How much guidewire is too much? Direct measurement of the distance from subclavian and internal jugular vein access sites to the superior vena cava-atrial junction during central venous catheter placement

Intravascular guide wire aspiration in a patient on extracorporeal membrane oxygenation: A case report

RATIONALE

Guide wire aspiration during central venous catheter (CVC) insertion in a patient on extracorporeal membrane oxygenation (ECMO) is a very rare but dangerous complication. A guide wire aspirated inside the ECMO can cause thrombosis, the ECMO to break down or shut off, and unnecessary ECMO replacement.

PATIENT CONCERNS

A 58-year-old man was scheduled for venovenous ECMO for acute respiratory distress syndrome. After his vital signs stabilized, we inserted a CVC. During CVC insertion, the guide wire was aspirated into the ECMO venous line.

INTERVENTION

After confirming the guide wire inside the ECMO venous line, we replaced the entire ECMO circuit.

OUTCOMES

ECMO was maintained for 57 days, and weaning was successful but the patient died 5 days afterward.

LESSONS

Care must be taken when inserting a CVC using a guide wire in ECMO patients: the guide wire should not be inserted deeply, it should be secured during insertion, the ECMO venous cannula tip requires proper positioning, and ECMO flow should be temporarily reduced.

Impact of central venous port implantation method and access choice on outcomes

BACKGROUND

Although the number of patients who need central venous ports for permanent vascular access is increasing, there is still no “gold standard” for the implantation technique.

AIM

To identify the implantation technique that should be favored.

METHODS

Two hundred central venous port-implanted patients in a tertiary hospital were retrospectively evaluated. Patients were assigned into two groups according to the access method. The first group comprised patients whose jugular veins were used, and the second group comprised patients whose subclavian veins were used. Groups were evaluated regarding age, sex, application side, primary diagnosis, active follow-up period in the hospital, chemotherapy agents administered, number of complications, and the Clavien-Dindo severity score. The distribution of the variables was tested with the Kolmogorov-Smirnov test and the Mann-Whitney U test. The χ² test was used to analyze the variables.

RESULTS

There was no statistically significant difference between the groups regarding age, sex, side, number of chemotherapy drugs, and duration of port usage (P > 0.05). Only 2 patients in group 1 had complications, whereas in group 2 we observed 19 patients with complications (P < 0.05). No port occlusion was found in group 1, but the catheters of 4 patients were occluded in group 2. One port was infected in group 1 compared to three infected ports in group 2. Two port ruptures, two pneumothorax, one revision due to a mechanical problem, one tachyarrhythmia during implantation, and four suture line problems were also recorded in group 2 patients. We also showed that it would be sufficient to evaluate and wash ports once every 2 mo.

CONCLUSION

Our results robustly confirm that the jugular vein route is safer than the subclavian vein approach for central venous port implantation.

Central venous catheter insertion- guidewire migration ratio: Right heart to inferior vena cava

BACKGROUND

Central Venous Catheters (CVC) are being used in both intensive care units and general wards for multiple purposes. A previous study Galante et al. (2017) observed that during CVC insertion through Subclavian Vein (SCV) or the Internal Jugular Vein (IJV) the guidewire is sometimes advanced to the Inferior Vena Cava (IVC), and at other times to the right atrium. The rate of IVC wire cannulation and the association with side and point of insertion is unknown.

OBJECTIVE

In this study, we describe guidewire migration location during real time CVC cannulation (right atrium versus IVC) and report the association between the insertion site and side of the CVC and the location of guidewire migration, Right Atrium (RA)/Right Ventricle (RV) versus IVC guidewire migration.

METHODS

This is a retrospective study in the medical intensive care unit among patients that have received CVC during the study years 2014-2020. The rate of IVC versus right atrium/right ventricle wire migration during the procedure were analyzed. The association between the side and point of CVC insertion and the wire migration site was analyzed as well.

