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Table of Contents
Year : 2019  |  Volume : 22  |  Issue : 4  |  Page : 455-456
How to avoid malpositioning of central venous catheter using ultrasound?

Department of Anaesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India

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Date of Web Publication4-Oct-2019

How to cite this article:
Nair AS, Naik V, Upputuri O, Rayani BK. How to avoid malpositioning of central venous catheter using ultrasound?. Ann Card Anaesth 2019;22:455-6

How to cite this URL:
Nair AS, Naik V, Upputuri O, Rayani BK. How to avoid malpositioning of central venous catheter using ultrasound?. Ann Card Anaesth [serial online] 2019 [cited 2022 Jan 24];22:455-6. Available from:

The Editor,

Central venous catheter (CVC) placement is a common procedure done in the practice of anesthesia and critical care medicine for several indications. The right internal jugular vein (IJV) is usually preferred as it has a straight course and has less tendency for thrombosis and venous stenosis.[1] Arrhythmias on negotiating a guidewire during CVC insertion is considered as a confirmatory sign of entering right atrium (RA) by many clinicians. Atrial and ventricular premature contractions are the most common however supraventricular tachycardia can also result when the guide wire touches atrioventricular node for a prolonged duration.[2] Electrocardiographic (ECG) guidance is also used for confirming correct entry of CVC into superior vena cava (SVC) and RA. However, it requires special equipment and Schummer et al. described that increase in P wave size need not always correspond with the entry into of guide wire into RA. Moreover, ECG guidance is also unable to distinguish between venous and arterial catheter placement.[3]

CVC under ultrasound (US) guidance is considered standard of care.[4] The needle is introduced under US guidance using either an out of a plane or an oblique approach to puncture the vein in real time. Most clinicians remove the US probe once the vein is punctured. A guide wire is inserted, and the CVC is introduced in the vein after dilating the skin. A chest radiograph is used to confirm the position of catheter after the procedure. The incidence of CVC malposition can be up to 5.01%.[5] Malpositioned CVC have been found occupying arteries, mediastinum, pleura, pericardium, trachea, esophagus, and subarachnoid space. Once malposition is confirmed on chest radiograph, the CVC is usually rewired redirected/repositioned over a guide wire with or without fluoroscopy. The process of repositioning not only adds to patient's discomfort and anxiety, it also delays further treatment for the patient. Repositioning can also compromise sterility.

In our practice, we include the supraclavicular area during sterile preparation and perform a scan of the area with the probe in caudal orientation once the guide wire is inserted. This way, one can follow the guide wire going down into SVC/RA. In case the wire is not visible, the probe is moved medially or laterally to trace the guide wire. [Figure 1] shows a guide wire which was inserted through right IJV, and instead of going down it took a right turn to enter the right subclavian vein (SCV). This can be repositioned in the same sitting before inserting the CVC by withdrawing the guide wire in real time till the right turn vanishes [Figure 2]. By rotating the guide wire, it is maneuvered in such a way that it goes down into SVC/RA. By following this technique, another procedure involving readjustment can be avoided. While cannulating the left IJV, the wire would be seen taking a right turn on US for entering the RA/SVC, and the guide wire should not be seen inside the left SCV in the supraclavicular area.
Figure 1: Guide wire turning right, into subclavian vein instead of superior vena cava

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Figure 2: Guide wire entering superior vena cava after rewiring in the same setting before introducing the central venous catheter

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In conclusion, we suggest to use US not only for puncturing a central vein but also to ensure that the catheter enters the destined place instead of getting malpositioned.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Ruesch S, Walder B, Tramèr MR. Complications of central venous catheters: Internal jugular versus subclavian access – A systematic review. Crit Care Med 2002;30:454-60.  Back to cited text no. 1
Kornbau C, Lee KC, Hughes GD, Firstenberg MS. Central line complications. Int J Crit Illn Inj Sci 2015;5:170-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
Schummer W, Schummer C, Schelenz C, Brandes H, Stock U, Müller T, et al. Central venous catheters – The inability of 'intra-atrial ECG' to prove adequate positioning. Br J Anaesth 2004;93:193-8.  Back to cited text no. 3
American Society of Anesthesiologists Task Force on Central Venous Access, Rupp SM, Apfelbaum JL, Blitt C, Caplan RA, Connis RT, et al. Practice guidelines for central venous access: A report by the American society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology 2012;116:539-73.  Back to cited text no. 4
Wang L, Liu ZS, Wang CA. Malposition of central venous catheter: Presentation and management. Chin Med J (Engl) 2016;129:227-34.  Back to cited text no. 5

Correspondence Address:
Abhijit S Nair
Department of Anaesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad - 500 034, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aca.ACA_101_18

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  [Figure 1], [Figure 2]