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Žarskus A, Zykutė D, Lukoševičius S, Jankauskas A, Trepenaitis D, Macas A. Precise Terminology and Specified Catheter Insertion Length in Ultrasound-Guided Infraclavicular Central Vein Catheterization. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:28. [PMID: 38256289 PMCID: PMC10820046 DOI: 10.3390/medicina60010028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/17/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: As the latest research encourages the ultrasound-guided infraclavicular central venous approach, due to the lateral puncture site displacement, in comparison to the anatomical landmark technique based on subclavian vein catheterization, the need to re-calculate the optimal catheter insertion length and possibly to rename the punctuated vessel emerges. Although naming a particular anatomical structure is a nomenclature issue, a suboptimal catheter position can be associated with multiple life-threatening complications and must be avoided. The main study objective is to determine the optimal catheter insertion length by the most proximal ultrasound-guided, in-plane infraclavicular central vein approach, to compare results with the anatomical landmark technique based on subclavian vein catheterization and to clarify the punctuated anatomical structure. Materials and Methods: 109 patients were enrolled in this study. All procedures were performed according to the same catheterization protocol. In order to determine optimal insertion length, chest X-ray scans with an existing catheter were performed. The definition of punctuated vessel was based on computer tomography and evaluated by radiologists. Independent predictors for optimal insertion length were identified, prediction equations were generated. Results: The optimal catheter insertion length is approximately 1.5 cm longer than estimated by Pere's formula and can be accurately calculated based on anthropometric data. Computed tomography revealed: five cases with subclavian vein puncture and three cases with axillary vein puncture. Conclusions: Even the most proximal ultrasound-guided infraclavicular central vein access does not guarantee subclavian vein catheterization. A more accurate term could be infraclavicular central venous access, with the implication that the entry point could be through either subclavian or axillary veins. The optimal insertion length is approximately 1.5 cm deeper than the length determined for the anatomical landmark technique based on subclavian vein catheterization.
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Affiliation(s)
- Ainius Žarskus
- Department of Anesthesiology, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Dalia Zykutė
- Department of Anesthesiology, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Saulius Lukoševičius
- Department of Radiology, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Antanas Jankauskas
- Department of Radiology, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Darius Trepenaitis
- Department of Anesthesiology, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
| | - Andrius Macas
- Department of Anesthesiology, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania
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Liu S, Jiang L, Wang X. Intelligent Internet of Things Medical Technology in Implantable Intravenous Infusion Port in Children with Malignant Tumors. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:8936820. [PMID: 34876968 PMCID: PMC8645386 DOI: 10.1155/2021/8936820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/18/2021] [Accepted: 10/25/2021] [Indexed: 11/17/2022]
Abstract
Due to the recent technological revolution that is centered around information technology, the Internet of Medical Things (IoMT) has become an important research domain. IoMT is a combination of Internet of Things (IoT), big data, cloud computing, ubiquitous network, and three-dimensional holographic technology, which is used to build a smart medical diagnosis and treatment system. Additionally, this system should automate various activities, such as the patient's health record and health monitoring, which is an important issue in the development of modern and smart healthcare system. In this paper, we have thoroughly examined the role of a smart healthcare system architecture and other key supporting technologies in improving the health status of both indoor and outdoor patients. The proposed system has the capacity to investigate and predict (if feasible) the clinical application and nursing effects of totally implantable intravenous port (TIVAP) in pediatric hematological tumors. For this purpose, seventy children with hematologic tumors were treated with TIVAP, and IoMT-enabled care was provided to them, where the occurrence of adverse events, specifically after the treatment, was observed. The experimental results collected after the 70 children were treated and cared for by TIVAP show that there were five cases of adverse events, whereas the incidence rate of the adverse events was 7.14%. Moreover, TIVAP has significant efficacy in the treatment of hematologic tumors in children, and it equally reduces the vascular injury caused by chemotherapy in younger patients. Likewise, targeted care reduces the incidence of adverse events in children with expected ratio.