RESULTS

One hundred and sixty-six patients were enrolled. 33.7% of wires migrated to the IVC and 66.3% to the versus right atrium/right ventricle. The rate of wire migration to the IVC was similar in the IJV site and the SCV site. There was no association between the side of CVC insertion and wire migration to the IVC.

CONCLUSION

About a third of all wire migrations, during CVC Seldinger technique insertion, were identified in the IVC, with no potential for wire associated arrhythmia. There was no association between CVC insertion point (SCV versus IJV) nor the side of insertion and the site of guidewire migration.

Minimal guidewire length for central venous catheterization of the right subclavian vein: A CT-based consecutive case series

Background:

Central venous catheter (CVC) misplacement occurs frequently after right subclavian vein catheterization. It can be avoided by using ultrasound to confirm correct guidewire tip position in the lower superior vena cava prior to CVC insertion. However, retraction of the guidewire during the CVC insertion may dislocate the guidewire tip from its desired and confirmed position, thereby resulting in CVC misplacement. The aim of this study was to determine the minimal guidewire length required to maintain correct guidewire tip position in the lower superior vena cava throughout an ultrasound-guided CVC placement in the right subclavian vein.

Methods:

One hundred adult patients with a computed tomography scan of the chest were included. By using multiplanar reconstructions from thin-sliced images, the distance from the most plausible distal puncture site of the right subclavian vein to the optimal guidewire tip position in the lower superior vena cava was measured (vessel length). In addition, measurements of equipment in common commercial over-the-wire percutaneous 15–16 cm CVC kits were performed. The 95th percentile of the vessel length was used to calculate the required minimal guidewire length for each CVC kit.

Results:

The 95th percentile of the vessel length was 153 mm. When compared to the calculated minimal guidewire length, the guidewires were up to 108 mm too short in eight of eleven CVC kits.

Conclusion:

After confirmation of a correct guidewire position, retraction of the guidewire tip above the junction of the brachiocephalic veins should be avoided prior to CVC insertion in order to preclude dislocation of the catheter tip towards the right internal jugular vein or the left subclavian vein. This study shows that many commercial over-the-wire percutaneous 15–16 cm CVC kits contain guidewires that are too short for right subclavian vein catheterization, i.e., guidewire retraction is needed prior to CVC insertion.

Fracture Embolism of In-situ Guidewire-Bewildering Aetiology of Protracted Pyrexia in a Patient with End Stage Renal Disease!

Guidewire embolism during venous access for haemodialysis is not uncommon yet potentially avoidable iatrogenic complication. Unrecognised, long-standing in-situ guidewire may predispose to thrombosis and become a nidus for infection. This entity should always be borne in mind and considered as one of the differentials of unexplained pyrexia in patient on maintenance haemodialysis. In this context, we report a patient on maintenance dialysis who presented with fever of 6 weeks duration with no localising history and failed response to empirical antibiotics. On imaging, he was detected to have in-situ guidewire with fracture embolism into inferior vena cava and right external iliac vein and soon patient became afebrile following guidewire retrieval using gooseneck snare device, thereby retrospectively confirming causality.

Intracranial entrapment of a haemodialysis catheter guidewire

A 49-year-old man with chronic obstructive pulmonary disease was hospitalised due to pneumonia and pulmonary embolisms. After subsequently developing septic shock and acute renal failure, he required dialysis. A haemodialysis catheter was planned inserted into the right subclavian vein, the guidewire was introduced using the Seldinger technique. When the guidewire's 20 cm marker entered the introducer needle, it suddenly encountered resistance. Repeated attempts to remove the guidewire failed. Vital signs and haemodynamic parameters remained unchanged throughout the procedure. CT angiography revealed cranial displacement of the wire into the right internal jugular vein, with the tip of the wire just cranial to the jugular foramen in the right sigmoid sinus. Interventional radiological removal attempts were unsuccessful. Thoracic and neurosurgical interventions were considered impossible and the guidewire was left in place. Due to the pulmonary embolism and the foreign object in the patient, life-long anticoagulation was considered, with close monitoring of compliance with the patient's comorbidity and medication.

