Malposition of central venous catheter in the jugular venous arch via external jugular vein -a case report-

The central venous cannulation is commonly performed in the operating rooms and intensive care units for various purposes. Although the central venous catheter (CVC) is used in many ways, the malpositioning of the CVC is often associated with serious complications. We report a case of an unexpected malposition of a CVC in the jugular venous arch via external jugular vein.

[Ultrasound guidance for placement control of central venous catheterization. Survey of 802 anesthesia departments for 2007 in Germany]

OBJECTIVES AND METHODS

In 2007 a survey on the development of the current practice of using ultrasound to assist central venous catheter (CVC) placement was carried out in 802 departments of anesthesiology and intensive care medicine in hospitals with more than 200 beds in Germany. These data were compared to data from a survey in 2003. Additionally, data regarding control of CVC positioning were collected.

RESULTS

The response rate was 58%. In these 468 departments approximately 340,000 CVCs are placed annually and 317 departments have access to an ultrasound machine. Ultrasound guidance is used by 188 (40%) departments for central venous cannulation. Of these only 24 (12.7%) use ultrasound routinely and 114 (60.6%) use it when faced with a difficult cannulation. Approximately one-third of the users perform continuous ultrasound guidance for CVC placement. Equipment was not at disposal in 115 (41.1%) departments not using ultrasound for CVC placement did not possess the equipment and 93 (33.2%) did not consider ultrasound necessary. Positioning of CVCs was controlled either by electrocardiogram (ECG) guidance and/or chest radiograph in 92%.

CONCLUSION

In Germany placement of central venous catheters is still usually based on anatomical landmarks. However, compared to 2003, ultrasound guidance for CVC placement is gradually being introduced (40% compared to 19%). Given the well-documented advantages of ultrasound guidance compared to landmark based approaches for central venous cannulation, acquisition of this technology should belong to the training programme of an anesthesiologist.

Advanced Practice Organ Procurement Techniques: Insertion of Central Venous Catheters

Placement of central venous catheters by organ procurement coordinators to assist in obtaining blood samples or for measuring intravascular pressure is appropriate. Preparation for this role should include appropriate didactic instruction and supervised clinical experience. The organ procurement organization must ensure that such training occurs and must support a continuing quality assurance program for such providers. Policies and procedures must be provided to guide practitioners in site selection, timing of implementation, and titration of measurements obtained. Also, resources must be readily available to treat any complications. This discussion reviews methods for insertion of venous catheters placed in the femoral, internal jugular, or subclavian veins.

Ultrasound-guided central venous cannulation: is there a difference between Doppler and B-mode ultrasound?

STUDY OBJECTIVE

To compare the success of Doppler and B-mode ultrasound-guided internal jugular vein (IJV) catheterization with respect to body mass index (BMI).

STUDY DESIGN

Prospective, randomized study.

SETTING

Section for cardiovascular anesthesia of a university hospital.

PATIENTS

338 consenting patients were analyzed.

INTERVENTIONS

Subjects receiving central venous catheters for scheduled cardiac surgery were divided into two groups. After induction of general anesthesia, the right or left IJV was assessed for midcervical cannulation approach. In the Doppler group (n = 189), a SonoGuide2 with a 5.0-MHz probe was used. In the B-mode group (n = 149), the SiteRite II ultrasound system with a 7.5-MHz transducer was used.

MEASUREMENTS AND MAIN RESULTS

There was a significant difference in the success rate of first needle pass between the two groups: Doppler group, 91% (172/189); B-mode group, 96.6% (144/149) (P = 0.045). A BMI of 30 and greater was associated with a significantly lower first needle pass success rate in the Doppler group (Doppler group, 77.1% [27/35]; B-mode group, 97.4% [38/39]; P = 0.011). The success rates in patients with a BMI below 30 for both methods were not different (Doppler group, 94.2% [145/154]; B-mode group, 96.4% [106/110]; P = 0.567). Arterial punctures occurred three times under Doppler guidance and twice under B-mode guidance.