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Affiliation(s)
- Shaohong Liu
- Department of Pediatric Surgery, Hunan Children's Hospital, Changsha 410007, China
| | - Luxing Jiang
- Department of Pediatric Surgery, Hunan Children's Hospital, Changsha 410007, China
| | - Xin Wang
- Department of Pediatric Surgery, Hunan Children's Hospital, Changsha 410007, China
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Yang S, Kong X, Liu L, Xu Y, Zhang J. Application of transesophageal echocardiography for localization in totally implantable venous access port implantation through subclavian approach in children. Clin Cardiol 2020; 44:129-135. [PMID: 33241579 PMCID: PMC7803355 DOI: 10.1002/clc.23518] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 11/03/2020] [Accepted: 11/10/2020] [Indexed: 11/18/2022] Open
Abstract
A totally implantable venous access port (TIVAP) is important in children who need intravenous infusion for a long time. A number of studies have shown methods for locating the tip of the TIVAP catheter. To explore whether transesophageal echocardiography (TEE) can be used to accurately locate the TIVAP catheter tip through a subclavian approach and to improve the rate of correct TIVAP catheter placement and reduce complications of TIVAP placement. In 36 children who needed TIVAP implantation surgery, we used real‐time TEE guidance to place the catheter tip around the crista terminalis. In all children, chest X‐rays were used to figure out whether the catheter tip as localized by TEE was within the T5‐T7 segment. Then, we compared the length of the catheter calculated by the height formula and the actual catheter length applied under TEE guidance. The medical records, surgical details, nursing records, and recorded complications were collected during the follow‐up. The success rate of TIVAP implantation was 100% in all enrolled patients and no hemopneumothorax or pinch‐off syndrome occurred. Compared with TEE, chest X‐ray showed a coincidence rate of 80.56% in correctly detecting the TIVAP catheter tip locate. The height‐derived catheter length (11.0 [9.6, 11.8]) cm and the TEE‐derived catheter length (10.0 [9.3, 10.8]) cm were significantly different (p < .001). TEE can be used to guide TIVAP catheter positioning through a left subclavian approach in children accurately and successfully and more accurate than chest X‐ray and height calculation formula.
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Affiliation(s)
- Shujun Yang
- Department of Anesthesiology, Chongqing Medical University Affiliated Children's Hospital, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,China International Science and Technology Cooperation Base of Child development and Critical Disorders, Chongqing, China.,Childrens Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xiangru Kong
- Department of Surgical Oncology, Chongqing Medical University Affiliated Children's Hospital, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,China International Science and Technology Cooperation Base of Child development and Critical Disorders, Chongqing, China.,Childrens Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Lifei Liu
- Department of Anesthesiology, Chongqing Medical University Affiliated Children's Hospital, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,China International Science and Technology Cooperation Base of Child development and Critical Disorders, Chongqing, China.,Childrens Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Ying Xu
- Department of Anesthesiology, Chongqing Medical University Affiliated Children's Hospital, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,China International Science and Technology Cooperation Base of Child development and Critical Disorders, Chongqing, China.,Childrens Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Jun Zhang
- Department of Surgical Oncology, Chongqing Medical University Affiliated Children's Hospital, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,National Clinical Research Center for Child Health and Disorders, Chongqing, China.,China International Science and Technology Cooperation Base of Child development and Critical Disorders, Chongqing, China.,Childrens Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China
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Stone M, Choi R, Ing RJ. Optimization of Right Internal Jugular Central Venous Catheter Length in Pediatric Cardiac Surgical Patients. J Cardiothorac Vasc Anesth 2020; 34:2392-2394. [DOI: 10.1053/j.jvca.2020.04.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/16/2020] [Indexed: 11/11/2022]
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Hirschl JR, Gadepalli SK, Derstine BA, Holcombe SA, Smith EA, Wang SC, Ehrlich PF, Jarboe MD. CT validation of SVC-RA junction location for pediatric central line placement: is vertebral bodies below the carina accurate? Pediatr Surg Int 2020; 36:1055-1060. [PMID: 32666296 DOI: 10.1007/s00383-020-04712-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The key landmark for tip position of a central venous catheter (CVC) is the SVC-RA junction. In adults, localization of the SVC-RA junction may be assessed as a function of vertebral body units (VBU) below the carina during CVC placement. We investigated the relationship between the SVC-RA junction and the carina in children. MATERIALS AND METHODS 584 CT scans of 0-18 years were analyzed. The carina was marked automatically by software while the SVC-RA junction and vertebrae were marked manually. The SVC-RA junction to carina (JC) distance was the primary study measurement reported in both VBU and mm. RESULTS The data show an average JC distance of 1.25 VBU for 0-1 year, 1.27 VBU for 1-4 years, 1.34 VBU for 4-9 years, 1.53 VBU for 9-15 years, and 1.64 VBU for 15-18 years. A positive relationship between weight and JC distance was also demonstrated. CONCLUSION JC distance is a useful predictor of SVC-RA junction location in children. Significant relationships were shown between JC distance and both age and weight. Due to small differences between age groups, however, average JC distance for all comers (1.48 VBU, 95% CI 0.7 - 2.3) can be used for SVC-RA junction identification in CVC placement.
