeds.
adj. retrograde injection (1).
Small- and medium-sized clinical studies have reported a 3.6 to 14% incidence of catheter malposition (defined as extrathoracic or ventricular positioning) (2-9), but to our knowledge no previous major study has thoroughly addressed this topic although catheter malposition has been claimed to be associated with mechanical complications (10-13).
This prospective clinical study was designed to determine the radiographic catheter tip positions after central venous cannulation by various routes, to identify clinical problems possibly associated with the use of malpositioned catheters and to make a cost-benefit analysis of routine chest X-ray with respect to catheter malposition.
PATIENTS AND METHODS
The study was approved by the Human Ethics Committee at the Medical Faculty, Lund University, Lund, Sweden.
All 2048 central venous cannulations made by the internal jugular jugular /jug·u·lar/ (jug´u-lar)
2. pertaining to a jugular vein.
3. a jugular vein.
adj. , external jugular or subclavian subclavian /sub·cla·vi·an/ (sub-kla´ve-an) below the clavicle.
Located beneath the collarbone (clavicle). routes at Malmo University Hospital, Lund University, Malmo, Sweden, between January 1, 2003, and December 31, 2005, were recorded prospectively in study protocols according to criteria reported below.
A total of 429 cannulations (21%) were excluded due to lack of information on the procedures (8.1%) or insufficient control chest X-ray reports (13%). Complete information was thus obtained in 1619 cannulations.
The puncture site and cannulation technique were chosen by the anaesthesiologist an·aes·the·si·ol·o·gist
Variant of anesthesiologist. according to the patient's individual needs and the catheter was introduced over a guidewire inserted percutaneously as guided by anatomical landmarks.
Information was obtained on patient age, patient gender and physician's experience of anaesthesia anaesthesia
anesthesia. and intensive care at the time of cannulation together with corresponding information on the procedure (clinical indication, hospital area and time of cannulation, puncture site, type of catheter, number of veins punctured and technical difficulty) recorded in the study protocol by the anaesthesiologist.
Clinical information on indwelling time and problems possibly associated with clinical use of malpositioned catheters (catheter dysfunction, vascular perforation, local venous thrombosis and cerebral symptoms) was recorded prospectively in study protocols by nurses in the wards and obtained retrospectively by the main investigator (AP) from patient charts.
The catheter tip positions were determined by different radiologists as part of their regular clinical work based on a routine chest X-ray in anterior-posterior supine view according to local guidelines. The junction between the SCV and right atrium was considered to be located at the intersection of the right lateral margin of the SCV (principally defining the right lateral border of the mediastinum mediastinum /me·di·as·ti·num/ (me?de-ah-sti´num) pl. mediasti´na [L.]
1. a median septum or partition.
2. ) and the superior border of the right atrium (cardiac silhouette). Routine examinations in lateral view were not made.
Possible radiographic catheter tip positions were divided according to Figure 1 into eight zones--(1) right atrium, (2) caudal third of SCV, (3) cranial two thirds of SCV or brachiocephalic brachiocephalic /bra·chio·ce·phal·ic/ (bra?ke-o-se-fal´ik) pertaining to the arm and head.
Relating to the arm and the head. veins, (4) intrathoracic part of right subclavian vein, (5) intrathoracic part of left subclavian vein, (6) right internal jugular vein, (7) left internal jugular vein and (8) other position. Radiographic malposition was defined as extrathoracic or ventricular positions of the catheter tip.
Actual charges for normal and bedside chest X-ray examinations at Mahn6 University Hospital were used to approximate, in U.S. dollars, the cost for detection of each malpositioned central venous catheter from the number of radiographic malpositions found and the total number of chest X-ray examinations carried out.
Numeric data is given as mean [+ or -] standard deviation (SD) and proportions are reported with 95% confidence intervals (CI). The modified Wald method (14) was used to calculate CI for complication ratios. Proportions were compared by Fisher's exact test or Chi square test. A P value of 0.05 or less was considered as statistically significant.
