Central Venous Catheter Intravascular Malpositioning: Causes, Prevention, Diagnosis, and Correction

The case for using implanted ports

Uses of central venous access devices (CVADs) include the administration of vital fluids and medications. Implanted ports are a type of CVAD that is used when long-term vascular access is required. The device is discreet and associated with a low risk of catheter-related bloodstream infection. This article describes the different types and components of ports and how to select them. It explains how to insert ports, and provides guidance on accessing and de-accessing them

Point-of-care ultrasound evaluation and puncture simulation of the internal jugular vein by medical students

Objectives

To show that medical students can evaluate the internal jugular vein (IJV) and its anatomical variations after rapid and focused training. We also aimed to evaluate the success rate of IJV puncture in simulation following traditional techniques (TTs) and monitored via ultrasound (US).

Materials and methods

Six medical students without experience with US were given 4 h of theoretical–practical training in US, and then evaluated the IJV and common carotid artery (CCA) of 105 patients. They also simulated a puncture of the IJV at a demarcated point, where a TT was theoretically performed.

Results

Adequate images were obtained from 95% of the patients; the IJV, on the right side, was more commonly found in the anterolateral position in relation to the CCA (38%). On the left side, the most commonly position observed was the anterior (36%). The caliber of the IJV relative to the CCA greatly varied. The success rate in the IJV puncture simulation, observed with US, by the TTs was 55%.

Conclusion

The training of medical students to recognize large neck vessels is a simple, quick, and feasible task and that can be integrated into the undergraduate medical curriculum.

Bedside ultrasound diagnosis of a malpositioned central venous catheter: A case report

RATIONALE

Central venous catheter (CVC) placement is commonly performed in intensive care unit. And CVC placement is associated with risks including CVC malposition, pneumothorax. Many of the previously reported cases are about catheter misplacement detected by bedside ultrasound, chest x-ray (CXR) and computed tomography. In this case, malposition was detected by bedside ultrasound incidentally particularly with no clinical manifestation.

PATIENT CONCERNS

An 88-year-old male with severe diabetic peripheral neuropathy secondary to type 2 diabetes mellitus was admitted for further treatment.

DIAGNOSES

We cannulated a single-lumen CVC via the right subclavian vein, and the tip ended up in the internal jugular vein on the same side. With bedside ultrasound, we discovered the malposition though it was mistaken by aspiration of venous blood. Later, CXR revealed malposition of the tip once again.

INTERVENTIONS

Since the patient was asymptomatic and the catheter was functioning normally, the catheter was used for the following 20 days without complications. Ultimately, we carefully performed the catheter removal.

OUTCOMES

After the inserted catheter was removed, we attempted a new CVC through the left internal jugular vein. After the procedure, bedside ultrasound and CXR confirmed the correct position of CVC. Following successful replacement of the central catheter, no further complications were observed.

LESSONS

Bedside ultrasound offers safety and effectiveness during insertion of CVC. It also exhibits promptness and accuracy compared to post-intervention radiological imaging.

Electrocardiography-controlled central venous catheter tip positioning in patients with atrial fibrillation

INTRODUCTION:

A significant increase of the p-wave of a real-time intracavitary electrocardiography is a reliable and safe method to confirm the central venous catheter tip position close to the atrium. However, conflicting data about the feasibility of electrocardiography exist in patients with atrial fibrillation.

METHODS:

An observational prospective case-control cohort study was set up to study the feasibility and accuracy of the electrocardiography-controlled central venous catheter tip placement in 13 patients with atrial fibrillation versus 10 patients with sinus rhythm scheduled for elective surgery. Each intervention was crosschecked with ultrasound-guided positioning via right supraclavicular fossa view and chest radiography. Ultrasound-guided supraclavicular venipuncture of the right subclavian vein and guidewire advancement were performed. A B-mode view of the superior vena cava and the right pulmonary artery was obtained to visualize the J-tip of the guidewire. The central venous catheter was advanced over the guidewire and the electrocardiography was derived from the J-tip of the guidewire protruding from the central venous catheter tip. Electrocardiography was read for increased p- and atrial fibrillation waves, respectively, and insertion depth was compared with the ultrasound method.

RESULTS:

Electrocardiography indicated significantly increasing fibrillation and p-waves, respectively, in all patients and ultrasound-guided central venous catheter positioning confirmed a tip position within the lower third of the superior vena cava.

