This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Bahk, J.-H. Articles by Stayer, S. A. Search for Related Content PubMed PubMed Citation Articles by Bahk, J.-H. Articles by Stayer, S. A.

---

LETTERS TO THE EDITOR

The Optimal Location of Central Venous Catheters

Department of Anesthesiology and Clinical Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea

To the Editor:

I read with interest the article by Andropoulos et al. (1) regarding the guidelines for correct initial length of insertion of central venous catheters (CVC) in children, where they had the goal of avoiding placement of the catheter in the right atrium (RA). I would like to raise two points concerning the article. First, where is the optimal place for CVC in children? Second, what is the scientific basis for combining the results of the internal jugular and subclavian vein catheters? There has been considerable debate in the literature about the optimal place. However, it is clear that as the axes of the catheter and vein are aligned parallel, there would be less perforation. Upper superior vena cava (SVC) is suitable only for tips of catheters placed via the right internal jugular route, and low SVC and upper RA is a suitable tip site from any access point in the upper body (2). The optimal position can be different depending on the route of entry.

In children, subclavian catheter frequently positions in the internal jugular vein (3,4) because the angle formed between the subclavian and innominate veins is more acute than in adults (3). Gross anatomic dissections and coronal magnetic resonance imaging demonstrated that the subclavian and internal jugular veins joined at an angle of 90° or greater in the neutral anatomic position (5). Although the subclavian catheter is directed to the SVC, if it is not pushed sufficiently deep after a sharp bend at the junction from the subclavian vein into the brachiocephalic vein, it may not be aligned parallel to the vessel wall. Thus CVC placement in the upper RA should not be abandoned but may be approved at least for the subclavian catheter. This is also supported by the fact that the relative location of CVC compared with the RA-SVC junction tends to appear deeper than the actual location on the portable anteroposterior radiograph (6).

References

1. Andropoulos DB, Bent ST, Skjonsby B, Stayer SA. The optimal length of insertion of central venous catheters for pediatric patients. Anesth Analg 2001; 93: 883–6.[Abstract/Free Full Text]
2. Fletcher SJ, Bodenham AR. Safe placement of central venous catheters: where should the tip of the catheter lie? Br J Anaesth 2000; 85: 188–91.[Free Full Text]
3. Cobb LM, Vinocur CD, Wagner CW, et al. The central venous anatomy in infants. Surg Gynecol Obstet 1987; 165: 230–4.[Web of Science][Medline]
4. Jung CW, Bahk JH, Kim MW, et al. Head position for facilitating the superior vena caval placement of catheter during right subclavian approach in children. Crit Care Med 2002; 30: 297–9.[Web of Science][Medline]
5. Jesseph JM, Conces DJ, Augustyn GT. Patient positioning for subclavian catheterization. Arch Surg 1987; 122: 1207–9.[Abstract/Free Full Text]
6. Andropoulos DB, Stayer SA, Bent ST, et al. A controlled study of transesophageal echocardiography to guide central venous catheter placement in congenital heart surgery patients. Anesth Analg 1999; 89: 65–70.[Abstract/Free Full Text]

Response

Division of Pediatric Cardiovascular Anesthesiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX

In Response:

We appreciate Dr. Bahk’s comments about optimal location for central venous catheter (CVC) placement in children. We agree that CVCs parallel to the superior vena cava (SVC) wall, whether high, mid, or low SVC, are much less likely to perforate the vessel (1). We also agree that right subclavian catheters have a higher incidence of being positioned across the midline, and may migrate after placement if left too high (2). Lower positioning in the low SVC with right subclavian CVC may be preferable because a longer length of catheter is parallel to the vein wall and less likely to migrate. We also agree that a CVC tip high in the right atrium (RA) that stays fixed in position, well away from the free wall, poses little risk of perforation.

However, we believe that positioning the CVC tip above the RA confers a greater margin of safety, particularly during "blind" insertion methods where the CVC will not be imaged for several hours. Thus our arguments that CVC tips should not be intentionally positioned in the RA are as follows.

1. As noted in our article, 90% of CVC perforations occur with catheter tips in the RA or right ventricle and only 10% when in the SVC (1).

