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Risk prevention

Misplacement and Malposition of Central Venous Access Devices

The main risks of central venous access devices misplacement include infections, bleeding, perforation of the vessel or organ, and difficulty in removing the device. Misplacement can also lead to catheter-related bloodstream infections and thrombosis, which can result in serious complications such as sepsis and pulmonary embolism. Prompt recognition and correction of misplacement are crucial to reduce these risks and improve patient outcomes.

Correct catheter tip positioning6

Conclusion:

„ [...] correct position of the catheter has to be ensured during placement"

scheme of catheter tip position Caers J, Fontaine C,Vinh-Hung V et al (2005) Catheter tip position as a risk factor for thrombosis associated with the use of subcutaneous infusion ports. Support Care Cancer 13:325-331​

Relation between catheter tip position and complication rate

Location of catheter tip positionNumber of patientsVenous thrombosisFunctional problems
Brachocephalic vein3245.2%6.5%
SVC cranial 1/34219%16.7%
SVC mid 1/31424.2%1.4%
SVC caudal 1/3661.5%0%
RA or inferior Vena Cava185.5%5.6%

Why is it important to achieve an "ideal" catheter tip location for CVC, TIVAD and PICC?

  • Infusion of vasopressors, irritant drugs, or parenteral nutrition requires maximal dilution,  avoiding mixing of multiple drugs such as chemo- and antibiotic therapy and blood sampling  
  • Extracorporeal circuits, e.g. dialysis requires a very high blood flow rate passing by the catheters, and separation of inflow and outflow of catheters to avoid blood recirculation
  • Measurement of ScvO2 requires catheter tip lies in or as close to the right atrium as possible

Misplacement/Malposition is one of the most common complications related to  CVADs7-10

Misplacement/Malposition could occur in different CVAD application

graphic-misplacement-one-of-the-mot-common-complications

Jugular vein right

Jugular vein right

Cannulation by the right internal vein n=1023 (63.2%)

Jugular vein left

Jugular vein left

Cannulation by the left internal jugular vein n= 104 (6.4%)

Subclavian vein right

Subclavian vein right

Cannulation by the right subclavian vein n=287 (17.7%)

Subclavian vein left

Subclavian vein left

Cannulation by the left subclavian vein n= 37 (2.3%)

GroupThrombosis Rate
Catheter tip in upper SVC Left sided port8/28 (28.6%)
Catheter tip in upper SVC Right sided port1/33 (3%)
Catheter tip in lover SVC Left sided port0/250
Catheter tip in lover SVC Right sided port1/68 (1.5%)

 

Intravascular MisplacementExtravascular Misplacement
Carotid arteryExtradural space
Azygos veinPericardium
Paersistent left sided superior vena cavaPleural space
Internal thoracic (mammarx) veinMediastinum
Vertebral veinThoracic duct

Intravascular Misplacement

Extravascular Misplacement

 

Estimated level of costs (time, material, and personnel) related to diagnostic procedures, delay of therapy and required management for misplaced CVADs.

Clinical Consequences

Clinical Examination and Treatment

Level of additional length of stay and cost

Complications related to CVAD application

  1. Catheter dysfunction

    Delay of therapy

Medica Image to detect misplaced catheter, chest X-ray, alternatively CT or MRI

+ ∼ +++
 

Removal of catheter, according to the sereneness (bedside, via Interventional radiology or via surgery
Insertion of new catheter.

+ ∼ ++++
 

Catheter removal via Interventional Radiology

+++

Complications related to the misplaced location 

  • Carotid artery: hypotension, hemorrhagig shock

    Azygos vein; pleural diffusion pulmonary edema, dyspnea, chest pain, back pack pain

    Pericardium: fatal ventricular fibrillation

 

Individual surgical or non-surgicak treatment according to the impaired organ or tissue

++ ∼ ++++

Drug extravasation into surrounding

Non-surgical or surgical treatment fot extravasation

++ ∼ ++++

Central Venous Catheters (CVC)

Certodyn® Pediatric Universal Adapter

Universal Adapter for recording alternately an intra-vascular and surface ECG for positioning of central venous catheters

Certodyn® Universal Adapter

Universal Adapter for recording alternately an intra-vascular and surface ECG for positioning of central venous catheters

Certofix® Mono

Single-lumen catheter set for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® Mono Paed

Single-lumen catheter set for paediatrics and neonatology according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® Mono Econoline & other Basic Set

Single-lumen catheter set for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® protect Duo HF

Antimicrobially modified double-lumen High Flow catheter sets for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® protect Trio HF

Antimicrobially modified triple-lumen High Flow catheter sets for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix protect Quinto

Antimicrobially modified five-lumen catheter sets for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® protect Mono

Antimicrobially modified single-lumen catheter sets for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® Quattro

Four-lumen catheter set for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® Safety Mono

Single-lumen catheter set for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® Safety Duo

Double-lumen catheter set for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® Safety Trio

Triple-lumen catheter set for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® Safety Quattro

Four-lumen catheter set for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® Safety Quinto

Five-lumen catheter set for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® Duo Econoline & other Basic Set

Double-lumen catheter set for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® Trio Econoline & other Basic Set

Triple-lumen catheter set for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® Duo Paed