CONCLUSION:

Electrocardiography-guided central venous catheter tip positioning is a feasible real-time method for patients with atrial fibrillation. Combined with ultrasound, the electrocardiography-controlled central venous catheter placement may eliminate the need for postinterventional radiation exposure.

Central Venous Catheter Placement in the Left Internal Jugular Vein Complicated by Perforation of the Left Brachiocephalic Vein and Massive Hemothorax: A Case Report

An elderly male presented for emergent repair of a ruptured abdominal aortic aneurysm. For anticipated volume resuscitation, vasopressor administration, and hemodynamic monitoring, a large-bore central venous catheter was placed in the left internal jugular vein under ultrasound guidance before surgical incision. Initially, there were no readily apparent signs of venous perforation. However, a massive left hemothorax developed because of perforation of the brachiocephalic vein and violation of the pleural space. This case report discusses both prevention and management of such a complication.

Delayed Migration and Perforation of the Jugular Vein by a Peripherally Inserted Central Catheter

We report a case of peripherally inserted central catheter (PICC) migration and perforation of the left internal jugular vein in a home health setting in an 80-year-old female. A left sided PICC was placed for treatment of diverticulitis following hospital discharge. She complained of sudden onset left sided neck pain immediately after starting an infusion of vancomycin. In the emergency department the injury was identified by portable chest radiograph and computed tomography of her neck. Following removal of the line, she had an uneventful course. Emergency physicians should be aware of this possible PICC line complication.

The malposition of a central venous catheter through a sheath introducer via the left internal jugular vein: A case report

RATIONALE

The misplacement of central venous catheter (CVC) can occur more often at the left jugular vein than the right side due to anatomic differences. And many of the previously reported cases are about catheter misplacement resulting from vessel penetration associated with guidewire. This case differs that the catheter itself through the sheath introducer can cause venous injury that may lead to the malposition of CVC particularly through an approach to the left internal jugular vein.

PATIENT CONCERNS, DIAGNOSIS, INTERVENTIONS, AND OUTCOMES

We cannulated a large-bore CVC with a sheath introducer, namely mult-lumen access catheter (MAC) in the left jugular vein of patient under anesthesia using ultrasound and inserted the additional central venous oximetry catheter through the sheath introducer of MAC and confirmed aspiration of blood. However, the postoperative imaging study revealed malposition of the tip of the oximetry catheter in the mediastinum.

MAIN LESSON

The insertion of additional catheter through the sheath introducer needs to be carried out as carefully as the insertion of guidewire and should be confirmed with imaging study after the procedure.

Repositioning of Central Venous Access Devices using a High-Flow Flush Technique - a Clinical Practice and Cost Review

Background

Malpositioned central venous access device (CVAD) tip locations can cause significant mechanical and chemical vessel-related injuries and complications if left in inappropriate positions. The aim of this study is to determine the use of a high-flow flush technique (HFFT) in successful correction of malpositioned catheters into the lower superior vena cava or cavoatrial junction and provide a cost comparison to interventional/fluoroscopic-based repositioning.

Methods

This is a retrospective chart and radiographic review of all inserted CVADs found malpositioned between 1996-2014 in a multi-specialty 1000-bed tertiary trauma center in Sydney, Australia. 7450 CVADs placed by a nurse-led vascular access service were reviewed. Catheters repositioned pre-2010 were excluded owing to radiology repositioning interventions.

Results

There were 3996 peripherally inserted central catheters (PICCs) and 3454 centrally inserted central catheters (CICCs) placed. Seventy-four were malpositioned post-2010. Of these, 53 devices were repositioned using the studied technique; 86% (46/53) of catheters were successfully repositioned on the first HFFT attempt. There was supportive evidence that device insertion side is important in potential catheter malposition.

Conclusions

Clinical outcomes suggest that CICCs and PICCs may be successfully repositioned utilizing this technique, with no adverse events associated and a prospective cost saving benefit when compared to interventional-based repositioning procedures.

Inferior Petrosal Sinus Thrombosis in a Child due to Malposition of Central Venous Catheter: A Case Report

OBJECTIVE

To report a case of inferior petrosal sinus thrombosis associated with malposition of central venous catheterization (CVC).

CLINICAL PRESENTATION AND INTERVENTION

A 5-month-old boy was admitted to Şifa University Hospital because of pneumonia. When exophthalmos occurred in the right eye, he was referred to Ege University Hospital. Cranial magnetic resonance imaging and magnetic resonance venography confirmed that the catheter in the right inferior petrosal sinus caused the thrombosis. The catheter was extracted and anticoagulant treatment was started.