A Review of Central Venous Access Using Ultrasound Guidance Technology

More than 5 million central lines are placed in the United States each year. Advanced practice providers place central lines and must understand the importance of ultrasound guidance technology. The use of anatomic landmarks to place central lines has been employed in the past and in some instances is still used. This method may make accessing the target vessel difficult in the patient with anomalous anatomy or in the obese patient. These characteristics decrease successful placement and increase complications. Different organizations have agreed that the use of ultrasound during central venous access has decreased rates of complication and cost. In addition to cannulating and accessing a central vein, ultrasound can be used to rapidly confirm placement and to rule out complications such as pneumothorax. Utilizing ultrasound to assist in performance of procedures, and in assessment of patients, is a skill that should be optimized by nurse practitioners.

Cannulation of the subclavian vein using real-time ultrasound guidance

Cannulation of the subclavian vein has many advantages when compared to other anatomical sites for central venous access. Difficulty in its ultrasonic visualisation, and the perceived consequent 'higher' complication rate, mean that this approach has fallen out of favour. This barrier, however, may now have disappeared. In this article, we discuss the indications, contraindications and complications associated with subclavian vein cannulation, and present an ultrasound-guided approach to infraclavicular subclavian cannulation.

Pipe-Cleaning Plugged Portacaths: How to Unclog an Implanted Port After Development of a Fibrin Sheath

Industry has long fought the battle to design a vascular catheter that is less thrombogenic. Indwelling catheters provide long-term central venous access, but they develop fibrin sheaths as the vascular system recognizes them as foreign bodies. Peripheral catheters and central catheters can be changed over a guidewire when they form a fibrin sheath or otherwise malfunction. However, totally implantable venous access devices such as a port cannot be easily exchanged over a wire. Therefore, when a port malfunctions, thrombolytics are usually the only option attempted before the port is explanted and a new site is prepared for access. We present a minimally invasive technique demonstrating port salvage that does not require explant.

Difficult Internal Jugular Central Venous Cannulation Using J-Tip Guidewire with Indwelling Peripherally Inserted Central Venous Catheters

Central venous cannulation is a commonly performed procedure while managing critically ill patients; increasingly we encounter patients with indwelling wires or devices, like pacemakers, implantable cardioverter defibrillator devices, and peripherally inserted central venous catheters which complicate insertion of central venous catheters further. We present two cases where use of standard J-tip guidewire may have exacerbated the difficulty associated with internal jugular cannulation in presence of peripherally inserted central venous catheters. Recognition and avoidance of possible complications are crucial, and we discuss complexity posed by indwelling peripherally inserted central venous catheters and possible solutions.

Common errors in temporary hemodialysis catheter insertion

Non-tunneled hemodialysis catheter (NTHC) insertion is an essential skill for nephrology practice and remains a requirement of training. However, improper insertion technique can increase the risk of potentially fatal infectious and mechanical complications. Evidence-based strategies can reduce the rates of such complications and should be integrated into practice and training. Ultrasound (US) guidance should routinely be used for NTHC insertion at the femoral and internal jugular sites (with avoidance of the subclavian site). Nephrologists should receive proper training in the use of US for line insertion. With respect to other aspects of the procedure, proper insertion technique readily prevents guidewire-induced arrhythmias. In addition, adherence to infection-control guidelines results in a sustainable reduction in bloodstream infections. All these aspects of NTHC insertion may be best taught and evaluated through a program that includes simulation-based mastery learning (SBML) training. As a separate issue, nephrologists (and intensivists) should be aware that a dysfunctional catheter should be replaced at a new site rather than being changed over a guidewire. This review of common errors related to NTHC insertion seeks to highlight evidence-based approaches to practice and training.

Routine chest X-ray is unnecessary after ultrasound-guided central venous line placement in the operating room

BACKGROUND

Central venous catheters (CVC) can be useful for perioperative monitoring and insertion has low complication rates. However, routine post insertion chest X-rays have become standard of care and contribute to health care costs with limited impact on patient management.

