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LETTER TO EDITOR Table of Contents   
Year : 2010  |  Volume : 13  |  Issue : 1  |  Page : 71-72
Bedside technique to detect misplaced sub-clavian vein catheter in internal jugular vein

Department of Cardiac Anaesthesia, Max Heart and Vascular Institute, 2 Press Enclave, Saket, Delhi - 110 017, India

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Date of Web Publication11-Jan-2010

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;13:71-2

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 2023 Jan 27];13:71-2. Available from:

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 Top

1.Waxman BP, Polglase AL. Internal Jugular vein malposition of subclavian catheters. Prevention and detection. Med J Aust 1981;1:296-8.  Back to cited text no. 1      
2.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.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Ambesh SP, Dubey PK, Matreja P, Tripathi M, Singh S. Manual occlusion of the internal jugular vein during subclavian vein catheterization: a maneuver to prevent misplacement of catheter into internal jugular vein. Anesthesiology 2002;97:528-9.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Rath GP, Bithal PK, Toshniwal GR, Prabhakar H, Dash HH. Saline flush test for bedside detection of misplaced subclavian vein catheter into ipsilateral internal jugular vein. Br J Anaesth 2009;102:499-502.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Chaney MA, Minhaj MM, Patel K, Muzic D. Transesophageal echocardiography and Central line insertion. Ann Card Anaesth 2007;10:127-31.  Back to cited text no. 5  [PUBMED]  Medknow Journal  
6.Andrews RT, Bova DA, Venbrux AC. How much guidewire is too much? Direct measurement of the distance from subclavian and internal jugular vein occur sites to the superior vena cava-atrial junction during central venous catheter placement? Crit Care Med 2000;28:138-42.  Back to cited text no. 6      
7.Starr DS, Cornicelli S. EKG guided placement of subclavian CVP catheters using J- wire. Ann Surg 1986; 204:673-6.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  

Correspondence Address:
Sanjay Goel
Department of Cardiac Anaesthesia, Max Heart and Vascular Institute, 2 Press Enclave, Saket, Delhi - 110 017
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9784.58841

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