|LETTER TO EDITOR
|Year : 2019 | Volume
| Issue : 2 | Page : 110-112
Malposition of central venous catheter in a pediatric patient
Shagufta Naaz1, Adil Asghar2, Madiha Shadab1, Erum Ozair3
1 Department of Anaesthesiology, AIIMS, Patna, Bihar, India
2 Department of Anatomy, AIIMS, Patna, Bihar, India
3 Department of Anesthesiology, JNMC, AMU Aligarh, Uttar Pradesh, India
|Date of Web Publication||28-Aug-2019|
Dr. Shagufta Naaz
Department of Anaesthesiology, AIIMS, Patna, Bihar
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Naaz S, Asghar A, Shadab M, Ozair E. Malposition of central venous catheter in a pediatric patient. Indian Anaesth Forum 2019;20:110-2
Central venous catheterization is done for various indications. Its common complications are pneumothorax, hydrothorax, hematoma formation, arterial puncture, air embolism, thrombosis, and infection. Central venous catheter (CVC) placement under ultrasound guidance reduces complications. The CVC tip should be located in the lower third of superior vena cava. The incidence of malposition of CVC is 3%–4% and more frequent in the subclavian approach than internal jugular vein (IJV). The tip of catheter has been misplaced to ipsilateral or contralateral IJV, hemiazygos vein, or tributaries of subclavian vein. We are reporting a case of unusual malposition of CVC to ipsilateral vertebral vein.
A 7-year-old female child had to undergo choledochal cyst surgery. After intubation, a 5F triple lumen CVC was placed under ultrasound guidance through the right IJV. The marking on the catheter was not visible in the midway of cannulation. Hence, the catheter was rotated; the posterior side was brought anteriorly to visualize the marking, further pushed up to 9 cm mark and fixed. The flow of blood in all the three lumens was checked. The surgery was uneventful. A chest radiograph was advised postoperatively to confirm the location of the tip of CVC and to rule out the associated complications. In the radiograph, the CVC tip was not directed to the superior vena cava. It was located behind the IJV in the right vertebral vein [Figure 1], directed upward at the level of transverse process of the 7th cervical vertebra after looping in the inferior bulb of IJV at the right sternoclavicular joint. This was confirmed by color Doppler. However, the catheter was functioning well. When malposition of the catheter was diagnosed, under sedation and full asepsis, it was withdrawn 5 cm outward. A sterile guide wire was inserted inside the central port of CVC, and then, it was pushed back up to 9 cm mark and fixed there. In repeat chest radiograph, it was found to be normally placed.
|Figure 1: Chest radiograph anteroposterior view showing central venous catheter forming a loop and going to vertebral vein|
Click here to view
The malposition of CVC depends on placement technique, anatomical variations, built of the patient, and direction of beveled end of the needle. In our case, while the CVC was being placed, it was rotated midway which could have rotated the guide wire leading its tip to the vertebral vein. Malpositioning increases the risk of catheter wedging, erosion or perforation of vessel walls, venous thrombosis, cranial retrograde injection, catheter blockade, thrombophlebitis, and cardiac tamponade. In an effort to decrease the chances of malpositioning of CVC, the right side of the venous system should be given preference. The appropriate length of the catheter should be chosen. Care should be taken to keep the bevel of the needle caudad when subclavian route is chosen and to the medial during IJV approach. The catheter should not be rotated midway while it is being placed as this can lead to malpositioning of the catheter as seen in our case. The position of the tip of the catheter should be confirmed after its placement by vascular ultrasound combined with echocardiography. A few milliliters of intravenous fluid is pushed through the lumen of CVC which is seen rushing into the right atrium by placing the linear or cardiac probe of ultrasound in subxiphoid region while visualizing the heart.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Moeinipour AA, Amouzeshi A, Joudi M, Fathi M, Jahanbakhsh S, Hafez S, et al.
Arare central venous catheter malposition: A case report. Anesth Pain Med 2014;4:e16049.
Tripathi M, Dubey PK, Ambesh SP. Direction of the J-tip of the guidewire, in Seldinger technique, is a significant factor in misplacement of subclavian vein catheter: A randomized, controlled study. Anesth Analg 2005;100:21-4.
Walshe C, Phelan D, Bourke J, Buggy D. Vascular erosion by central venous catheters used for total parenteral nutrition. Intensive Care Med 2007;33:534-7.
Patel RY, Friedman A, Shams JN, Silberzweig JE. Central venous catheter tip malposition. J Med Imaging Radiat Oncol 2010;54:35-42.
Smit JM, Raadsen R, Blans MJ, Petjak M, Van de Ven PM, Tuinman PR. Bedside ultrasound to detect central venous catheter misplacement and associated iatrogenic complications: A systematic review and meta-analysis. Crit Care 2018;22:65.