Patients The age of the patients was 61.4 [+ or -] 9.8 years at the time of cannulation and 823 (51%) were females.
Approximately half (52%) of the cannulations were made by specialists. The remaining cannulations were made by residents of anaesthesia and intensive care with less or more than two years' experience of the specialty (both 24%).
Clinical indications, hospital areas and time
The most common clinical indications for central venous cannulation were venous access (52.3%) or total parenteral nutrition (18.3%). Others were measurement of central venous pressure, administration of irritant drugs, renal replacement therapy Renal replacement therapy is a term used to encompass life-supporting treatments for renal failure.
The cannulations were carried out in operating theatres (51%), intensive care units (17%), postoperative (14%) or preoperative pre·op·er·a·tive
Preceding a surgical operation.
preceding an operation.
the preparation of a patient before operation. (13%) units, emergency departments (0.1%) or other wards (2.5%).
Three quarters (72%) of the cannulations were made during regular office hours and mainly in non-emergency situations.
[FIGURE 1 OMITTED]
The puncture site was adequately recorded and a control chest X-ray made after each cannulation. Eighty-nine percent cannulations (89%) were made from the right side. The right internal jugular vein was the most common puncture site (63%), followed by the right subclavian (18%) and right external jugular (8.0%) veins.
The type of catheter was not reported in 6.7% of the cannulations. Single-, double- or triple-lumen catheters all made of polyurethane were used in 558 (37%), 734 (49%) and 218 (14%), respectively, of the remaining 1510 cannulations. Most catheters (90%) were 20 cm or shorter. There were no pulmonary artery catheters.
One vein was punctured in 1447 cannulation procedures (89%), two veins were punctured in 155 (9.6%) and three or more veins were punctured in the remaining 17 procedures (1.1%).
Almost one fifth (17%) of the cannulations were reported as technically difficult. The right subclavian approach was significantly more often reported as technically difficult than was the right internal jugular approach (20% vs. 15%, P=0.0435), but the right subclavian vein was not significantly more often cannulated after failed attempts at other sites than was the right internal jugular vein (12% vs. 8.5%; P=0.132).
As shown in Table 1 and Figure 1, the right internal jugular or subclavian approaches were associated with a similar incidence of catheter tip positioning within the caudal third of the SCV (33% vs. 35%; P >0.300).
The incidence of atrial atrial /atri·al/ (a´tre-al) pertaining to an atrium.
Of or relating to an atrium.
Having to do with the upper chambers of the heart. placement after internal jugular cannulation was two thirds of that after subclavian cannulation (11% vs. 15%; P=0.0321). No catheter tip was positioned within the right ventricle.
The total incidence of radiographic malposition of the catheter tip was 3.3% (CI 2.5 to 4.3%) as shown in Table 2.
Malpositioning was found to be more than five times as common after subclavian cannulation than after internal jugular cannulation (8.3% vs. 1.6%; P <0.0001) and more than six times as common after cannulation by the right subclavian than by the right internal jugular vein (9.1% vs. 1.4%; P <0.0001).
There was no significant difference in the incidence of catheter malpositioning between the right and left external jugular (P >0.300), internal jugular (P=0.0762) or subclavian (P >0.300) approaches.
Radiographic malpositioning of the catheter tip was found not to be significantly associated with patient age (P >0.300) or gender (P >0.300), physician's experience of anaesthesia and intensive care (P=0.102), length >20 cm (P=0.257) or design (P >0.300) of catheter, number of punctured veins (P >0.300), time of cannulation (P >0.300) or technical difficulty (P=0.0850). Furthermore, there was no significant correlation between radiographic malposition and removal of the catheter because of catheter dysfunction (P=0.218).
The catheters were used for 8 [+ OR -] 8 days and 5.5% were removed because of catheter dysfunction.