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Affiliation(s)
- Jacob R Hirschl
- Section of Pediatric Surgery, Mott Children's Hospital, University of Michigan, 1540 E. Hospital Drive., SPC 4211, Ann Arbor, MI, 48109-4211, USA
| | - Samir K Gadepalli
- Section of Pediatric Surgery, Mott Children's Hospital, University of Michigan, 1540 E. Hospital Drive., SPC 4211, Ann Arbor, MI, 48109-4211, USA
| | - Brian A Derstine
- Morphomics Analysis Group, University of Michigan, Ann Arbor, MI, USA
| | - Sven A Holcombe
- Morphomics Analysis Group, University of Michigan, Ann Arbor, MI, USA
| | - Ethan A Smith
- Department of Radiology and Medical Imaging, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Stewart C Wang
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA.,Morphomics Analysis Group, University of Michigan, Ann Arbor, MI, USA
| | - Peter F Ehrlich
- Section of Pediatric Surgery, Mott Children's Hospital, University of Michigan, 1540 E. Hospital Drive., SPC 4211, Ann Arbor, MI, 48109-4211, USA
| | - Marcus D Jarboe
- Section of Pediatric Surgery, Mott Children's Hospital, University of Michigan, 1540 E. Hospital Drive., SPC 4211, Ann Arbor, MI, 48109-4211, USA.
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Kang SS, Shin YS, Lee SY, Kim H. Simplified equation for determining proper depth of peripherally inserted central catheter in relation to anatomical landmarks. Korean J Anesthesiol 2018; 71:300-304. [PMID: 29684986 PMCID: PMC6078871 DOI: 10.4097/kja.d.18.27185] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 08/22/2017] [Indexed: 11/25/2022] Open
Abstract
Background The aim of this study was to develop a formula guiding the peripherally inserted central catheter (PICC) tip placement based on anatomical landmarks such as the upper arm, clavicle, and sternum as well as the patient’s height, weight, and body mass index. Methods Fifty-five patients who were scheduled to have PICCs were included in the study. We measured four distances along the passage of the PICC, which were as follows; the tip of the third finger to the middle of the elbow crease (Distance A), the middle of the elbow crease to the acromion process (Distance B), the acromion process to the sternal head of the clavicle (Distance C), and the sternal head of the clavicle to the end of the xiphoid process (Distance D). The lengths from the elbow creases to their carina bifurcations as determined by fluoroscopy during PICC insertions were recorded and used as reference. Results The formula for determining PICC depth based on the four distances was determined by regression analysis. The optimal formula was determined to be 25.3 + 0.5 × (Distance C) + 0.6 × (Distance D) which yielded an R2 value of 0.3. Conclusions The formula proposed for proper depth of the adult, 25.0 + 0.5 × (clavicle length) + 0.6 × (sternum length) for PICC insertion can be used to place the tip at the carina bifurcation level. The distance from elbow crease to catheter insertion point should be added to the length generated by this formula.
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Affiliation(s)
- Sang-Soo Kang
- Department of Anesthesiology and Pain Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Yang-Sik Shin
- Department of Anesthesiology and Pain Medicine, Cha Bundang Hospital, Cha University College of Medicine, Seongnam, Korea
| | - Seon-Yi Lee
- Department of Anesthesiology and Pain Medicine, Cha Bundang Hospital, Cha University College of Medicine, Seongnam, Korea
| | - Hyunzu Kim
- Department of Anesthesiology and Pain Medicine, Inha University College of Medicine, Incheon, Korea
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Mundi MS, Nystrom EM, Hurley DL, McMahon MM. Management of Parenteral Nutrition in Hospitalized Adult Patients [Formula: see text]. JPEN J Parenter Enteral Nutr 2016; 41:535-549. [PMID: 27587535 DOI: 10.1177/0148607116667060] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Despite the high prevalence of malnutrition in adult hospitalized patients, surveys continue to report that many clinicians are undertrained in clinical nutrition, making targeted nutrition education for clinicians essential for best patient care. Clinical practice models also continue to evolve, with more disciplines prescribing parenteral nutrition (PN) or managing the cases of patients who are receiving it, further adding to the need for proficiency in general PN skills. This tutorial focuses on the daily management of adult hospitalized patients already receiving PN and reviews the following topics: (1) PN basics, including the determination of energy and volume requirements; (2) PN macronutrient content (protein, dextrose, and intravenous fat emulsion); (3) PN micronutrient content (electrolytes, minerals, vitamins, and trace elements); (4) alteration of PN for special situations, such as obesity, hyperglycemia, hypertriglyceridemia, refeeding, and hepatic/renal disease; (5) daily monitoring and adjustment of PN formula; and (6) PN-related complications (PN-associated liver disease and catheter-related complications).