METHODS

200 patient charts who underwent pancreaticoduodenectomy with central line placement and early line removal were reviewed for clinical complications related to central line placement as well as radiographic evidence of malpositioning. A cost analysis was performed to estimate savings if CXR had not been performed across routine surgical procedures requiring central access.

RESULTS

In 200 central line placements for Whipple procedures, 198 lines were placed in the right internal jugular and 2 were placed in the subclavian. No cases of pneumothorax or hemothorax were identified and 30 (15.3%) of CVCs were improperly positioned. Only 1 (0.5%) of these was deemed clinically significant and repositioned after the CXR was performed.

CONCLUSION

Routine CXR consumes valuable time and resources (≅$155,000 annually) and rarely affects management. Selection should be guided by clinical factors.

Preventing Retained Central Venous Catheter Guidewires: A Randomized Controlled Simulation Study Using a Human Factors Approach

BACKGROUND

Retained central venous catheter guidewires are never events. Currently, preventative techniques rely on clinicians remembering to remove the guidewire. However, solutions solely relying upon humans to prevent error inevitably fail. A novel locked procedure pack was designed to contain the equipment required for completing the procedure after the guidewire should have been removed: suture, suture holder, and antimicrobial dressings. The guidewire is used as a key to unlock the pack and to access the contents; thereby, the clinician must remove the guidewire from the patient to complete the procedure.

METHODS

A randomized controlled forced-error simulation study replicated catheter insertion. We created a retained guidewire event and then determined whether clinicians would discover it, comparing standard practice against the locked pack.

RESULTS

Guidewires were retrieved from 2/10 (20%) standard versus 10/10 (100%) locked pack, n = 20, P < 0.001. In the locked pack group, participants attempted to complete the procedure; however, when unable to access the contents, this prompted a search for the key (guidewire). Participants discovered the guidewire within the catheter lumen, recovered it, utilized it to unlock the pack, and finish the procedure. A structured questionnaire reported that the locked pack also improved subjective safety of central venous catheter insertion and allowed easy disposal of the sharps and guidewire (10/10).

CONCLUSIONS

The locked pack is an engineered solution designed to prevent retained guidewires. Utilizing forced-error simulation testing, we have determined that the locked pack is an effective preventative device and is acceptable to clinicians for improving patient safety.

Guide Wire Induced Cardiac Tamponade: The Soft J Tip Is Not So Benign

Central venous catheter (CVC) insertion rarely causes cardiac tamponade due to perforation. Although it is a rare complication, it can be lethal if not identified early. We report a case of cardiac tamponade caused by internal jugular (IJ) central venous catheter (CVC) insertion using a soft J-tipped guide wire which is considered safe and rarely implicated with cardiac tamponade. A bedside transthoracic echocardiogram (TTE) revealed a pericardial effusion with tamponade. An emergent bedside pericardiocentesis was done revealing bloody fluid and resulted in clinical stabilization.

Iatrogenic Transient Complete Heart Block in a Preexisting LBBB

Catheter induced cardiac arrhythmia is a well-known complication encountered during pulmonary artery or cardiac catheterization. Injury to the cardiac conducting system often involves the right bundle branch which in a patient with preexisting left bundle branch block can lead to fatal arrhythmia including asystole. Such a complication during central venous cannulation is rare as it usually does not enter the heart. The guide wire or the cannula itself can cause such an injury during central venous cannulation. The length of the guide wire, its rigidity, and lack of set guidelines for its insertion make it theoretically more prone to cause such an injury. We report a case of LBBB that went into transient complete heart block following guide wire insertion during a central venous cannulation procedure.

