The Incidence and Risk of Central Venous Catheter Malpositioning: A Prospective Cohort Study in 1619 Patients

Abstract

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.

Noncardiac entrapment of a pulmonary artery catheter during heart transplantation: inadvertent cannulation and perforation of the internal thoracic vein

“…Chest radiography continues to be the accepted modality to diagnosis catheter malposition [16,17]. Due to the anterior position of the internal thoracic vein, a catheter in this vein may appear more lateral than a catheter in the IJV of the same side on a posteroanterior chest radiograph [14].…”

Unanticipated complication of a malpositioned central venous catheter

“…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-fl ow use, or the infusion of local irritant drugs [3]. In our patient, the PICC was seen very close to the anastomosis in the left cervical region, but when the malpositioned tip was recognized there was no evidence of vascular erosion or fl uid extravasation near the site.…”

Peut-on réduire le nombre de radiographies de thorax en réanimation ?

“…Plusieurs travaux suggèrent que, suite à l'insertion d'un CVC par la voie jugulaire essentiellement droite [35], la RT est de peu d'intérêt à certaines conditions (durée de pose du CVC brève, insertion simple, aspiration de sang aisée [lorsqu'il n'existe pas d'hémothorax avant insertion] [36], pas de mesure de la pression veineuse centrale, administration de produits non irritants [chimiothérapie] ni administrés à haut débit [35,37,38]). L'utilisation de cathéters de 15 cm permet (chez l'adulte, sauf en cas de morphologie extrême) que l'extrémité du cathéter ne soit jamais placée au-delà de la partie inférieure de la veine cave supérieure [39], mais cela n'est vérifié qu'avec la voie jugulaire interne droite.…”

“…Dans une série de 470 CVC introduits dans le territoire cave supérieur, le recueil de paramètres permettant de considérer que l'insertion facile prédisait que le placement du cathéter était correct dans 95,3 % des cas, mais les auteurs considéraient que la position dans la partie supérieure de l'oreillette droite est acceptable [35]. De façon similaire, dans une série colligeant 1 679 CVC, une insertion simple a été associée à une malposition dans seulement 3,3 % des cas [37]. Il faut noter, dans ce travail, que seules les positions extrathoracique et intraventriculaire étaient considérées comme incorrectes et que le positionnement dans l'oreillette droite était observé dans 11 % des cas.…”