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Affiliation(s)
- Manpreet S Mundi
- 1 Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Erin M Nystrom
- 2 Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel L Hurley
- 1 Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - M Molly McMahon
- 1 Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
Central venous catheterization is an indispensable tech nique in today's practice of medicine. It was initially used to monitor central venous pressure; however, this method has become obsolete. Central venous access is now more commonly established to administer hyper tonic intravenous alimentation or to insert pulmonary artery catheters. The sites available for central venous catheterization include the antecubital veins, external and internal jugular veins, subclavian vein, and femoral vein. Many of these sites offer more than one method of insertion. Although the indications for central venous access are well known, there is a general lack of respect for the considerable incidence of associated complica tions. It is useful to separate complications into two categories: those associated with venipuncture and catheter insertion, which will vary greatly depending on the route chosen, and those associated with catheter maintenance, which tend to be similar. The various methods of central venous catheterization are com prehensively reviewed with regard to specific indica tions, technique, and complications.
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Affiliation(s)
- Michael G. Seneff
- Departments of Internal Medicine and Clinical Investigation, Naval Hospital, San Diego, CA
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Mundi MS, Edakkanambeth Varayil J, McMahon MT, Okano A, Vallumsetla N, Bonnes SL, Andrews JC, Hurt RT. Accuracy of Intravenous Electrocardiography Confirmation of Peripherally Inserted Central Catheter for Parenteral Nutrition. Nutr Clin Pract 2016; 31:207-10. [DOI: 10.1177/0884533615621548] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Manpreet S. Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Jithinraj Edakkanambeth Varayil
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Family Medicine, University of Illinois College of Medicine at Rockford, Rockford, Illinois, USA
| | - Megan T. McMahon
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Akiko Okano
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nishanth Vallumsetla
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Sara L. Bonnes
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ryan T. Hurt
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Kentucky
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Mousa AY, Abu-Halimah S, Nanjundappa A, AbuRahma AF. Inadvertent subclavian artery cannulation and options for management. Vascular 2014; 23:132-7. [PMID: 24857936 DOI: 10.1177/1708538114534841] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Central line placement is an integral part of our daily routine and although it is necessary in a select group of patients, serious complications may occur in up to 10% of cases. Inadvertent placement in the subclavian artery is considered to be one of the most challenging complications to the vascular specialist, which is mainly due to its deep anatomical location. Several endovascular options are available and should be tailored to fit each scenario. Herein, we present different approaches for the management of three cases of inadvertent subclavian artery cannulation. The first patient was treated with a covered stent, the second with prolonged balloon inflation, and the third with a closure device.
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Affiliation(s)
- Albeir Y Mousa
- Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA
| | - Shadi Abu-Halimah
- Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA
| | - Aravinda Nanjundappa
- Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA
| | - Ali F AbuRahma
- Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA
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Nguyen V, Jarry J, Farthouat P, Bourilhon N, Milou F, Michel P. Pose de chambre implantable par abord percutané échoguidé : à propos d’une série de 102 patients. ACTA ACUST UNITED AC 2013; 38:6-12. [DOI: 10.1016/j.jmv.2012.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 11/14/2012] [Indexed: 01/21/2023]
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14
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Tekin M, Özbay B, Katı I, Arslan H. MISPLACEMENTS OF CENTRAL VENOUS CATHETERS: INTERNAL JUGULAR VERSUS SUBCLAVIAN ACCESS IN CRITICAL CARE PATIENTS. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2007. [DOI: 10.29333/ejgm/82506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Tan PL, Gibson M. Central venous catheters: the role of radiology. Clin Radiol 2006; 61:13-22. [PMID: 16356812 DOI: 10.1016/j.crad.2005.07.010] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2005] [Revised: 07/06/2005] [Accepted: 07/13/2005] [Indexed: 01/08/2023]
Abstract
The insertion and management of long-term venous catheters have long been the province of anaesthetists, intensive care physicians and surgeons. Radiologists are taking an increasing role in the insertion of central venous catheters (CVCs) because of their familiarity with the imaging equipment and their ability to manipulate catheters and guide-wires. The radiological management of the complications of CVCs has also expanded as a result. This article reviews the role of radiology in central venous access, covering the detection and management of their complications.
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Affiliation(s)
- P L Tan
- Department of Radiology, John Radcliffe Hospital, Oxford, UK.