Six of the 53 malpositioned catheters were adjusted or removed due to initial positions in small intrathoracic or cervical veins and intended administration of local irritant drugs. There were no clinical signs of vascular perforation or local venous thrombosis during clinical use in the remaining 47 malpositioned catheters (Table 2) or in those 184 catheters (11%) with atrial position, of which none was adjusted.
No cerebral symptoms were reported during clinical use for 5 [+ or -] 5 days (until adjustment or removal) in seven patients with cranially directed catheters, or in the remaining 12 patients with cranially directed catheters removed immediately after X-ray control.
[FIGURE 2 OMITTED]
The current charge at Malmo University Hospital is approximately US$117 for a normal and US$181 for a bedside chest X-ray examination. A total number of 31 chest X-ray examinations, corresponding to a total cost of approximately US$5400, were required to detect each catheter malposition.
This prospective study reports clinically relevant aspects on central venous cannulation with respect to radiographic catheter tip positioning. To our knowledge no previous study on this subject has been carried out in such detail and in so many patients.
The present study indicates that the right internal jugular approach should normally be preferred for central venous cannulation to reduce the incidence of extrathoracic positioning. Our lower incidence of catheter malposition compared with previous smaller studies (2-8) might have resulted from higher differences in statistical power and accuracy as well as from more frequent use of the right internal jugular approach in the present study. Lower incidence of malpositioning including atrial placement after internal jugular than after subclavian cannulation might have anatomical reasons but could also have resulted from more personal experience of the internal jugular approach for central venous cannulation, in agreement with recent findings (8), and from slightly more frequent, though statistically nonsignificant non·sig·nif·i·cant
1. Not significant.
2. Having, producing, or being a value obtained from a statistical test that lies within the limits for being of random occurrence. , use of the subclavian route when other routes have failed. The low total number of left internal jugular cannulations might partly explain why the right internal jugular route was associated with a lower, though not statistically significant, incidence of malpositioning (15).
Transoesophageal echocardiography Echocardiography Definition
Echocardiography is a diagnostic test that uses ultrasound waves to create an image of the heart muscle. Ultrasound waves that rebound or echo off the heart can show the size, shape, and movement of the heart's valves and has been suggested for determination of the guide wire position during central venous cannulation (16) and anaesthesiologists have been reported to be able to identify catheter malposition bedside by transthoracic transthoracic /trans·tho·rac·ic/ (-thah-ras´ik) through the thoracic cavity or across the chest wall.
Across or through the thoracic cavity or chest wall. ultrasonic evaluation (17).
The catheter tip position has also been proposed to be predictable from clinical judgements in adults, and intravascular intravascular /in·tra·vas·cu·lar/ (in?trah-vas´ku-lar) within a vessel.
Within one or more blood vessels. distances from the cannulation site to the SCV-atrial junction have been determined and reported for both the internal jugular and subclavian veins (18,19).
Radiographic catheter malposition, although subjected to methodological inaccuracy (20,21), anatomical variation (22)' and interobserver variability (22), has been proposed to be associated with vascular perforation, local venous thrombosis, catheter dysfunction and cranial retrograde injection (10-12).
The risk of vascular perforation during clinical use of modern softer catheters made of polyurethane is low (23) in agreement with our findings. Four cases of cardiac tamponade Cardiac Tamponade Definition
Cardiac tamponade occurs when the heart is squeezed by fluid that collects inside the sac that surrounds it.