Vena Caval Filters: A Review for Intensive Care Specialists

Venous thromboembolism (VTE) is a common complication among patients in the intensive care unit. While anticoagulation remains standard therapy, vena caval filters are an important alternative when anticoagulation is contraindicated. To determine the safety and efficacy of vena caval filters in the treatment of VTE, a comprehensive review of the English-language medical literature was performed. Except for one randomized controlled trial, the literature supporting the use of vena caval filters consists almost exclusively of case series, which in many instances are limited by incomplete and short follow-up. While case series suggest that filters function effectively in the prevention of pulmonary embolism (2%-4% symptomatic pulmonary embolism [PE], fatal PE < 2%), recent higher quality studies indicate that filters may not provide significant additional protection to that provided by anticoagulation alone. Furthermore, filters are associated with a 2- fold increase in the incidence of recurrent DVT. Until randomized comparative studies are available, the safety and efficacy of all the available devices should be considered to be roughly equivalent. Since filters do not inhibit continued clot formation, all filter patients should receive anticoagulation for durations appropriate for their thrombotic disorder. Although extended anticoagulation may prevent thrombotic complications associated with filter placement, this strategy has yet to be experimentally tested. While many additional indications for vena caval filter use have been proposed (VTE in cancer patients, PE prophylaxis in trauma patients, etc), well-designed clinical trials demonstrating their efficacy in these situations are lacking. Further development of temporary/retrievable filters, which offer the potential to avoid the long-term complications of permanent filters, should be a research priority. Until additional data are available, vena caval filters should generally be restricted to patients with VTE who cannot receive anticoagulation.

Inferior vena cava filters: current best practices

Venous thromboembolism (VTE) is a common cause of inpatient and outpatient morbidity and mortality. While anticoagulant therapy is considered the primary means of prevention and treatment of VTE, inferior vena cava filters (IVCFs) are often used as an alternative or adjunct to anticoagulation. With the advent of retrievable filters indications have liberalized, to include placement for primary prophylaxis in high-risk patients. However, this practice is based on limited evidence supporting their efficacy in preventing clinically relevant outcomes. Since indiscriminate use of IVCFs can be associated with net patient harm and increased health care costs, knowledge of the literature surrounding IVCF utilization is critical for providers to adopt best practices. In this review, we will provide an overview of the literature as it relates to specific clinical questions that arise when considering IVCF utilization in the prevention and treatment of VTE. Practice-based recommendations will be reviewed to provide the clinician with guidance on challenging clinical scenarios.

Unusual but completely avoidable complication during central venous catheterization

Central venous catheterization is generally a safe procedure, but several complications such as pneumothorax, arrhythmias, arterial puncture, infection, and thrombosis are known to occur even in the experienced hands. Complications related to guide wire are very rare and mostly relate to the expertise of operating person. We hereby report a rare but completely avoidable complication, that is, complete loss of the guide wire into the subclavian vein which was successfully retrieved by surgery.

Systemic oxygen extraction during exercise at high altitude

Background

Classic teaching suggests that diminished availability of oxygen leads to increased tissue oxygen extraction yet evidence to support this notion in the context of hypoxaemia, as opposed to anaemia or cardiac failure, is limited.

Methods

At 75 m above sea level, and after 7–8 days of acclimatization to 4559 m, systemic oxygen extraction [C(a−v)O₂] was calculated in five participants at rest and at peak exercise. Absolute [C(a−v)O₂] was calculated by subtracting central venous oxygen content (CcvO₂) from arterial oxygen content (CaO2) in blood sampled from central venous and peripheral arterial catheters, respectively. Oxygen uptake (V˙O2) was determined from expired gas analysis during exercise.

Results

Ascent to altitude resulted in significant hypoxaemia; median (range) SpO2 87.1 (82.5–90.7)% and PaO2 6.6 (5.7–6.8) kPa. While absolute C(a−v)O₂ was reduced at maximum exercise at 4559 m [83.9 (67.5–120.9) ml litre⁻¹vs 99.6 (88.0–151.3) ml litre⁻¹ at 75 m, P=0.043], there was no change in oxygen extraction ratio (OER) [C(a−v)O₂/CaO₂] between the two altitudes [0.52 (0.48–0.71) at 4559 m and 0.53 (0.49–0.73) at 75 m, P=0.500]. Comparison of C(a−v)O₂ at peak V˙O2 at 4559 m and the equivalent V˙O2 at sea level for each participant also revealed no significant difference [83.9 (67.5–120.9) ml litre¹vs 81.2 (73.0–120.7) ml litre⁻¹, respectively, P=0.225].

