Year : 2010  |  Volume : 13  |  Issue : 1  |  Page : 71--72

Bedside technique to detect misplaced sub-clavian vein catheter in internal jugular vein


Sanjay Goel, Manish Tandon, Bishnu Panigrahi 
 Department of Cardiac Anaesthesia, Max Heart and Vascular Institute, 2 Press Enclave, Saket, Delhi - 110 017, India

Correspondence Address:
Sanjay Goel
Department of Cardiac Anaesthesia, Max Heart and Vascular Institute, 2 Press Enclave, Saket, Delhi - 110 017
India




How to cite this article:
Goel S, Tandon M, Panigrahi B. Bedside technique to detect misplaced sub-clavian vein catheter in internal jugular vein.Ann Card Anaesth 2010;13:71-72


How to cite this URL:
Goel S, Tandon M, Panigrahi B. Bedside technique to detect misplaced sub-clavian vein catheter in internal jugular vein. Ann Card Anaesth [serial online] 2010 [cited 2022 Aug 19 ];13:71-72
Available from: https://www.annals.in/text.asp?2010/13/1/71/58841


Full Text

The Editor,

In intensive care units (ICU), subclavian venous access is preferred over internal jugular vein (IJV) for central venous cannulation (CVC), for easier maintenance and patient's comfort. However, at times, inadvertent placement of the catheter into ipsilateral internal jugular vein might occur during attempted right subclavian cannulation by infra-clavicular approach. Various methods for the identification of such events have been described; ipsilateral head turning and supra-clavicular pressure, [1] keeping the guidewire J-tip directed downward, [2] and manual occlusion of the ipsilateral IJV at the time of insertion of guidewire. [3] Similarly, saline flush test [4] has also been used for bedside detection of the misplaced catheter. Despite all these reports, the problem of misplacement remains. Trans-esophageal (TEE) and trans-thoracic echocardiography [5] have also been used to confirm the presence of guidewire into the right atrium. Both these techniques need availability of the equipment as well as experience. Moreover, TEE is mainly used after the patient is anesthetized for cardiac surgery. Its use in the intensive care set up is still uncommon. Post-procedure chest X-ray is always required to rule out the misplacement, hemothorax, and pneumothorax.

It is the author's experience that continuous ECG monitoring, during subclavian vein cannulation and observing for atrial premature beats, while intentionally inserting the guidewire to sufficient length confirms its presence into right atrium. If atrial premature beat is not seen during insertion even after sufficient length is inserted, then this is likely, that the there is misplacement of guidewire to ipsilateral IJV. Thus reinsertion of guidewire, with J tip downward, in conjunction with ECG monitoring, decreases the misplacement of central venous catheter. There is always the concern of how much length to insert? According to a study by Andrews et al., [6] 18-19 cm should be considered the upper limit of the guidewire introduced during right sub-clavian venous cannulation. We insert the guidewire slowly while observing for the atrial ectopics and as soon as ectopics are seen, guidewire is pulled out slightly. Slow insertion and immediate withdrawal prevents fatal arrhythmias and any injury to vascular structures. Furthermore, if guidewire has gone to the ipsilateral IJV, one usually gets the resistance much before the usual length. In our literature search, we could find one study related to this technique who found 100% success with this method and success fell to 50% if no arrhythmia was noted. [7] There are some concerns of fatal arrhythmias with this technique. We feel that this is the intrinsic risk of guidewire and can occur with all techniques. Therefore, this method is not advisable for the patient with rhythm disturbance, however, it can be safely used in the patients with sinus rhythm admitted in the ICU.

References

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