The heart is surrounded by a sac called the pericardium. have been reported two to 24 hours after central venous catheterisation in patients subjected to major orthopaedic surgery (24) where the catheter tip had been either maintained in the atrium (in one patient) or repositioned into the SCV (in two patients) after initial chest X-ray control. The rapid progress of clinical symptoms in these patients suggests that the complications could have resulted from the cannulation procedures rather than from clinical use (24,25). Moreover, it cannot be excluded that the cardiac tamponade resulted from high-energetic thoracoabdominal trauma in the fourth patient (where no radiographic catheter position was reported). It has been suggested, since cardiac tamponade has been reported in patients with a radiographic catheter tip position within the cardiac silhouette (26), that the optimal tip position is within the SCV outside the pericardium pericardium: see heart. and that the carina Carina (kərē`nə) [Lat.,=the keel], southern constellation, representing the keel of the ancient constellation Argo Navis, or Ship of the Argonauts. Carina contains Canopus, the second brightest star in the sky. can be used as a landmark on a frontal chest X-ray (27). However, a catheter tip within the SCV (on a chest X-ray) may also erode the vessel and cause either mediastinal mediastinal /me·di·as·ti·nal/ (-as-ti´n'l) of or pertaining to the mediastinum.
of or pertaining to the mediastinum. haematoma Noun 1. haematoma - a localized swelling filled with blood
intumescence, intumescency - swelling up with blood or other fluids (as with congestion) , pleural Pleural
Pleural refers to the pleura or membrane that enfolds the lungs.
Mentioned in: Pneumothorax
emanating from or pertaining to the pleura. infusion or pericardial pericardial /peri·car·di·al/ (-kahr´de-al)
1. pertaining to the pericardium.
2. surrounding the heart.
pertaining to the pericardium. tamponade tamponade /tam·pon·ade/ (tam?po-nad´)
1. surgical use of a tampon.
2. pathologic compression of a part. (28). A radiographic catheter tip positon close to the carina increases the possibility of the catheter not being aligned with the long axis of the SCV, particularly after introduction from the subclavian or left jugular veins (29), thereby possibly increasing the risk of vascular perforation on long-term use (30). Most cardiac tamponades result from pericardial infusion of fluid (26), which like pleural infusion (23) could be avoided by careful aspiration of blood or (if no blood can be obtained) chest X-ray with intravenous contrast injection before clinical use. Five cases of pleural infusion were recently reported to be associated with total parenteral nutrition by polyethylene or polyurethane catheters inserted from the left side, but no radiographic tip positions were reported (23). To summarise, any central venous catheter adequately positioned within the SCV could be associated with vascular perforation (Figure 2), indicating that there is no safe or optimal catheter position and that knowledge about the radiographic position has no clinical value in these aspects. Furthermore, these complications are probably associated with the cannulation procedure rather than with short-term catheter use.
No clinical signs of venous thrombosis were found in our patients with catheter malposition, probably due to relatively short indwelling times. Symptomatic local venous thrombosis is considered to be associated with long-term catheter use, especially with tip positions within the cranial part of the SCV (31), but also within the caudal part of the SCV (32) or in the right atrium (32,33). Surface deposition of thrombotic material at the catheter tip is probably not uncommon during clinical use but has little clinical relevance in a short-term perspective as long as the catheter function is normal. It cannot be excluded that investigation by ultrasound or phlebography phlebography /phle·bog·ra·phy/ (fle-bog´rah-fe)
1. venography; angiography of a vein.
2. the graphic recording of the venous pulse.
n. in our patients with catheter dysfunction could have revealed subclinical subclinical /sub·clin·i·cal/ (sub-klin´i-k'l) without clinical manifestations.
Not manifesting characteristic clinical symptoms. Used of a disease or condition. venous thromboses.
As also found here, clinical use is not affected by moderate catheter dysfunction due to suboptimal Suboptimal
A solution is called suboptimal if a part of the solution has been optimized without regards to the overall objective. position unless high flow rates are required, e.g. during haemodialysis Noun 1. haemodialysis - dialysis of the blood to remove toxic substances or metabolic wastes from the bloodstream; used in the case of kidney failure
A cranial course of a catheter is often adjusted to avoid local venous thrombosis or retrograde cerebral injection, although these complications have never been reported in patients. Cerebral retrograde injection has even been shown to be impossible in humans (35), in agreement with the lack of cerebral symptoms during clinical use of cranially directed catheters in the present study.
