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LETTER TO EDITOR  
Year : 2011  |  Volume : 14  |  Issue : 1  |  Page : 69-70
ECG-guided central venous catheterization - can it truly detect internal jugular venous malpositioning of subclavian catheter


Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India

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Date of Web Publication31-Dec-2010
 

How to cite this article:
Jain A, Mangal K. ECG-guided central venous catheterization - can it truly detect internal jugular venous malpositioning of subclavian catheter. Ann Card Anaesth 2011;14:69-70

How to cite this URL:
Jain A, Mangal K. ECG-guided central venous catheterization - can it truly detect internal jugular venous malpositioning of subclavian catheter. Ann Card Anaesth [serial online] 2011 [cited 2021 Oct 20];14:69-70. Available from: https://www.annals.in/text.asp?2011/14/1/69/74413


The Editor,

We read the letter to the editor, "Bedside technique to detect misplaced subclavian vein catheter in internal jugular vein". [1] We agree with the authors' suggestion that the ECG-guided insertion of subclavian vein (SCV) cannulation increases the success rate and decreases the overall rate of malpositioning of central venous pressure (CVP) catheter. However, the authors' inference that the technique could be used for detecting the ipsilateral internal jugular vein (IJV) malpositioning of CVP catheter is debatable.

Starr et al, [2] showed that the occurrence of premature atrial contraction (PAC) or other cardiac arrhythmias during guidewire placement is a reliable guide to correct subsequent placement of the CVP catheter. However, only 76 % patients had PACs on the first attempt. Furthermore, in 50% cases wherein CVP catheter was inserted when no PAC was identified, a proper placement of CVP catheter was observed on chest X-ray. Thus, the positive predictive value of the ECG-guided technique for detecting malpositioning of CVP catheter is only 50% i.e., equivalent to simple tossing of a coin. Further, of the two patients, one had an inadvertent internal jugular vein (IJV) cannulation, while in the other patient SCV catheter was misplaced in the innominate vein.

Though, malpositioning of catheter tip in ipsilateral IJV is most common (5.4%), catheter tip placements in the contralateral SCV, left internal mammary vein, azygous vein, hemiazygos vein, lateral thoracic vein, inferior thyroid vein, left superior intercostal vein, thymic vein, pleural cavity, and the jugular foramen have been reported. [3]none Undoubtfully, ECG-guided technique can not differentiate these from the IJV malpositioning of SCV catheter.

Certainly, the saline flush test, echocardiography and chest X-ray can reliably detect the catheter malpositioning in the IJV. [1] The "IJV occlusion test" (applying external pressure on the IJV in the supraclavicular area and observing the changes in the CVP and its waveform pattern) [2] and "auscultatory test" [4] are other bed-side methods to detect this complication. However, methods including ipsilateral head turning and supraclavicular pressure, [4] keeping the guidewire J-tip directed downward, [2] and manual occlusion of the ipsilateral IJV at the time of insertion of guidewire [5] can only be used to prevent malpositioning of catheter tip in ipsilateral IJV. These techniques can not detect malpositioning once it occurs.

The optimum length of insertion of the guidewire based on the occurrence of PAC, as described by the authors, can be unreliable. Rather, the morphology of P-wave should be observed during ECG-guided central venous catheterization to determine the optimal site for CVC tip positioning. The transesophageal echocardiographic evaluation of the ECG-guided central venous catheterization revealed that the tallest peaked P wave may be used to place the CVC tip at the superior vena cava-atrial junction, while the biphasic P waves identify right atrium localization. [6]

Although we differ with the authors' suggestions and the issue may be contentious because of its interwoven complexity, they must be complemented for their efforts to conceptualize the technique of ECG-guided central venous catheterization.

 
   References Top

1.Goel S, Tandon M, Panigrahi B. Bedside technique to detect misplaced subclavian vein catheter in internal jugular vein. Ann Card Anaesth 2010;13:71-2.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.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. 2
[PUBMED]  [FULLTEXT]  
3.D'souza N, Gupta B, Sawhney C, Chaturvedi A. Misdirected central venous catheter. J Emerg Trauma Shock 2010;3:209-10.  Back to cited text no. 3
    
4.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. 4
[PUBMED]    
5.Ambesh SP, DubeyPK, 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. 5
    
6.Jeon Y, Ryu HG, Yoon SZ, Kim JH, Bahk JH. Transesophageal echocardiographic evaluation of ECG-guided central venous catheter placement. Can J Anaesth 2006;53:978-83.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  

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Correspondence Address:
Amit Jain
Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.74413

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