Conclusion

In acclimatized individuals at 4559 m, there was a decline in maximum absolute C(a−v)O₂ during exercise but no alteration in OER calculated using central venous oxygen measurements. This suggests that oxygen extraction may have become limited after exposure to 7–8 days of hypoxaemia.

Useful Equation for Proper Estimate of Left Side Peripherally Inserted Central Venous Catheter Length in Relation to the Height

Purpose

Direct measurement of venous length is easy to cause contamination during bedside insertion of peripherally inserted central venous catheter (PICC). It is necessary to provide an equation for proper estimate of catheter length in case of bedside insertion of PICC in relation to patient height.

Methods

For 165 PICC cases through left arm vein in 151 adult patients (male: female = 72:79), the cubital crease to carina length (CCL) was calculated as follows: CCL = (distance from cubital crease to puncture point) + (length of PICC inside body) – (distance from carina to catheter tip on post-procedural chest radiograph). We analyzed the relationship between CCL and height with regression analysis and suggest a new equation of CCL based on height.

Results

The mean CCL through the left arm vein was 47.1 ± 2.6 cm in male and 44.0 ± 2.9 cm in female. CCL was significantly correlated with patient height. Equation of CCL (cm) based on height was as follows: CCL = height* 0.19 + 14.

Conclusions

The equation of our study would provide a new equation for proper estimation of catheter length in case of bedside insertion of left arm PICC in relation to height and be helpful for optimal positioning of catheter tip of PICC.

Tricuspid valve endocarditis following central venous cannulation: The increasing problem of catheter related infection

A central venous catheter (CVC) is inserted for measurement of haemodynamic variables, delivery of nutritional supplements and drugs and access for haemodialysis and haemofiltration. Catheterization and maintenance are common practices and there is more to the technique than routine placement as evident when a procedure-related complication occurs. More than 15% of the patients who receive CVC placement have some complications and infectious endocarditis involving the tricuspid valve is a rare and serious complication with high morbidity and mortality. Overenthusiastic and deep insertion of the guide wire and forceful injection through the CVC may lead to injury of the tricuspid valve and predispose to bacterial deposition and endocarditis. We report a case of tricuspid valve endocarditis, probably secondary to injury of the anterior tricuspid leaflet by the guide wire or the CVC that required open heart surgery with vegetectomy and repair of the tricuspid valve.

Lethal cardiac arrhythmia during central venous catheterization in a uremic patient: a case report and review of the literature

Double-lumen central venous catheter (CVC) is a rapid access technique for hemodialysis (HD) when an arteriovenous fistula or graft is not available. A variety of procedure-related complications have been reported, such as infection and pneumothorax, but serious cardiac complications are relatively less mentioned. We report a uremic woman with preexisting left bundle branch block who required emergent HD and received jugular double-lumen CVC insertion, which was complicated by short-duration ventricular tachycardia followed by complete atrio-ventricular block and bradycardia. Pharmacological management did not reverse heart rate and rhythm. External pacing was not applied because she remained hemodynamically stable in the course of HD. Heart rate returned to sinus rhythm with left bundle branch block 4 hours later and did not recur through the whole admission period. We speculate that the transient arrhythmia might have been induced by mechanical contact with the ventricular wall during the procedure with the guided metallic wire. In conclusion, physicians responsible for CVC catheterization should pay more attention to patients with preexisting cardiac arrhythmia to prevent such technical mistakes from transpiring.