Another main purpose of the study was to make a cost-benefit analysis of routine chest X-ray with respect to catheter malposition after central venous cannulation. This analysis was made without considering complications possibly associated with clinical use of malpositioned catheters or the cannulation procedure, since no specific catheter position has to our knowledge been shown to be associated with such complications during short-term catheter use.
There are two possible limitations of the study. First, it is a single-centre study, which could (although it is large) limit the generalisability. Secondly, the low incidence of malpositioning reported does not include atrial placement. The risk associated with atrial positioning of central venous catheters particularly for prolonged periods of time remains uncertain, since the absolute number of atrial placements in this study was small and the catheters were used for short periods of time.
Taking all these aspects into consideration, we conclude that the radiographic incidence of central venous catheter malpositioning is low and that clinical use of malpositioned catheters is associated with few complications. However, determination of the catheter position by chest X-ray should be considered when mechanical complications cannot be excluded, aspiration of venous blood is not possible, or the catheter is intended for central venous pressure monitoring, high flow use or infusion of local irritant drugs.
Accepted for publication on September 5, 2007.
(1.) Vesely TM. Central venous catheter tip position: a continuing controversy. J Vasc Interv Radiol2003; 14:527-534.
(2.) Padberg FT Jr, Ruggiero J, Blackburn GL, Bistrian BR. Central venous catheterization catheterization
Threading of a flexible tube (catheter) through a channel in the body to inject drugs or a contrast medium, measure and record flow and pressures, inspect structures, take samples, diagnose disorders, or clear blockages. for parenteral nutrition. Ann Surg 1981;193:264-270.
(3.) Eisenhauer ED, Derveloy RJ, Hastings PR. Prospective evaluation of central venous pressure (CVP CVP central venous pressure.
central venous pressure
central venous pressure.
CVP Central venous pressure, see there ) catheters in a large city-county hospital. Ann Surg 1982; 196:560-564.
(4.) Sitzmann JV, Townsend TR, Siler MC, Bartlett JG. Septic and technical complications of central venous catheterization. A prospective study of 200 consecutive patients. Ann Surg 1985; 202:766-770.
(5.) Mansfield PF, Holm DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Eng] J Med 1994; 331:1735-1738.
(6.) Yilmazlar A, Bilgin H, Korfali G, Eren A, Ozkan U. Complications of 1303 central venous cannulations. J R Soc Med 1997; 90:319-321.
(7.) Gladwin MT, Slonim A, Landucci DL, Gutierrez DC, Cunnion RE. Cannulation of the internal jugular vein: is postprocedural chest radiography always necessary? Crit Care Med 1999; 27:1819-1823.
(8.) Molgaard O, Nielsen MS, Handberg BB, Jensen JM, Kjaergaard J, Juul N. Routine X-ray control of upper central venous lines: Is it necessary? Acta Anaesthesiol Scand 2004; 48:685-689.
(9.) Peres PW Positioning central venous catheters-a prospective survey. Anaesth Intensive Care 1990; 18:536-539.
(10.) Ahmed N. Thrombosis after central venous cannulation. Med J Aust 1976; 1:217-220.
(11.) Thomas CS, Jr., Carter JW, Lowder SC. Pericardial tamponade from central venous catheters. Arch Surg 1969; 98:217-218.
(12.) Petersen J, Delaney JH, Brakstad MT, Rowbotham RK, Bagley CM Jr. Silicone venous access devices positioned with their tips high in the superior vena cava superior vena cava
n. Abbr. SVC
A large vein formed by the union of the two brachiocephalic veins and the azygos vein that receives blood from the head, neck, upper limbs, and chest, and empties into the right atrium of the heart. are more likely to malfunction. Am J Surg 1999; 178:38-41.
(13.) Webster CS, Merry AF, Emmens DJ, Van Cotthem IC, Holland RL. A prospective clinical audit of central venous catheter use and complications in 1000 consecutive patients. Anaesth Intensive Care 2003; 31:80-86.