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Albrecht K, Nave H, Breitmeier D, Panning B, Tröger HD. Applied anatomy of the superior vena cava—the carina as a landmark to guide central venous catheter placement. Br J Anaesth 2004; 92:75-7. [PMID: 14665557 DOI: 10.1093/bja/aeh013] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Cardiac tamponade is a serious complication of central venous catheter (CVC) insertion. Current guidelines strongly advise that the CVC tip should be located in the superior vena cava (SVC) and outside the pericardial sac. This may be difficult to verify as the exact location of the pericardium cannot be seen on a normal chest x-ray. The carina is an alternative radiographic marker for correct CVC placement, suggested on the basis of studies of embalmed cadavers. METHODS We set out to confirm this radiographic landmark in 39 fresh cadavers (age 58.4 (3.4) (mean and SE) yr) and to compare the results with those from ethanol-formalin-fixed cadavers. RESULTS We found that the carina was 0.8 (0.05) cm above the pericardial sac as it transverses the SVC. In no case was the carina inferior to the pericardial reflection and our study confirmed the previous findings. All the measured distances were significantly greater in fresh cadavers. CONCLUSIONS We confirm that the carina is a reliable, simple anatomical landmark that can be identified in vivo for the correct placement of CVCs outside the boundaries of the pericardial sac.
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Affiliation(s)
- K Albrecht
- Institute of Legal Medicine, Medical School Hannover, D-30623 Hannover, Germany.
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Andropoulos DB, Bent ST, Skjonsby B, Stayer SA. The optimal length of insertion of central venous catheters for pediatric patients. Anesth Analg 2001; 93:883-6. [PMID: 11574350 DOI: 10.1097/00000539-200110000-00016] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
UNLABELLED Incorrect positioning of central venous catheters (CVC) in infants and children may lead to serious complications such as perforation of the heart or great vessels. CVC position is not usually assessed until the first postoperative chest radiograph, potentially leaving malposition undetected for several hours. We studied a series of 452 right internal jugular and subclavian catheter placements in infants and children undergoing surgery for congenital heart disease, and measured the distance from the skin insertion site to the radiographic junction of the superior vena cava and right atrium (RA). Based on these data, the following formulae predict that a CVC will be positioned above the RA 97% of the time: correct length of insertion (cm) = (height in cm/10) - 1 for patients < or =100 cm in height, and (height in cm/10) - 2 for patients >100 cm in height. Weight-based recommendations were also developed which predict placement of CVC above the RA 98% of the time. IMPLICATIONS This study assessed central venous catheter placement in 452 infants and children undergoing cardiac surgery. Simple, clinically useful guidelines based on height and weight were developed to prevent malposition of these catheters, which may cause serious complications such as perforation of the heart or great vessels.
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Affiliation(s)
- D B Andropoulos
- Division of Pediatric Cardiovascular Anesthesiology, Texas Children's Hospital, Houston, Texas 77030-2399, USA.
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Leipälä JA, Petäjä J, Fellman V. Perforation complications of percutaneous central venous catheters in very low birthweight infants. J Paediatr Child Health 2001; 37:168-71. [PMID: 11328473 DOI: 10.1046/j.1440-1754.2001.00625.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To prospectively survey perforation complications of consecutively inserted percutaneous central venous catheters (PCVC) in very low birthweight (VLBW) infants over a 2 year period. METHODOLOGY AND RESULTS Three serious perforation complications were encountered in a series of 100 consecutive PCVC. One infant (birthweight 685 g) developed pericardial effusion and fatal cardiac tamponade during the use of a polyurethane PCVC. At autopsy, the pericardial sac contained 8 mL fluid with a glucose concentration of 109 mmol/L and the catheter tip was embedded in the right ventricular wall. The second infant (birthweight 1380 g) showed pleural effusion and transient immobility of the right diaphragmatic leaf after perforation of a similar PCVC into the right pleural cavity. The third perforation, causing subcutaneous oedema, occurred in a 655 g infant who had a silastic PCVC. CONCLUSIONS The data suggest a 3% incidence for PCVC-associated symptomatic perforation complications and a 1% incidence for fatal perforations, despite a policy of careful placement. The data also indicate that perforation complications occur regardless of the size or material of the PCVC. Proper visualization of the PCVC and vigilant attention to its location is required to prevent these rare but potentially fatal complications.
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Affiliation(s)
- J A Leipälä
- Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland.