A complication of double lumen hemocatheter guide wire entrapment in a hemodialysis patient

Double lumen hemocatheter is commonly used for temporary hemodialysis patient and various complications have been documented but few reports of guide wire-related complications. We report a complication of double lumen hemocatheter guide wire entrapment in a 43-year-old female of type 1 diabetes mellitus and hemodialysis patient. She was admitted for left arteriovenous shunt dysfunction and right internal jugular vein hemocatheter chamber clotting was found while on hemodialysis, so a new hemocatheter was changed over guide wire. Guide wire was introduced without any resistance and the clotting hemocatheter was removed. During the procedure, the J-tipped guide wire could not be withdrawn and portable chest radiography revealed the J-tip of the guide wire was in the right ventricle near the region of tricuspid valve. Fluoroscopy was arranged and it also confirmed the J-tip was lying in the ventricle near the tricuspid valve where it was stuck. Snare catheter kit was inserted through the 10 Fr sheath and the cardiologist untied the knot by endovascular snare and removed the guide wire smoothly. This report emphasizes the importance of awareness on guide wire entrapment while inserting double lumen hemocatheter. When a guide wire became hard to withdraw, extracting an entrapped guide wire with fluoroscopy guide and snare catheter is a preferable and minimal invasive approach.

Guidewire-Related Complications during Central Venous Catheter Placement: A Case Report and Review of the Literature

Seldinger's technique is widely used to place central venous and arterial catheters and is generally considered safe. The technique does have multiple potential risks. Guidewire-related complications are rare but potentially serious. We describe a case of a lost guidewire during central venous catheter insertion followed by a review of the literature of this topic. Measures which can be taken to prevent such complications are explained in detail as well as recommended steps to remedy errors should they occur.

Anatomic considerations for central venous cannulation

Central venous cannulation is a commonly performed procedure which facilitates resuscitation, nutritional support, and long-term vascular access. Mechanical complications most often occur during insertion and are intimately related to the anatomic relationship of the central veins. Working knowledge of surface and deep anatomy minimizes complications. Use of surface anatomic landmarks to orient the deep course of cannulating needle tracts appropriately comprises the crux of complication avoidance. The authors describe use of surface landmarks to facilitate safe placement of internal jugular, subclavian, and femoral venous catheters. The role of real-time sonography as a safety-enhancing adjunct is reviewed.

Safe placement of central venous catheters: a measured approach

INTRODUCTION

To develop a simple method for safely placing central venous catheters (CVCs) outside the heart from the subclavian or internal jugular vein in compliance with Food and Drug Administration (FDA) and manufacturer guidelines.

METHODS

Patients requiring CVCs were enrolled into this prospective trial. Central venous catheters were inserted into the subclavian or internal jugular vein from either the right or left side to a depth of 15 cm. Chest radiographs were obtained immediately after insertion of the catheter to check tip placement and to evaluate for mechanical complications.

RESULTS

Operators successfully placed 201 of 210 (96%) CVCs outside the heart. Six of these required repositioning. Nine catheter tips were located in an intracardiac position. No cases of pneumothorax, hemothorax, or pericardial tamponade occurred. One case of delayed hydrothorax due to superior vena cava injury occurred.

CONCLUSIONS

Using a 15-cm insertion depth via the internal jugular or subclavian vein results in safe catheter tip location in the majority of procedures consistent with FDA and manufacturer guidelines.

Vascular procedures in the critically ill obese patient

The increasing societal prevalence of obesity is consequential to the increasing number of critically ill obese patients. Vascular procedures are an essential aspect of care in these patients. This article reviews the general, anatomic, and physiologic considerations pertaining to vascular procedures in critically ill obese patients. In addition, the use of ultrasonography for these procedures is discussed.

Missing the guidewire: an avoidable complication

Central venous catheterization is an imperative tool in the critically ill patient to administer fluids, medications and for monitoring the central venous pressure. This procedure is associated with a variety of complications, some of which can be life threatening. In this brief report, we are addressing one of the rare complications of central venous catheterization which is missing the guidewire. We also described several precautions to avoid this complication as well as modifications in the guidewire to prevent its escape.