Double-lumen catheter set for paediatrics and neonatology according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® Trio Paed

Triple-lumen catheter set for paediatrics and neonatology according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® Quinto

Five-lumen catheter set for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® Duo

Double-lumen catheter set for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® Trio

Triple-lumen catheter set for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® Trio HF

Triple-lumen High Flow catheter set for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® protect Duo

Antimicrobially modified double-lumen catheter sets for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® protect Trio

Antimicrobially modified triple-lumen catheter sets for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® protect Quattro

Antimicrobial modified four-lumen catheter sets for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

Certofix® Duo HF

Double-lumen High Flow catheter set for catheterization of the vena cava according to the Seldinger method with the possibility of ECG based Central Venous Catheter tip placement and position control

[1]   Ho C, Spry C. Central Venous Access Devices (CVADs) and Peripherally Inserted Central Catheters (PICCs) for Adult and Pediatric Patients: A Review of Clinical Effectiveness and Safety 2017. 

[2]   M. Pittiruti, A. La Greca, G. Scoppettuolo. The Electrocardiographic Method for Positioning the Tip of Central Venous Catheters. undefined 2011. 

[3]   Graham AS, Ozment C, Tegtmeyer K, Lai S, Braner DAV. Videos in clinical medicine. Central venous catheterization. N Engl J Med 2007; 356: e21. https://doi.org/10.1056/NEJMvcm055053

[4]   Gibson F, Bodenham A. Misplaced central venous catheters: applied anatomy and practical management. British journal of anaesthesia 2013; 110: 333–46. https://doi.org/10.1093/bja/aes497

[5]   Schutz JCL, Patel AA, Clark TWI, et al. Relationship between chest port catheter tip position and port malfunction after interventional radiologic placement. Journal of vascular and interventional radiology: JVIR 2004; 15: 581–87. https://doi.org/10.1097/01.rvi.0000127890.47187.91

[6]   Caers J, Fontaine C, Vinh-Hung V, et al. Catheter tip position as a risk factor for thrombosis associated with the use of subcutaneous infusion ports. Supportive care in cancer: official journal of the Multinational Association of Supportive Care in Cancer 2005; 13: 325–31. https://doi.org/10.1007/s00520-004-0723-1

[7]   Kornbau C, Lee KC, Hughes GD, Firstenberg MS. Central line complications. International Journal of Critical Illness and Injury Science 2015; 5: 170–78. https://doi.org/10.4103/2229-5151.164940

[8]   McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003; 348: 1123–33. https://doi.org/10.1056/NEJMra011883

[9]   Rossetti F, Pittiruti M, Lamperti M, Graziano U, Celentano D, Capozzoli G. The intracavitary ECG method for positioning the tip of central venous access devices in pediatric patients: results of an Italian multicenter study. The journal of vascular access 2015; 16: 137–43. https://doi.org/10.5301/jva.5000281

[10]   Pelagatti C, Villa G, Casini A, Chelazzi C, Gaudio AR de. Endovascular electrocardiography to guide placement of totally implantable central venous catheters in oncologic patients. The journal of vascular access 2011; 12: 348–53. https://doi.org/10.5301/JVA.2011.8380

[11]   Parienti J-J, Mongardon N, Mégarbane B, et al. Intravascular Complications of Central Venous Catheterization by Insertion Site. N Engl J Med 2015; 373: 1220–29. https://doi.org/10.1056/NEJMoa1500964

[12]   Wang L, Liu Z-S, Wang C-A. Malposition of Central Venous Catheter: Presentation and Management. Chin Med J (Engl) 2016; 129: 227–34. https://doi.org/10.4103/0366-6999.173525

[13]   Smit JM, Raadsen R, Blans MJ, Petjak M, van de Ven PM, Tuinman PR. Bedside ultrasound to detect central venous catheter misplacement and associated iatrogenic complications: a systematic review and meta-analysis. Critical care (London, England) 2018; 22: 65. https://doi.org/10.1186/s13054-018-1989-x

[14]   Roldan CJ, Paniagua L. Central Venous Catheter Intravascular Malpositioning: Causes, Prevention, Diagnosis, and Correction. West J Emerg Med 2015; 16: 658–64. https://doi.org/10.5811/westjem.2015.7.26248

[15]   Fletcher SJ, Bodenham AR. Safe placement of central venous catheters: where should the tip of the catheter lie? British journal of anaesthesia 2000; 85: 188–91. https://doi.org/10.1093/bja/85.2.188

[16]   Stas M, Mulier S, Pattyn P, Vijgen J, Wever I de. Peroperative intravasal electrographic control of catheter tip position in access ports placed by venous cut-down technique. European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 2001; 27: 316–20. https://doi.org/10.1053/ejso.2000.1047

[17]   Venugopal AN, Koshy RC, Koshy SM. Role of chest X-ray in citing central venous catheter tip: A few case reports with a brief review of the literature. Journal of anaesthesiology, clinical pharmacology 2013; 29: 397–400. https://doi.org/10.4103/0970-9185.117114

[18]   Pittiruti M, Bertollo D, Briglia E, et al. The intracavitary ECG method for positioning the tip of central venous catheters: results of an Italian multicenter study. The journal of vascular access 2012; 13: 357–65. https://doi.org/10.5301/JVA.2012.9020