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Pan D, Moore HG, Angood P, Rabinovici R. Aortic injury resulting from attempted subclavian central venous catheter placement. THE JOURNAL OF TRAUMA 1999; 47:403-5. [PMID: 10452483 DOI: 10.1097/00005373-199908000-00037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- D Pan
- Section of Trauma & Surgical Critical Care, Yale University School of Medicine, New Haven, Connecticut 06520, USA
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Petersen J, Delaney JH, Brakstad MT, Rowbotham RK, Bagley CM. Silicone venous access devices positioned with their tips high in the superior vena cava are more likely to malfunction. Am J Surg 1999; 178:38-41. [PMID: 10456700 DOI: 10.1016/s0002-9610(99)00124-5] [Citation(s) in RCA: 96] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Silicone venous access devices (VADs) are commonly used for multiple intravenous infusions and blood sampling in chronically ill patients, particularly cancer patients. These devices are susceptible to malfunctions most commonly characterized by difficulty infusing fluids or withdrawing blood. We hypothesized that the incidence of such malfunctions is primarily related to the position of the catheter tip relative to the superior vena cava/right atrial junction. METHODS We reviewed medical records for 141 patients in whom silicone venous access devices were used. Chest radiographs obtained following catheter insertion were reviewed by a single radiologist to rule out pneumothorax and determine the position of the catheter tip. Other potential factors included in the analysis were catheter brand, the vein into which the catheter was inserted, and the side (right or left). A malfunction was defined as resistance to flushing or infusion of a substance, complete inability to infuse a substance, resistance to blood aspiration attempts, or absence of blood return with aspiration, occurring any time during which the catheter was in place. Multiple logistic regression was used to determine which factor(s) most strongly predicted catheter malfunction. RESULTS Catheter tip location was the only factor that was statistically predictive of malfunctions (coefficient 0.842, P < 0.001). A significant increase in malfunctions was observed in cases where the catheter tip was located greater than 4 cm superior to the junction of the right atrium and the superior vena cava (z-test of proportions, P = 0.003). Malfunctions were minimized in those cases where the catheter tip was located in the right atrium. CONCLUSIONS These results indicate that malfunctions can be minimized in silicone venous access catheters by locating the catheter tip as close to the superior vena cava/right atrial junction as possible, or slightly inside the right atrium. To ensure proper location of the catheter tip, placement should be performed under fluoroscopy, and a radiograph should be obtained immediately following placement, with the patient in the upright position.
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Affiliation(s)
- J Petersen
- Department of Oncology, Northwest Hospital, Northwest Cancer Center, Seattle, Washington 98133, USA
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22
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Andropoulos DB, Stayer SA, Bent ST, Campos CJ, Bezold LI, Alvarez M, Fraser CD. A Controlled Study of Transesophageal Echocardiography to Guide Central Venous Catheter Placement in Congenital Heart Surgery Patients. Anesth Analg 1999. [DOI: 10.1213/00000539-199907000-00012] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Andropoulos DB, Stayer SA, Bent ST, Campos CJ, Bezold LI, Alvarez M, Fraser CD. A controlled study of transesophageal echocardiography to guide central venous catheter placement in congenital heart surgery patients. Anesth Analg 1999; 89:65-70. [PMID: 10389780 DOI: 10.1097/00000539-199907000-00012] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Transesophageal echocardiography (TEE) and central venous catheter (CVC) placement are often used during congenital cardiac surgery. Complications of CVC placement include cardiac perforation, inadvertent arterial placement, and erroneous hemodynamic data from unrecognized malposition. In this study, we used a prospective, randomized, controlled design to evaluate the use of TEE to guide depth of insertion and confirm superior vena cava cannulation, and to improve the percentage of correctly placed CVCs and reduce complications of CVC placement. One hundred forty-five patients were studied. Eighty patients were randomized to have subclavian vein insertion, 64 to have internal jugular insertion, and 1 to have external jugular insertion of CVC. TEE-guided CVC placement resulted in 100% correct placement when assessed by preoperative TEE, versus 86% in the control group (72 of 72 vs. 63 of 73; P = 0.01). There was no difference in correct placement between the two groups when assessed by postoperative chest radiograph (81.9% TEE versus 75.3% control; P = not significant). One significant complication, a superior vena cava perforation, occurred in the control group. Time to placement was 9.6 min in the TEE group versus 8.0 min in the control group (P = 0.015). IMPLICATIONS Transesophageal echocardiography can be used to guide central venous catheter placement in congenital heart surgery. Central venous catheters that seem to be located high in the right atrium by chest radiograph in these patients are often actually in the superior vena cava and pose little risk of cardiac perforation.
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Affiliation(s)
- D B Andropoulos
- Division of Pediatric Cardiovascular Anesthesiology, Texas Children's Hospital and Baylor College of Medicine, Houston 77030-2399, USA.