(14.) Agresti A, Coull BA. Approximate is better than "exact" for interval estimation of binomial binomial (bī'nō`mēəl), polynomial expression (see polynomial) containing two terms, for example, x+y. The binomial theorem, or binomial formula, gives the expansion of the nth power of a binomial (x+ proportions. American Statistician 1998; 52:119-126.
(15.) Muralidhar K Left internal versus right internal jugular vein access to central venous circulation using the Seldinger technique. J Cardiothorac Vasc Anesth 1995; 9:115-116.
(16.) Sawchuk C, Fayad A. Confirmation of internal jugular guide wire position utilizing transesophageal echocardiography. Can J Anaesth 2001; 48:688-690.
(17.) Maury E, Guglielminotti J, Alzieu M, Guidet B, Offenstadt G. Ultrasonic examination: an alternative to chest radiography after central venous catheter insertion? Am J Respir Crit Care Med 2001; 164:403-405.
(18.) Andrews RT, Bova DA, Venbrux AC. How much guidewire is too much? Direct measurement of the distance from subclavian and internal jugular vein access sites to the superior vena vena /ve·na/ (ve´nah) pl. ve´nae [L.] vein.
v. ca´va infe´rior inferior vena cava: the venous trunk for the lower extremities and the pelvic and abdominal viscera; it begins at the cavaatrial junction during central venous catheter placement. Crit Care Med 2000; 28:138-142.
(19.) Chalkiadis GA, Goucke CR. Depth of central venous catheter insertion in adults: an audit and assessment of a technique to improve tip position. Anaesth Intensive Care 1998; 26:61-66.
(20.) Nazarian GK, Bjarnason H, Dietz CA Jr, Bernadas CA, Hunter DW Changes in tunneled catheter tip position when a patient is upright. J Vasc Interv Radiol1997; 8:437-441.
(21.) Kowalski CM, Kaufman JA, Rivitz SM, Geller SC, Waltman AC. Migration of central venous catheters: implications for initial catheter tip positioning. J Vasc Interv Radiol 1997; 8:443447.
(22.) Aslamy Z, Dewald CL, Heffner JE. MRI 1. (application) MRI - Magnetic Resonance Imaging.
2. MRI - Measurement Requirements and Interface. of central venous anatomy: implications for central venous catheter insertion. Chest 1998; 114:820-826.
(23.) Walshe C, Phelan D, Bourke J, Buggy D. Vascular erosion by central venous catheters used for total parenteral nutrition. Intensive Care Med 2007; 33:534-537.
(24.) Kalen V, Medige TA, Rinsky LA. Pericardial tamponade secondary to perforation by central venous catheters in orthopaedic patients. J Bone Joint Surg Am 1991; 73:1503-1506.
(25.) Robinson JF, Robinson WA, Cohn A, Garg K, Armstrong JD 2nd. Perforation of the great vessels during central venous line placement. Arch Intern Med 1995; 155:1225-1228.
(26.) Collier PE, Goodman GB. Cardiac tamponade caused by central venous catheter perforation of the heart: a preventable complication. J Am Coll Surg 1995; 181:459-463.
(27.) Albrecht K, Nave H, Breitmeier D, Panning B, Troger HD. Applied anatomy of the superior vena cava-the carina as a landmark to guide central venous catheter placement. Br J Anaesth 2004; 92:75-77.
(28.) Ellis LM, Vogel SB, Copeland EM 3rd. Central venous catheter vascular erosions. Diagnosis and clinical course. Ann Surg 1989;209:475-478.
(29.) Fletcher SJ, Bodenham AR. Safe placement of central venous catheters: where should the tip of the catheter lie? Br J Anaesth 2000; 85:188-191.
(30.) Duntley P, Siever J, Korwes ML, Harpel K, Heffner JE. Vascular erosion by central venous catheters. Clinical features and outcome. Chest 1992; 101:1633-1638.
