|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 3 | Page : 435-436
Displacement of optimally placed subclavian central venous catheter by dialysis catheter - retrospection after radiography
Arun Kumar, Souvik Chaudhuri, Shaji Mathew, Kush Goyal
Department of Anaesthesia, Kasturba Medical College, Manipal, Karnataka, India
|Date of Web Publication||22-Jul-2014|
Department of Anaesthesia, Kasturba Medical College, Manipal - 576 104, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kumar A, Chaudhuri S, Mathew S, Goyal K. Displacement of optimally placed subclavian central venous catheter by dialysis catheter - retrospection after radiography. J Anaesthesiol Clin Pharmacol 2014;30:435-6
|How to cite this URL:|
Kumar A, Chaudhuri S, Mathew S, Goyal K. Displacement of optimally placed subclavian central venous catheter by dialysis catheter - retrospection after radiography. J Anaesthesiol Clin Pharmacol [serial online] 2014 [cited 2020 Apr 7];30:435-6. Available from: http://www.joacp.org/text.asp?2014/30/3/435/137293
Incidence of malposition of central venous catheter (CVC) ranges from 1-60%.  The right subclavian vein is associated with the highest risk of malposition of about 9.1%.  Most common cause of early CVC malfunction is malposition of the catheter tip during insertion and it can be detected immediately after chest radiography. , We report a case of an optimally placed right subclavian CVC which was displaced proximally to the left innominate vein after insertion of dialysis catheter through left internal jugular vein (IJV). Even though CVC tip is optimally placed, it may be displaced completely after the subsequent placement of another CVC, in spite of it being from the opposite side.
A 36-year-old male patient was admitted to the surgical ICU after polytrauma and was on mechanical ventilation due to poor Glasgow coma scale (GCS) score. On seventh day post admission, he was shifted to multi-disciplinary intensive care unit (MICU) in view of pulmonary edema, hemodynamic instability and renal failure. A 15 cm, 7 French triple lumen CVC was secured in the right subclavian vein in first attempt using Seldinger technique, and backflow of blood was confirmed in all three lumens. Right subclavian CVC was inserted for the purpose of hemodynamic monitoring and drug infusions. The optimal position of the right subclavian CVC tip was ensured after chest radiography [Figure 1]. Due to acute renal failure (ARF), hemodialysis was planned. Dialysis catheter was inserted from the left IJV. Due to open wounds over both the groin areas, femoral route was not used for dialysis catheter insertion. Post-insertion, chest radiography showed the right subclavian CVC pulled and displaced proximally to the left innominate vein by the left sided dialysis catheter [Figure 2]. The right subclavian CVC was promptly removed, and left sided subclavian CVC was inserted [Figure 3]. During the course of his stay in ICU, the patient gradually improved and was shifted to step down ICU for further management.
To ensure the optimal position of CVC tip radiographically, three zones for catheter tip positioning can be categorized.  Zone A represents lower superior vena cava (SVC) and upper right atrium and represents a necessary compromise for the left sided CVC to ensure they lie parallel to vessel wall. Zone B represents the area around the junction of the left and the right innominate veins and upper SVC, and is a suitable area for CVC placed from the right side.  Zone C represents the left innominate vein proximal to SVC and is suitable site for tip position when catheter is introduced from the left subclavian vein or IJV, but for short term fluid therapy and CVP monitoring. ,
The chest radiograph in our patient after right subclavian CVC insertion showed the tip lying above carina in Zone B. But after the insertion of dialysis catheter through the left IJV, chest radiograph revealed displacement of right subclavian CVC proximally to the left innominate vein by the dialysis catheter (Zone C). Since its tip was now lying in the innominate vein, it was considered not suitable for inotrope infusion or for long-term use.  Malposition of the CVC increases the possibility of its tip abutting the venous wall. This along with the acidic pH of inotropes increases the chance of vessel wall perforation. , Hence the inotrope infusion was stopped and administered through a 16 gauge peripheral intravenous (IV) line till we secured a left subclavian CVC and confirmed its tip position.
Misplacement of CVC is associated with serious complications. If the CVC tip lies too proximal, there can be mechanical or chemical irritation of the vessel wall leading to thrombophlebitis, infection and increase in morbidity. , If the CVC tip lies too distal, that is below the pericardial reflection, there is a higher chance of pericardial tamponade. 
In our case, the guidewire of the left sided CVC inserted through the IJV would have hooked the optimally placed right subclavian CVC and displaced it proximally.
Other causes of CVC misplacement may be due to movement of catheter tip with changes in head and neck position, poor skin fixation of the CVC or due to "twiddler's syndrome". ,, Migration of CVC may also occur post perforation of vessel wall by its tip, especially if catheter is stiff and touches the vessel wall. Infusion of acidic, alkaline or hyperosmolar solutions may also lead to vessel wall erosion during the long term use, and subsequent migration. ,
Movement of the head or neck can cause displacement of subclavian catheters up to 3 cm towards the heart. Optimally placed CVC may also be manipulated by the patients, the "twiddler's syndrome". 
Misplacement of CVC can also cause misinterpretation of CVP values, which becomes so crucial in critically ill patients. , The anesthesiologist must be extremely cautious not to administer drugs through a previously optimally placed CVC catheter until its tip position is re-confirmed if there is another CVC insertion.
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[Figure 1], [Figure 2], [Figure 3]