Malposition of central venous access catheters

Hippokratia 1997, 1(2):98-105

C. Tsiotras, D. Gakis, G. Papaioannou, K. Chatzinikolaou


Erroneous insertion and positioning of central venous catheters is the main reason of complication occurrence. The majority of life-threatening injuries, occur at the time of initial catheter insertion. Rarely primary or delayed catheter tip malpositioning is related with the development of serious complications. We reviewed our experience, in a two year period, with the percutaneous insertion or correction of 314 central venous catheters. Special attention was given to the malposition of these catheters. All catheters were inserted in different departments of our hospital. 182 catheters were placed with infraclavicular subclavian approach, (130 single lumen, 16 double lumen and 36 double lumen hemodialysis catheters). Through the internal jugular vein were placed 58 catheters (51 single lumen, 4 double lumen hemodialysis and 3 Hickmann catheters). Through the external jugular vein were introduced 32 catheters (10 single lumen, 6 Hickmann, 4 Infuse-A-Ports and 12 double lumen hemodialysis catheters). Through antecubital vein were placed 42 single lumen long central venous catheters. Catheter malposition occurred in 10 patients (3%). In 4 patients catheter was mal-positioned in the contralateral subclavian vein, in 3 in the ipsilateral internal jugular vein. In a patient, hydropneumothorax was developed as the result of intrapleural catheter malposition after cannulation of the right subclavian vein. In one case a catheter placed through the right external jugular vein was curled into the ipsilateral subclavian vein. Finally a long peripheral venous catheter, placed through the right external jugular vein, was advanced, until the tip was located in the peripheral lung vessels thus producing a peripheral pulmonary infarct. In 7 cases catheter malposition was diagnosed early, after catheter insertion, before catheter use, by a bedside confirming x-ray. In the rest three cases, on site confirming x-rays, were not diagnostic, because of poor quality. That resulted in major complication occurrence (subclavian vein thrombosis, pulmonary infarct, hydrothorax). Confirming of catheter tip placement in the superior vena cava (SVC), by an on site x-ray, is an expensive and time consuming method and involves the danger of allergic reactions due to use of contrast media. Its diagnostic accuracy depends on the quality of x-rays, contrast use and results in patient and personnel radiation. Recently we used, in 7 patients, a technique for electrocardiographic (ECG) guided percutaneous placement of central venous catheters. Using a small metallic tube, placed between the catheter and a syringe filled with normal saline and connected with an ECG monitor, the ECG is recorded with the catheter tip functioning as one of the electrodes. If the catheter tip is situated in the right atrium the ECG will record a biphasic or elevated P-wave. When the catheter is pulled back into the SVC the atrial-P will assume a normal shape. The method proved to be inexpensive, time saving and could be applied in emergency situation and intraoperatively permitting the im-mediated use of the catheter.