31.) Caers J, Fontaine C, Vinh-Hung V, De Mey J, Ponnet G, Oost C et al. Catheter tip position as a risk factor for thrombosis associated with the use of subcutaneous infusion ports. Support Care Cancer 2005; 13:325-331.
(32.) Gilon D, Schechter D, Rein AJ, Gimmon Z, Or R, Rozenman Y et al. Right atrial thrombi thrombi /throm·bi/ (throm´bi) plural of thrombus. are related to indwelling central venous catheter position: insights into time course and possible mechanism of formation. Am Heart J 1998; 135:457-462.
(33.) Ghani MK, Boccalandro F, Denktas AE, Barasch E. Right atrial thrombus thrombus /throm·bus/ (throm´bus) pl. throm´bi a stationary blood clot along the wall of a blood vessel, frequently causing vascular obstruction. formation associated with central venous catheters utilization in hemodialysis patients. Intensive Care Med 2003;29:1829-1832.
(34.) Jean G, Chazot C, Vanel T, Charra B, Terrat JC, Calemard E et al. Central venous catheters for haemodialysis: looking for optimal blood flow. Nephrol Dial Transplant 1997; 12:16891691.
(35.) Engstrom M, Ramgren B, Romper B, Reinstrup E Should central venous catheters, with the tip accidentally placed retrograde in the internal jugular vein, be corrected. Acta Anaesthesiol Scand 2001; 45:653-654.
A. PIKWER *, L. BAATH ([dagger]), B. DAVIDSON ([double dagger]), I. PERSTOFT ([section]), J. AYESON **
Departments of Anaesthesiology an·aes·the·si·ol·o·gy
Variant of anesthesiology.
the branch of medical science that studies anesthesia and anesthetics. and Intensive Care Medicine, and of Diagnostic Radiology, Lund University, Malmo University Hospital, Malmo, Sweden
* M.D., Resident Anaesthesiologist, Department of Anaesthesiology and Intensive Care Medicine.
[dagger] M.D., Ph.D., Consultant Radiologist, Department of Diagnostic Radiology.
[double dagger] M.D., Consultant Anaesthesiologist, Department of Anaesthesiology and Intensive Care Medicine.
[section] Nurse Anesthetist and IT Technician, Department of Anaesthesiology and Intensive Care Medicine.
** M.D., Ph.D., Associate Professor and Consultant Anaesthesiologist, Department of Anaesthesiology and Intensive Care Medicine.
Address for reprints: Dr A. Pikwer, Department of Anaesthesiology and Intensive Care Medicine, Lund University, Malmo University Hospital, SE-205 02 Malmo, Sweden.
TABLE 1 Puncture sites and corresponding radiographic catheter tip positions of central venous catheters inserted at Malmo University Hospital during the three-year study period 2003 to 2005 Puncture site (%) Radiographic catheter tip positions (%) with 95% confidence intervals within region 1 2 3 4 UV 1127 (70) 123 (11) 356 (32) 615 (55) 11 (1.0) 9.2-13 29-34 52-58 0.5-1.8 right 1023 (63) 118 (12) 334 (33) 543 (53) 10 (1.0) 9.7-14 30-36 50-56 0.5-1.8 