Bedside ultrasound can safely eliminate the need for chest radiographs after central venous catheter placement: CVC sono in the surgical ICU (SICU)

BACKGROUND

Real-time ultrasound guidance of central venous catheter (CVC)/peripherally inserted central catheter (PICC) insertion improves safety and efficacy. We hypothesized that a more robust ultrasound surveillance technique incorporating thoracic, vascular, and cardiac views-the CVC sono-would avoid the need for chest radiography to realize cost and efficiency gains.

METHODS

We conducted a prospective data collection in a high-volume, urban, academic SICU. A single surgical intensivist, blinded to the results of chest radiography, performed all CVC sonos post-insertion. Catheter malposition was defined as location extrinsic to the superior vena cava and determined by a board-certified radiologist on chest radiography. CVC sono consisted of (1) mechanical complications screen (hemo-, pneumothorax), (2) intravenous tip screen, (3) intracardiac tip screen. The result of CVC sono was compared with chest radiography.

RESULTS

CVC sono evaluated 83 catheters (42 CVCs and 41 PICCs) and was considered technically adequate in 59 (71%). Incomplete studies were significantly more common in those with chest tubes (P = 0.02), but not in those with cervical collars (P = 0.07), an open abdomen (P = 0.28), or BMI > 40 (P = 0.33). Mean CVC sono time was 10.8 min, compared with chest radiography of 75.3 min (P < 0.001). No hemo-pneumothoraces developed. Presence of multiple indwelling central catheters (>1 CVC) trended for inaccurate CVC sono for catheter malposition (accuracy: 79% versus 93%, P = 0.11).

CONCLUSION

A novel ultrasound technique, CVC sono eliminated the need for chest radiography in most patients after CVC/PICC insertion, saving time and money. Those with multiple indwelling central catheters may still require post-insertion conventional chest radiography.

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 to assess the location of the catheter tip. This prospective clinical study was designed to determine the radiographic 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. 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, 9.1%, compared with 1.4% by the right internal jugular vein. Six of the 53 malpositioned catheters were removed or adjusted. No case of malposition was associated with vascular perforation, local venous thrombosis or cerebral symptoms. 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.

Angiotomographically-proven Left Innominate Vein Occlusion in Dialysis Patients With Prior Left Internal Jugular Vein Catheterization Presenting With Arm Swelling After Ipsilateral Access Creation: Report of Four Cases

Central vein occlusion (CVO) is not uncommonly observed after hemodialysis (HD) catheter placement and it may prevent subsequent ipsilateral arteriovenous (AV) access creation. Right internal jugular vein catheterization (RJVC) appears to be the insertion site with the lowest incidence of CVO, but little is known about the incidence of CVO following left internal jugular vein catheterization (LJVC). We report on four patients with left innominate vein occlusion after LJVC who developed severe arm swelling after ipsilateral AV access creation. In three of the four cases swelling appeared 12-26 months after access creation, and in the fourth, swelling developed immediately after surgery while the catheter was still in place. Two patients underwent access ligation and in the remainder the arm swelling improved either spontaneously or after LJVC removal. LJVC is not as safe as RJVC as an insertion route for HD catheter placement in terms of CVO frequency.

Central venous catheterization

OBJECTIVE

To provide current information related to central venous catheterization.

DESIGN

Review of literature relevant to central venous catheterization and its indications, insertion techniques, and prevention of complications.

RESULTS

Central venous catheterization can be lifesaving but is associated with complication rates of approximately 15%. Operator experience, familiarity with the advantages and disadvantages of the various catheterization sites, and strict attention to detail during insertion help in reducing mechanical complications associated with catheterization. Strict aseptic technique and proper catheter maintenance decrease the frequency of catheter-related infections.

CONCLUSIONS

Appropriate catheter and site selection, sufficient operator experience, careful technique, and proper catheter maintenance with removal as soon as possible are associated with optimal outcome.