Year : 2011 | Volume
: 14 | Issue : 1 | Page : 70-
Sanjay Goel, Manish Tandon, Bishnu Panigrahi
Department of Cardiac Anaesthesia, Max Heart and Vascular Institute, 2 Press Enclave, Saket Delhi - 110 017, India
Department of Cardiac Anaesthesia, Max Heart and Vascular Institute, 2 Press Enclave, Saket, Delhi - 110 017
|How to cite this article:|
Goel S, Tandon M, Panigrahi B. Author's reply.Ann Card Anaesth 2011;14:70-70
|How to cite this URL:|
Goel S, Tandon M, Panigrahi B. Author's reply. Ann Card Anaesth [serial online] 2011 [cited 2021 Dec 1 ];14:70-70
Available from: https://www.annals.in/text.asp?2011/14/1/70/74414
We thank the authors for their interest and comments regarding our article titled "Bedside technique to detect misplaced subclavian vein catheter into the internal jugular vein".  We agree with Dr. Jain that Intravenous (IV) Electrocardiography (ECG) is a preferable technique to properly locate the tip of the central venous catheter (CVC) at the junction of the right atrium and superior vena cava (SVC). However, one needs to carefully analyze the ECG while inserting the CVC. Schummer et al. reported that the ECG changes during insertion of the CVC in the right atrium could be because of the pericardial reflection.  In addition, intravenous ECG guidance was unable to distinguish between venous and arterial catheter position. This means that even if one gets P wave in the ECG, he needs to confirm the presence of the catheter in the venous system. In another study, Schummer et al. reported that it is not a reliable method for confirming the position of left-sided CVCs.  Thus, transesophageal echocardiography (TEE) is necessary in addition to the use of IV ECG. TEE demonstrates the presence of the CVC in venous system as well as confirms the correct position of the tip. Expense and availability of both these techniques could be the issue and one needs to be experienced in TEE as well.
We chose to use surface ECG instead of IV ECG because of its easy availability, low cost and easy usability. Induction of ventricular premature contraction (VPC) sometimes could be hazardous but it is the intrinsic problem of any seldinger technique. One needs to be cautious while inducing it. In addition, we would like to cite the study by Starr et al.  which states that VPC could be induced in 76% cases in the first attempt. Overall, VPC could be induced in 95% of the cases and the correct location could be demonstrated in all of them. Whereas, VPC could not be induced in four (5%) cases and two of them had CVC malposition.
Thus, induction of VPC at least could confirm the presence of CVC in venous system, that too, in the right atrium. We agree with authors that this technique cannot be used to position the tip of the catheter at the junction of the right atrium and SVC. However, this may not be a problem in the intensive care setting.
To conclude, although various techniques are mentioned in the literature, experience in ultrasound (both TEE and transthoracic echocardiography) could be the answer for the problem. 
|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.|
|2||Schummer1 W, Schummer C, Schelenz C. Central venous catheters-the inability of 'intra-atrial ECG' to prove adequate positioning. Br J Anaesth 2004;93:193-8.|
|3||Schummer1 W, Schummer C, Schelenz C. Intra-atrial ECG is not a reliable method for positioning left internal jugular vein catheters. Br J Anaesth 2003;91:481-6.|
|4||Starr DS, Cornicelli S. EKG guided placement of subclavian CVP catheters using J-wire. Ann Surg 1986;204:673-6.|
|5||Schwemmer U, Brederlau J, Roewer N. Ultrasound use in non-cardiac surgery. Best Pract Res Clin Anaesthesiol 2009;23:237-47.|