CONCLUSION

Cannulation of the IJV can be ensured and first needle pass success rate maximized by both ultrasound techniques. In patients with a BMI greater than 30, B-mode technique is superior to Doppler ultrasound.

The Anterior Jugular Venous System: Variability and Clinical Impact

The anterior jugular venous system, with its interconnections to the subclavian and deep jugular veins, provides a collateral venous network across the midline of the neck area, which is especially important in unilateral occlusion of an innominate vein. We illustrate the variability of this system and its clinical impact on catheterization by three cases of landmark-guided central venous cannulation. Case 1: Cannulation of the left internal jugular vein with a central venous catheter and of the left innominate vein (LIV) with a pulmonary artery catheter resulted in correctly positioned catheter tips. However, these catheters were actually not placed in the innominate vein but coursed through the jugular venous arch. Case 2: Cannulation of the left subclavian vein was complicated by resistance of guidewire advancement at 13 cm. Occlusion of the LIV and enlargement of the jugular venous arch were present. Case 3: Insertion of a pulmonary artery catheter and a central venous catheter through the LIV. The pulmonary artery catheter was correctly placed. The tip of the central venous catheter was mistakenly positioned in the left anterior jugular vein. We describe the normal anatomy of the anterior jugular venous system and its role as a major collateral. Correct placement of central venous catheters may be possible via the anterior jugular venous system. Conversely, central venous catheters malpositioned in the anterior jugular vein can increase the risk for complications and should be removed.

Central venous catheters: choosing the most appropriate access route

Intravenous therapy and care is a complex and intricate area of practice, which is being subsumed into the core role of registered nurses. As more patients become recipients of a vascular access device (VAD), particularly those requiring intermediate to long-term central venous access, it is important to ensure that not only the device but also the most appropriate vein meets their clinical physiological and psychological needs. There is much research and literature on the insertion and care of central venous catheters (CVCs) as well as the detection and treatment of complications. However, apart from a few small studies comparing the performance of devices placed either in the subclavian or jugular veins, there is little to guide doctors or nurses as to which vein is preferable, if secondary complications are to be avoided. This article will describe a number of primary and secondary complications associated with both the subclavian and internal jugular veins and how these can be minimized by selecting the most appropriate vessel. The article concludes with the author's suggestions for correct patient assessment in order that the correct vein is utilized.

Lower extremity deep vein thrombosis: a prospective, randomized, controlled trial in comatose or sedated patients undergoing femoral vein catheterization

OBJECTIVES

To determine the rate of lower extremity deep vein thrombosis after the use of femoral catheters in intensive care unit (ICU) comatose or sedated adults. Results were then compared with results of patients undergoing superior vena cava catheterization.

DESIGN

Prospective, randomized, controlled, unblinded study.

SETTING

A mixed medical/surgical ICU in a university hospital.

PATIENTS

Sixty-one comatose or sedated patients admitted to the ICU who underwent central venous catheterization.

INTERVENTIONS

Patients were monitored for signs of thrombotic complications. On catheter removal, a lower-extremity bilateral phlebographic examination was performed in each patient.

MEASUREMENTS AND MAIN RESULTS

After randomization, 31 patients underwent femoral vein catheterization and 30 patients underwent superior vena cava catheterization, either by axillary (21 patients) or internal jugular vein (10 patients) cannulation. Single lumen polyurethane catheters were inserted for a mean duration of 7.1 +/- 4.6 (SD) days in the femoral vein group and 9.9 +/- 5.5 days in the superior vena cava group (p = NS). No patient had clinical signs of leg venous thrombosis or pulmonary embolism during the study period. In each patient, lower extremity bilateral phlebography was performed at the time of catheter removal. Leg phlebographies were normal in 18 (60%) patients in the femoral vein group and 26 (84%) patients in the superior vena cava group. Fibrin sleeves which developed around the femoral catheters were seen in seven (23.3%) patients in the femoral vein group and in no patients in the superior vena cava cannulation group. Three patients had femoral vein thrombosis, two (6.6%) patients in the femoral vein group (two nonobstructive thromboses, adherent to the common femoral vein wall) and one (3.0%) patient in the superior vena cava group (nonobstructive thrombosis which developed in the superficial femoral vein) (p = NS). Lower deep extremities thrombosis developed in five (16.7%) patients in the femoral vein group and in five (16%) patients in the superior vena cava group (p = NS).