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Czepizak CA, O'Callaghan JM, Venus B. Evaluation of formulas for optimal positioning of central venous catheters. Chest 1995; 107:1662-4. [PMID: 7781364 DOI: 10.1378/chest.107.6.1662] [Citation(s) in RCA: 85] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE To evaluate the accuracy of formulas designed to estimate the optimum intravenous length of central venous catheters. DESIGN A prospective study of catheter insertion sites to evaluate the accuracy of predetermined formulas that predict the intravascular insertion length required to avoid intracardiac catheter tip placement. SETTING A 320-bed tertiary hospital. PATIENTS Critically ill patients requiring central venous access for therapy or monitoring. MAIN RESULTS The formulas accurately predicted required intravascular length of the central venous catheter in 217 of 228 (95%) cases. The formula for predicting catheter length was most accurate when the subclavian vein was used. It was least accurate when the right internal jugular vein was selected. CONCLUSIONS The formulas can accurately predict the required length of catheters and thereby reduce the possibility of complications and save time and expense.
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Affiliation(s)
- C A Czepizak
- Department of Critical Care Medicine, Colombia Memorial Hospital, Jacksonville, Fla. 32216, USA
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26
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Abstract
A premature infant developed pericardial effusion four days after the insertion of a 25-gauge silastic percutaneous central venous catheter. The effusion contained parenteral nutrition fluid and resolved rapidly after withdrawal of the catheter. Pericardial effusion is a potential complication of percutaneous, as well as surgically placed, central venous catheters.
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Affiliation(s)
- P G Beattie
- Department of Paediatrics, National Women's Hospital, Epsom, Auckland, New Zealand
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Horowitz MD, Alkire MJ, Lickstein DA, Bauerlein EJ. Aortic injury as a complication of central venous catheterization. Am Heart J 1991; 122:595-7. [PMID: 1858653 DOI: 10.1016/0002-8703(91)91029-m] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- M D Horowitz
- Division of Thoracic and Cardiovascular Surgery, University of Miami/Jackson Memorial Medical Center, FL
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28
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Bersten AD, Williams DR, Phillips GD. Central venous catheter stiffness and its relation to vascular perforation. Anaesth Intensive Care 1988; 16:342-51. [PMID: 3189745 DOI: 10.1177/0310057x8801600317] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Delayed central venous perforation is an uncommon but serious complication of central venous catheter insertion. An increase in catheter stiffness may have been responsible for our association of venous perforation with use of a guidewire insertion technique. A bench model was used to investigate the stiffness characteristics of thirty-four different types of catheters. The initial stiffness is poorly described by material or catheter gauge. A large range of values is seen between apparently similar catheters--the 16 gauge polyethylene catheter associated with two perforations at our institution had an initial stiffness value 7.5 Nm2 X 10(-5) at 37 degrees C in comparison with our previous standard--the 16 gauge Deseret Intracath with an initial stiffness of 2 Nm2 X 10(-5). Multilumen catheters had a similar range of stiffness to single lumen catheters, while paediatric catheters in general were less stiff. Dialysis catheters were up to five times as stiff as the stiffest central venous catheter. Stiffness decayed at a rate and to an extent which differed from catheter to catheter. Absorption of water by the catheter appears to be one factor involved in stress relaxation.
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Affiliation(s)
- A D Bersten
- Department of Anaesthesia and Intensive Care, Flinders Medical Centre, Bedford Park, South Australia
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Abstract
Pericarditis is a common but frequently subclinical entity. There are a number of causes, including infection, systemic illness, cardiac disease, trauma, and neoplasm. Iatrogenic causes include surgery, cardiac instrumentation, irradiation, and medications. The clinical presentation varies, depending on the cause. Chest pain and dyspnea are characteristic complaints. A typical progression of ECG changes occurs during the course of acute pericarditis. These changes occasionally require differentiation from those of acute myocardial infarction or normal variant ST segment elevation. Echocardiography is the most sensitive technique for detecting the presence of pericardial effusion. In addition, a number of echocardiographic findings are characteristic of larger effusions and cardiac tamponade. Any form of pericarditis may lead to the development of cardiac tamponade. Malignant effusion is probably the most common single cause.
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Affiliation(s)
- G L Sternbach
- Department of Emergency Medicine, Stanford University Medical Center, California 94305
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Abstract
Myocardial perforations with a central venous catheter are rare in adults (67 cases published since 1968). These accidents are fatal in more than two-thirds of the cases owing to confusion caused by misleading symptoms which suggest pulmonary embolism. The perforation is generally localized in the right atrium (29 cases), less frequently in the right ventricle (18 cases). The superior vena cava is rarely affected (3 cases). The site of the perforation was not found in the other published cases. Clinical symptoms are signs of tamponade with disorders of cardiac rhythm. An enlargement of the cardiac shadow and an abnormal position of the catheter, buckled or openly intrapericardial, make the diagnosis radiologically. Echocardiography provides some information, but this is often too late for practical application. The diagnosis is made with right catheterization when it shows an equalization of the diastolic pressures. This allows the patient to be watched closely following the pericardial tap, after which a surgical approach may be indicated and performed. Prevention of these iatrogenic accidents must be systematic and strictly controlled for.
