A Study of Malposition of Central Venous Catheter – A Comparative Study between Ultrasound Guided and Anatomical Landmark Technique

Abstract

Introduction: Central venous catheterization is a routine procedure for long-term infusion therapy and central venous pressure measurement. Sometimes, the catheter tip may be unintentionally placed at the position other than the junction of superior vena cava and right atrium. This is called malposition and can lead to erroneous pressure measurement, increase risk of thrombosis, venous obstruction or other life threatening complications like pneumothorax, cardiac temponade.Objectives: This study aimed to observe the incidence of the malposition and compare the same between ultrasound guided catheterization and blind anatomical landmark technique.Methodology: This study was a prospective comparative study conducted at the intensive care unit of Birat Medical College and Teaching Hospital for two-year duration. All the catheterizations were done either with the use of real time ultrasound or blind anatomical landmark technique. The total numbers of central venous catheterization, the total incidences of malposition were observed. Finally the incidences were compared between real time ultrasound guided technique and blind anatomical landmark technique.Results: In two-year duration of the study, a total of 422 central venous cannulations were successfully done. The real time ultrasound was used for 280 cannulations while blind anatomical landmark technique was used for 162 patients. The study observed various malposition in 36 cases (8.5%). The most common malposition was observed for subclavian vein to ipsilateral internal jugular vein (33.3%) followed by subclavian to subclavian vein (27.8%) and internal jugular to ipsilateral subclavian vein (16.7%). In four patients the catheter had a reverse course in the internal jugular vein while the tip was placed in pleural cavity in three cannulations. There was coiling of the catheter inside left subclavian vein in one patient. The malposition was significantly reduced with the use of the real time ultrasound (P< 0.001). However there is no significant difference in the incidence of the various malposition between ultrasound guidance technique and blind anatomical landmark technique when compared individually.Conclusion: The malposition of the central venous catheter tip was common complication with the overall incidence of 8.5%. The most common malposition was subclavian vein to internal jugular vein. The use of real time ultrasound during the catheterization procedure can significantly reduced the risk of malposition.Birat Journal of Health SciencesVol.2/No.3/Issue 4/Sep- Dec 2017, Page: 277-281

Malposition of Central Venous Catheter Inserted under Ultrasound Guidance in Intensive Care Unit: A Case Series

“…The possible reason for malpositions could be the change in the direction of the J tip of the guide wire during the procedure, excessive force applied during threading of guidewire or catheter, excessive length of guidewire insertion, the position of head and shoulder 2 and in our patient increase angle between SCV and IJV may be the cause of malposition.…”

“…The possible ways to decrease malposition is to keep the guidewire J-tip directed caudad, 3 insertion under fluoroscopic guidance, application of external pressure of IJV during threading of guidewire from SCV. 2 …”

“…Complication like malposition, arrhythmia, infection, artery perforation, pneumothorax, hemothorax thrombosis has decreased by use of ultrasound during insertion of CVC. 2 Malposition is defined as central venous catheter tip placement in a vein other than superior vena cava (SVC), or the right atrium, impingement with the lateral wall of SVC and arterial cannulation 3 and occurs in 1.5 to 9.1% patients. 3 , 4 We report a case series of three patients that had malposition of CVC inserted under ultrasound guidance that was detected by chest X-ray.…”