2. RA CVC may cause arrhythmias, specifically premature atrial contractions, supraventricular tachycardia, and ectopic atrial tachycardia (3).

3. The RA contracts vigorously but the SVC does not. Thus the RA free wall is not fixed in position, and if the CVC is in any other place but the high RA (i.e., in the mid or low RA, in the appendage, or at an acute angle to the RA wall), perforation risk is increased because of the contraction of the free wall of the RA against the CVC tip (4).

4. The CVC tip will migrate up to several cm distally with head and neck movement (5), arm movement, and respiratory variation. If the tip is already in the RA, distal movement may perforate the free wall of the RA.

5. Surgical manipulation, either of the heart itself, or with retraction in the right upper quadrant may lead to distal migration of the CVC tip and perforation (6).

6. Examination of our data reveals a wide variation in the location of the SVC/RA junction in any individual patient. During blind insertion methods, allowing a lower tip position may lead to a greater percentage of CVC in the mid or low RA, leading to increased perforation risk. The few CVC tips in our series that were in the RA were all within 1 cm of the SVC/RA junction.

One may consider placing the CVC tip high in the SVC to be preferable because perforation at this level is above the pericardial reflection and less likely to cause tamponade. Perforation in the RA may, of course, lead to catastrophe (7,8). During several hundred transesophageal echocardiographically guided CVC placements (2), we have observed the distance from the SVC/RA junction to the RA free wall to be only 2–3 cm or less in patients weighing less than 10 kg. Therefore, a seemingly small migration of the tip may place the CVC much deeper in the RA and at increased perforation risk.

We combined right subclavian and right internal jugular data because, after separate evaluation, the proposed guidelines for the depth of insertion were the same for both groups. Combining the data meant that one set of clinically useful guidelines could be made for both insertion sites, with a high degree of success in predicted proper placement, i.e., 97% for all CVC versus 99% and 93% for right internal jugular and right subclavian alone, respectively, when using the height based formulae, and similar success predicted when using the weight-based formulae.

In our opinion, given the individual variation in each patient, the best method to ensure proper placement is to image the CVC tip as soon as possible. Transesophageal echocardiography, if available, is useful because the tip position can be easily adjusted before final securing (2). If this is not possible, chest radiography should be performed as soon as possible to confirm tip position. In certain difficult or questionable cases, immediate radiography in the operating room before the start of a long surgical procedure may be indicated.

References

1. Collier PE, Ryan JJ, Diamond DL. Cardiac tamponade from central venous catheters: report of a case and review of the literature. Angiology 1984; 35: 595–600.
2. Andropoulos DB, Stayer SA, Bent ST, et al. A controlled study of transesophageal echocardiography to guide central venous catheter placement in congenital heart surgery patients. Anesth Analg 1999; 89: 65–70.
3. Conwell JA, Cocalis MW, Erickson LC. EAT to the beat: "ectopic" atrial tachycardia caused by catheter whip. Lancet 1993; 342: 740.
4. Brandt RL, Foley WJ, Fink GH, et al. Mechanism of perforation of the heart with the production of hydropericardium by a venous catheter and its prevention. Am J Surg 1970; 119: 311–6.[Web of Science][Medline]
5. Fischer GW, Scherz RG. Neck vein catheters and pericardial tamponade. Pediatrics 1973; 52: 868–71.[Abstract/Free Full Text]
6. Leech RC, Watts AD, Heaton ND, Potter DR. Intraoperative cardiac tamponade after central venous cannulation in an infant during orthotopic liver transplantation. Anesth Analg 1999; 89: 342–3.[Free Full Text]
7. Bone DK, Maddrey WC, Egan J, Cameron JL. Cardiac tamponade: a fatal complication of central venous catheterization. Arch Surg 1973; 106: 868–70.[Abstract/Free Full Text]
8. Dane TEB, King EG. Fatal cardiac tamponade and other mechanical complications of central venous catheters. Br J Surg 1975; 62: 6–10.[Web of Science][Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Bahk, J.-H. Articles by Stayer, S. A. Search for Related Content PubMed PubMed Citation Articles by Bahk, J.-H. Articles by Stayer, S. A.