CONCLUSIONS

Femoral vein catheterization with a polyurethane catheter is associated with a lower rate of extremity deep vein thrombosis which is similar to the rate observed after superior vena cannulation in comatose or sedated patients. Femoral vein thrombosis was observed at a rate of 6.6% after femoral vein cannulation and a rate of 3% after superior vena cava cannulation. Given the acceptable rate of this clinically important complication, femoral vein cannulation offers an attractive alternative to insertion via the vena cava in the critically ill.

A prospective evaluation of the use of femoral venous catheters in critically ill adults

OBJECTIVE

To determine the rate of complications following the use of femoral catheters in adults.

DESIGN

Prospective survey of major and minor complications.

SETTING

A mixed medical/surgical intensive care unit (ICU) in a university hospital.

PATIENTS

Eighty consecutive patients admitted to the ICU who underwent right femoral venous catheterization over a 13-month period.

INTERVENTIONS

Patients were carefully monitored for mechanical, infectious, and thrombotic complications. On catheter removal, a lower extremity bilateral phlebographic examination was performed in each patient.

MEASUREMENTS AND MAIN RESULTS

There were 80 polyurethrane catheters inserted for a mean duration of 8.8 +/- 4.4 (SD) days. Catheters were inserted by interns or residents (75%) or by critical care fellows (25%). Minor complications consisted of arterial puncture (15%), local hematoma (4.4%), local bleeding (3%), and local inflammation (5%). After insertion, 17% of catheter tips were in the right atrium, 13% in the abdominal vena cava, 63% in the thoracic inferior vena cava (correct position), and 8% in aberrant abdominal intravascular positions. After repositioning, 80% of catheter tips were in the thoracic inferior vena cava. One patient developed a catheter-related bacteremia. Catheter-related sepsis were seen in three (3.7%) patients and catheter colonization in 11 (13.7%) patients. No patient had clinical signs of deep vein thrombosis or pulmonary embolism. Bilateral phlebography was performed in 70 patients at the time of catheter removal and was normal in 45 (64%) patients. Fibrin sleeves were seen in 11 (15.7%) patients. Lower extremity deep vein thrombosis developed in 24 (34%) patients. Six (8.5%) patients had femoral vein thrombosis (common femoral vein in two patients, and superficial femoral vein in four patients). Eighteen (25.7%) patients developed popliteal vein or posterior tibial vein thrombosis that was either bilateral (n = 16) or homolateral (n = 2) to the femoral catheter.

CONCLUSIONS

Based on the data from this study, we conclude that femoral vein catheterization with a polyurethane catheter is associated with an 8.5% frequency rate of femoral vein thrombosis. Thrombosis in the popliteal vein or posterior tibial vein is higher (25.7%), but is homolateral to the catheter with only a 2.8% frequency rate. Infectious complications are low and similar to those of other central venous routes. Given the acceptable rate of clinically important complications, femoral venous catheterization offers an attractive alternate site of insertion to the jugular and subclavian veins for central venous access in the critically ill.