left 104 (6.4) 5 (4.8) 22 (21) 72 (69) 1 (1.0) 1.8-11 14-30 60-77 0-5.8 SV 324 (20) 50 (15) 114 (35) 127 (39) 3 (0.9) 12-20 30-40 34-45 0.2-2.8 right 287 (18) 47 (16) 100 (35) 109 (38) 2 (0.7) 12-21 30-40 33-44 0-2.7 left 37 (2.3) 3 (8.1) 14 (38) 18 (49) 1 (2.7) 2.1-22 24-54 34-64 0-15 EJV 168 (10) 11 (6.5) 58 (34) 90 (54) 1 (0.6) 3.8-12 28-42 46-61 0-3.6 right 130 (8.0) 9 (6.9) 52 (40) 63 (48) 1 (0.8) 3.5-13 32-49 40-57 0-4.7 left 38 (2.3) 2 (5.3) 6 (16) 27 (71) 0 (0.0) 0.5-18 7.1-31 55-83 0-11 Total 1619 (100) 184 (11) 528 (33) 832 (51) 15 (0.9) 9.9-13 30-35 49-54 0.6-1.5 Puncture site (%) Radiographic catheter tip positions (%) with 95% confidence intervals within region 5 6 7 8 UV 1127 (70) 4 (0.4) 4 (0.4) 1 (0.1) 13 (1.2) 0.1-0.9 0.1-0.9 0-0.6 0.7-2.0 right 1023 (63) 4 (0.4) 4 (0.4) 0 (0) 10 (1.0) 0.1-1.0 0.1-1.0 0-0.5 0.5-1.8 left 104 (6.4) 0 (0.0) 0 (0) 1 (1.0) 3 (2.9) 0-4.3 0-4.3 0-5.8 0.6-8.5 SV 324 (20) 3 (0.9) 5 (1.5) 3 (0.9) 19 (5.9) 0.2-2.8 0.6-3.7 0.2-2.8 3.7-9.0 right 287 (18) 3 (1.0) 5 (1.7) 2 (0.7) 19 (6.6) 0.2-3.2 0.6-4.1 0-2.7 4.2-10 left 37 (2.3) 0 (0) 0 (0) 1 (2.7) 0 (0) 0-11 0-11 0-15 0-11 EJV 168 (10) 0 (0) 1 (0.6) 2 (1.2) 5 (3.0) 0-2.7 0-3.6 0.1-4.5 1.1-7.0 right 130 (8.0) 0 (0) 1 (0.8) 2 (1.5) 2 (1.5) 0-3.5 0-4.7 0.1-5.8 0.1-5.8 left 38 (2.3) 0 (0) 0 (0) 0 (0) 3 (7.9) 0-11 0-11 0-11 2.0-22 Total 1619 (100) 7 (0.4) 10 (0.6) 6 (0.4) 37 (2.3) 0.2-0.9 0.3-1.2 0.2-0.8 1.7-3.1 IJV=internal jugular vein, SV=subclavian vein, EJV=external jugular vein, 1=right atrium, 2=caudal third of superior caval vein, 3=cranial two thirds of superior caval or brachiocephalic vein, 4=intrathoracic part of right SV, 5=intrathoracic part of left SV, 6=right UV, 7=left IJV, 8=other position. TABLE 2 Central venous catheter malposition (defined as extrathoracic or ventricular radiographic catheter tip positions) and reported multiple or difficult punctures (in numbers and percent of catheters introduced from that site) at Malmo University Hospital during the three-year study period 2003 to 2005 Puncture site Malposition >1 punctured vein n % CI n % CI Internal jugular vein, right 14 1.4 0.8-2.3 87 8.5 6.9-10 Internal jugular vein, left 4 3.8 1.2-9.8 21 20 14-29 Subclavian vein, right 26 9.1 6.2-13 33 12 8.3-16 Subclavian vein, left 1 2.7 0-15 3 8.1 2.1-22 External jugular vein, right 5 3.8 1.4-8.9 18 14 8.9-21 External jugular vein, left 3 7.9 2.0-22 7 18 8.9-34 All 53 3.3 2.5-4.3 169 10 9.0-12 Puncture site Difficult puncture n % CI Internal jugular vein, right 149 15 12-17 Internal jugular vein, left 31 30 22-39 Subclavian vein, right 56 20 15-24 Subclavian vein, left 7 19 9.2-34 External jugular vein, right 12 9.2 5.2-16 External jugular vein, left 6 16 7.1-31 All 261 16 14-18 CI=95% confidence interval, n=number of catheters.