CONCLUSION

In this case report, malpositioning of the CVC was the cause of the thrombosis. To minimize such complications, catheterization should be done with the supervision of an expert and postprocedure radiography should also be performed.

Exam 3 Questions

Which of thefollowing is true regarding the Barrow classification system for carotid cavernous fistulae?A.

Type A shunts are indirect shunts between branches of the internal carotid artery (ICA) and cavernous sinus

B.

Type B shunts are direct shunts between the ICA and cavernous sinus

C.

Type C shunts are indirect shunts between branches of the external carotid artery (ECA) and cavernous sinus

D.

Type D shunts are high-flow shunts

E.

All of the above

A 80-year-old male with an intracranial neoplasm presents to the emergency department with weight loss, drowsiness, and tachypnea for 1 month. On examination, his respiratory rate is 28 breaths/minute with a normal oxygen saturation. His lungs are clear to auscultation. An arterial blood gas reveals the following: pH 7.60, PCO₂ 14 mmHg, PaO₂ 115 mmHg. A chest x-ray, bedside echocardiogram, and EKG are all unremarkable. No other pulmonary, metabolic, or pharmacologic etiologies for the breathing pattern are found. What is the most likely diagnosis?A.

Central neurogenic hyperventilation

B.

Cheyne-Stokes respirations

C.

Apneustic breathing

D.

Ataxic breathing

E.

Cluster breathing

A 48-year-old female is admitted to the ICU with a Hunt-Hess 2 modified Fisher 2 subarachnoid hemorrhage (SAH). She remains intact neuro-cognitively, but has transcranial doppler (TCD) mean flow velocities up to 150 cm/s, and a serum platelet count twice her baseline. You are worried about vasospasm and impending delayed cerebral ischemia. Which of the following should be performed next?A.

An additional 100 mL/h of normal saline should be given on top of maintenance fluids

B.

CT perfusion scan to assess for any ongoing hypoperfusion

C.

Evaluate volume status with hemodynamic monitoring and give fluid boluses accordingly

D.

Induce hypertension to a systolic pressure of 160 mmHg

E.

Conventional angiography

A 25-year-old male is currently in the ICU with an anoxic brain injury after diving into shallow waters and suffering a high cervical cord transection. Two weeks after his injury, he remains comatose, has diffuse loss of gray-white differentiation on noncontrast head CT, and exhibits myoclonic status epilepticus. The family is devastated by his poor prognosis, and distraught by his uncontrollable shaking. What is your rationale behind your decision about starting an antiepileptic regimen?A.

Phenytoin and propofol will be used, and escalated until eradication of his myoclonus to assess his underlying brain damage

B.

Levetiracetam and lacosamide will be used, and escalated until eradication of his myoclonus to assess his underlying brain damage

C.

If EEG reveals dyssynchronous spikes on a severely slow background, myoclonus invariably portends death or a vegetative state, and midazolam should only be used for palliative purposes

D.

Regardless of EEG or clinical exam, half of patients in myoclonic status epilepticus will have a good neurologic recovery by 90 days

E.

Regardless of EEG or clinical exam, myoclonic status epilepticus is always ominous, not amenable to treatment. and should lead to immediate withdrawal of life-support

An 18-year-old female presents to the emergency department with several months of progressive left-sided hearing loss and tinnitus. An MRI of the brain is performed, demonstrating bilateral enhancing dumbbell shaped lesions extending from the auditory canal to the cerebellopontine angle. Which of the following genetic disorders is associated with this finding?A.

Von Hippel-Lindau syndrome

B.

Neurofibromatosis type II

C.

Tuberous sclerosis

D.

Schwannomatosis

E.

Alport syndrome

A 23-year-old female is brought to the emergency department by her boyfriend with difficulty breathing. She cannot provide her history, but her boyfriend states that she has asthma, although he is unsure of her medications. On physical exam the woman is noted to have nasal flaring, is diaphoretic, cannot lie flat, and is breathing at a rate of 40 breaths/minute. She is given short acting ß₂ agonist treatments with no obvious relief of her symptoms. Serial arterial blood gases are done and show a pCO₂ that has increased from 25 to 40. What is the next best step in the patient’s management?A.

Continue short-acting ß₂ agonist treatment, as her pCO₂ is normalizing, and continue observation in the emergency department

B.