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Affiliation(s)
- A Chabanier
- Department of Cardiology, Dupuytren Hospital, Limoges, France
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Long R, Kassum D, Donen N, De Pape A, Taylor J, Warrian K. Cardiac tamponade complicating central venous catheterization for total parenteral nutrition: A review. J Crit Care 1987. [DOI: 10.1016/0883-9441(87)90119-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Collier PE, Ryan JJ, Diamond DL. Cardiac tamponade from central venous catheters. Report of a case and review of the English literature. Angiology 1984; 35:595-600. [PMID: 6486523 DOI: 10.1177/000331978403500909] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
A case of acute cardiac tamponade caused by an internal jugular central venous catheter which was successfully treated is reported. The English literature is reviewed and shows that tamponade can occur up to 37 days after insertion and has a 65% mortality. The tamponade is usually caused by the actual infusate and not by blood.
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Harford FJ, Kleinsasser J. Fatal cardiac tamponade in a patient receiving total parenteral nutrition via a silastic central venous catheter. JPEN J Parenter Enteral Nutr 1984; 8:443-6. [PMID: 6431135 DOI: 10.1177/0148607184008004443] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
This is the first reported case of cardiac tamponade secondary to ventricular perforation involving a silastic catheter. The catheter had advanced into the right ventricle and become enmeshed in the trabeculae carnae. At autopsy there was an area of necrosis which we presumed was caused by the continuous direct contact of a small area of endocardium and subadjacent myocardium with the hypertonic infusate used for parenteral nutrition.
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Jebson PJ, Rempe LE. Perforation of intrathoracic great veins by parenteral nutrition catheters. JPEN J Parenter Enteral Nutr 1982; 6:528-31. [PMID: 6820078 DOI: 10.1177/0148607182006006528] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Perforation of intrathoracic great veins by parenteral nutrition catheters has been previously reported as an unusual complication. The following three case reports illustrate the varied clinical picture that may appear following perforation. The differential diagnosis may be difficult to clarify so early recognition is essential if rapid deterioration in the patient's condition is to be avoided. Each patient in this report provides a useful example for diagnosing this complication. Included are some basic suggestions to help the clinician in early detection.
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Criado A, Mena A, Figueredo R, Reig E, Avello F. Late perforation of superior vena cava and effusion caused by central venous catheter. Anaesth Intensive Care 1981; 9:286-8. [PMID: 7283126 DOI: 10.1177/0310057x8100900314] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
A patient developed right-side pleural effusion secondary to perforation of the superior vena cava by a catheter which had been inserted seven days previously through the left internal jugular vein.
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36
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Axelsson CK, Knudsen FU. Catheter-induced ascites--an unusual complication of parenteral feeding. Intensive Care Med 1978; 4:91-2. [PMID: 418089 DOI: 10.1007/bf01684391] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A nearly fatal complication of parenteral feeding is reported. An emaciated infant with severe Shigella dysentery was treated with intravenous feeding through a catheter in the inferior vena cava. After three days severe ascites developed acutely. Venocavography revealed effusion into the peritoneal cavity due to the catheter having penetrated the wall of the inferior vena cava.
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Abstract
The first case of spontaneous cardiac tamponade caused by wire suture for sternotomy closure is presented. The proper analysis of bloody pericardial fluid, including simultaneous aspirate and venous hematocrit, oxygen content, and coagulation studies, is emphasized. In addition, the causes of acute hemopericardium are reviewed. Spontaneous cardiac tamponade as a potential late complication of cardiac surgery should be considered in the postoperative patient who presents with pericarditis or a sudden change in cardiac status.
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38
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Greenall MJ, Blewitt RW, McMahon MJ. Cardiac tamponade and central venous catheters. BRITISH MEDICAL JOURNAL 1975; 2:595-7. [PMID: 1131628 PMCID: PMC1673526 DOI: 10.1136/bmj.2.5971.595] [Citation(s) in RCA: 87] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
An analysis of the reports on 16 patients who developed cardiac tamponade, complicating the use of central venous catheters, showed that 14 died. The two survivors were treated by removal of the catheter and needle aspiration of the pericardial fluid. Some patients complained of warning symptoms such as nausea, pain, and dyspnoea, and the combination of tachycardia, hypotension, and raised venous pressure was common. We suggest that awareness of the hazard, radiographic visualization of the catheter tip, and expeditious treatment would reduce the mortality.
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