Misplacement and Malposition of Central Venous Catheters Risk prevention

The misplacement or malposition of a central venous catheter describes the improper location of the catheter tip.¹

Why is it important to achieve an "ideal" catheter tip location for CVC?

• Infusion of vasopressors, irritant drugs or parenteral nutrition requires maximal dilution
• Avoiding the mixing of multiple drugs
• Extracorporeal circuits, e.g. dialysis requires 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 a CVC^3,4

Misplacement/Malposition could occur in different CVC application process steps: during insertion or in a later application by catheter migration^3,4

Potential Causes of Catheter Misplacement

Type and Position of Catheter Misplacement⁸

Complications related to CVC application

• Catheter dysfunction
• Delay of critical therapy (e.g. Vasopressors)

Complications related to the misplaced location

• Carotid Artery: Hypotension, hemorrhagic shock
• Azygos Vein: Pleural diffusion pulmonary edema, dyspnea, chest pain, back pain
• Pericardium: Fatal ventricular fibrillation
• Drug extravasation into surrounding -> tissue necrosis, organ dysfunction⁸

Estimated level of costs (time, material, and personnel) related to diagnostic procedures, delay of therapy and required management for misplaced CVC^8-11

Select the proper vessel

• Incidence of malpositioning is higher in the left thoracic venous system than in the right side
• The right side of the circulation should be considered of first preference for CVC insertion unless those insertion sites are contraindicated
• Use ultrasound for selecting the proper vessel for insertion

Select proper catheter length according to the insertion site and patient´s condition

Select proper technique to guide insertion and confirm tip position

• Ultrasound guidance
• Intraatrial (Intravascular) ECG
• Chest X-Ray
• Other supporting methods/techniques: electromagnetic, manometry (needle and catheter), pressure waveform analysis, blood gas analysis^8-11

Use of Valve Needle for venous access: save time/no disconnection needed

Verification of Catheter Position with Medical Imaging

X-Ray

• Plain Chest X-Ray is most commonly used to confirm catheter position within the chest and to detect pneumothorax, haemothorax or effusions after CVC placement

• Due to the 2D projection the close anatomical proximity of major arteries, veins, and pleura in the neck and chest causes difficulties and it is not possible to reliably state whether the distal section of the catheter is in an artery, vein, pleura, or mediastinum in the chest

• The intraatrial (intravascular) ECG technique can be used to confirm CVC tip position during or after CVC placement

• Ultrasound can be used to assess the jugular, femoral, axillary, and arm veins to aid insertion of a CVC, but is of limited value in confirming tip position in the SVC
• Transesophageal ultrasound (TEE) can be used if available to directly image the SVC, but this has practical limitations due to availability and operator training
• Transthoracic echo (TTE) can identify catheters in the RA, particularly with the injection of bubble contrast, but is not used in routine practice^8-11

1. Graham AS et. al. Central Venous Catheterization. N Engl J Med 2007; 356;21.
2. 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. J Anaesthesiol Clin Pharmacol 2013;29:397-400
3. McGee DC; Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33.
4. Kornbau C. et al. Central line complications. Int J Crit Illn Inj Sci. 2015 Jul-Sep; 5(3): 170–178.
5. Gibson F, Bodenham A. Misplaced central venous catheters: applied anatomy and practical management. British Journal of Anaesthesia  2013:110 (3): 333–46
6. Pikwer A, Baath L, Davidson B, Perstoft I, Akeson J. The incidence and risk of central venous catheter malpositioning: a prospective cohort study in 1,619 patients. Anaesth Intensive Care. 2008;36:30–7.
7. Parienti JJ et al. Intravascular Complications of Central Venous Catheterization by Insertion Site. N Engl J Med 2015;373:1220-9.;
8. Wang L, Liu ZS, Wang CA. Malposition of Central Venous Catheter: Presentation and Management. Chin Med J 2016;129:227-34.
9. Smit et al. Bedside ultrasound to detect central venous catheter misplacement and associated iatrogenic complications: a systematic review and meta-analysis.Critical Care (2018) 22:65h
10. Rodan C, Paniagua L. Central Venous Catheter Intravascular Malpositioning: Causes, Prevention, Diagnosis, and Correction. Western Journal of Emergency Medicine. 2015 Sep. 658-664
11. Fletcher Safe placement of central venous catheters: where should the tip of the catheter lie? British Journal of Anaesthesia 2000 85, 188-191