Intubate the patient and admit to the ICU

C.

Administer intravenous corticosteroids and admit to the general medical ward

D.

Place the patient on non-invasive positive pressure ventilation and admit to the general medical ward

E.

Administer a long-acting ß₂ agonist agent and admit to the general medical ward

Cerebellar hypoplasia without displacement through the foramen magnum is best described as a:A.

Chiari I malformation

B.

Chiari II malformation

C.

Chiari III malformation

D.

Chiari IV malformation

E.

Chiari V malformation

A 77-year-old female with a history of hypertension, atrial fibrillation, and diabetes mellitus has recently been taken off of warfarin due to frequent falls and gait instability. She has not had any prior significant bleeding or ischemic events. A recent echocardiogram demonstrates moderate aortic regurgitation with grossly preserved systolic and diastolic function. Which of the following elements is not a stroke risk factor in this patient?A.

Age

B.

Female gender

C.

Hypertension

D.

Diabetes mellitus

E.

Aortic regurgitation

Which of the following is the most effective measure to prevent aspiration in an intubated patient?A.

Elevation of the head of the bed

B.

Subglottic drainage

C.

Gastric volume monitoring

D.

Nasogastric tube placement

E.

Percutaneous endoscopic gastrotomy

Which of the following is a unique feature of Comprehensive Stroke Centers?A.

Dedicated stroke unit availability

B.

24/7 ability to administer tPA

C.

24/7 interventional neuroradiology availability

D.

24/7 CT angiography availability

E.

Ambulance receiving capability

Which of the following segments of the internal carotid artery is farthest from it’s origin?A.

Ophthalmic segment

B.

Petrous segment

C.

Cavernous segment

D.

Clinoid segment

E.

Lacerum segment

A 44-year-old male is intubated secondary to a high-grade subarachnoid hemorrhage, and is admitted to the ICU. On the sixth postoperative day, he develops worsening hypoxemia and bilateral interstitial infiltrates on his chest x-ray, consistent with acute respiratory distress syndrome (ARDS). Which of the following interventions has not been demonstrated to improve outcomes in ARDS in a prospective randomized trial?A.

Prone positioning

B.

Lung-protective ventilation

C.

Extracorporeal membrane oxygenation (ECMO)

D.

Neuromuscular blocking agents

E.

High-frequency oscillatory ventilation (HFOV)

A 56-year-old female is currently intubated in the ICU following a left basal ganglia hemorrhage. The nurse reports the patient is having copious thick secretions, and you are considering initiating inhaled N-acetylcysteine therapy. What element of the patient’s past medical history may serve as a relative contraindication to this treatment?A.

Amiodarine-induced pulmonary fibrosis

B.

Newly diagnosed metastatic adenocarcinoma of the lung

C.

Recent course of outpatient antibiotics for community-acquired pneumonia

D.

Poorly controlled asthma

E.

All of the above

An 18-year-old female is currently being evaluated for amenorrhea. In addition, she endorses fatigue, cold intolerance, polyuria and dizziness upon standing. On examination, she is thin but appears well hydrated. Blood pressure and heart rate when supine are 90/60 mmHg and 80 beats/minute, respectively. When standing, they are 60/40 mmHg and 120 beats/minute, respectively. Pubic and axillary hair growth is sparse. Eye examination reveals an asymmetric bitemporal hemianopsia. Imaging reveals a cystic, calcified suprasellar mass. Which of the following statements is true regarding the most likely diagnosis?A.

Medical management is the mainstay of treatment

B.

Recovery of pituitary function is common

C.

This patient likely has the papillary subtype of this neoplasm

D.

This neoplasm has a bimodal age distribution

E.

This neoplasm arises from modified glial cells that reside in the infundibular neurohypophysis

A 55-year-old female presents to the emergency department after collapsing at home. The patient was arguing with her husband before she suddenly became unresponsive. The patient is intubated, and a non-contrast head CT is performed (see Image 1). The patient then undergoes conventional angiography, revealing occlusion of the proximal bilateral middle cerebral and anterior cerebral arteries with extensive collateral vessels noted. All of the following are true regarding the most likely diagnosis except:A.

The disease can be either congenital or acquired

B.

Patients may suffer recurrent infarcts, or remain completely asymptomatic

C.

There are no effective surgical interventions available

D.

It is more commonly seen in women than in men

E.

Patients may initially present with persistent headaches