Do pulmonary artery catheters improve patient outcome? No

The PAC has allowed physicians to obtain information that was unavailable prior to its introduction into clinical medicine. There are numerous pitfalls, however, in obtaining and interpreting this information. Even if these pitfalls are avoided, changing therapy to the patient's benefit based on PAC data is not guaranteed. In addition, application of new technologies, particularly TEE, has led to the suspicion that PA catheterization may frequently yield an incorrect assessment of the patient. Can PA catheterization lead to an improved outcome in an individual patient? If the patient is chosen carefully, the catheter inserted successfully and safely, the data obtained meticulously and interpreted correctly, and this interpretation leads to a change in therapy to which the patient responds appropriately, then the patient will experience an improved outcome based on PAC use. Does this happen often enough in the millions of catheterizations that are performed each year to improve the outcome of the group significantly as a whole? Almost certainly not.

Delayed Bilateral Pneumothorax after Subclavian Vein Catheterization

A delayed bilateral pneumothorax complicated unilateral left subclavian vein catheterization and required treatment with tube thoracostomy. This case is unique in the demonstration that bilateral pneumothorax can present in a delayed fashion, and that, as a result of a previously formed pleuropleural fistula, it can occur in patients with a history of noncardiac surgery involving median sternotomy. Historical data on delayed pneumothoraces and bilateral pneumothoraces are presented.

Subclavian venous catheterization: greater success rate for less experienced operators using ultrasound guidance

OBJECTIVE

To determine if ultrasound guidance can be safely performed and improve success rates for subclavian venous catheterization performed by less experienced operators.

DESIGN

Prospective, randomized study.

SETTING

Twenty-bed trauma-surgical-medical intensive care unit in a 524-bed, community, tertiary care, teaching hospital.

PATIENTS

After the decision for central venous cannulation was made, informed consent was obtained, and less experienced operators then attempted to insert subclavian catheters in 33 critical care patients.

INTERVENTIONS

Catheter placements were attempted, either by landmark technique, ultrasound technique, or by landmark attempts with ultrasound salvage. Catheterization techniques to be used were randomized using a random number table.

MEASUREMENTS AND MAIN RESULTS

Fifty-three placement procedures were attempted in 33 patients. One procedure was excluded from data analysis. Successful catheterizations, occurrence rates of complications, number of attempts, and number of catheter kits used were recorded. In the analysis, 52 catheterization procedures were studied. Twelve (44%) catheters were successfully placed from 27 attempts using the landmark technique vs. 23 (92%) successful catheterizations during 25 ultrasound procedures (p = .0003). Fifteen failed landmark technique attempts had ultrasound salvage attempted, with 12 (80%) catheters successfully inserted. Eleven complications (minor) occurred in 27 attempts of subclavian venous catheterization using conventional landmark technique vs. one complication (minor) in 25 attempts of subclavian venous catheterization with ultrasound guidance (p = .002). There were no major complications in either group. The landmark group required an average of 2.5 venipunctures and 1.4 catheter kits per attempted catheterization. The ultrasound group required an average of 1.4 venipuncture attempts and 1.0 insertion kit. The statistical significance in differences in groups for the average number of venipunctures was p = .0007 and average number of kits used was p = .0003.

CONCLUSIONS

Ultrasound guidance improves the success rate of subclavian venous catheterization performed by less experienced operators. There were no major complications in either group. Ultrasound guidance is usually successful in allowing performance of subclavian venous catheterizations when landmark techniques fail.

Central venous thrombophlebitis diagnosed by computerized tomography scanning

A case is described in which computerized tomography scanning aided in a prompt diagnosis and assessment of an intravenous catheter-induced septic thrombus. Computerized tomography scanning detected gas bubbles within the thrombus, which extended from the right subclavian vein into the superior vena cava, and retrograde propagation of the thrombus into the right internal jugular vein. Computerized tomography scanning also helped in the assessment of the amount of deep tissue swelling present and the competence of the upper respiratory tract.

When is pulmonary artery catheterization worth the risks?

Bedside pulmonary artery catheterization has proven to be an important addition to the clinical assessment of critically ill patients. Properly used, the procedure may provide hemodynamic information that is not apparent from physical examination or radiography. It may be safely accomplished through various venous routes, but care must be taken to avoid potential complications.