Malpositioning of Central Venous Catheter: A Case Report

Central Venous Catheter (CVC) malpositioning is a frequently observed complication, ranging in incidence from 3 to 15% [1]. CVC insertion is still a blind process. Although use of ultrasoundguided insertion has advantage in terms of improved accuracy of insertion site, assessing the location of the tip of the catheter is still a challenge during insertion. Transoesophageal echocardiography can detect the location of the tip of the catheter in relation to the Superior Vena Cava (SVC) and Right Atrium (RA), but its availability as a bedside tool is very limited [2]. Most commonly a chest radiography is performed after the procedure to confirm the tip [3]. We report here a case of mispositioning of the catheter into the contralateral subclavian vein.


Introduction
Central Venous Catheter (CVC) malpositioning is a frequently observed complication, ranging in incidence from 3 to 15% [1]. CVC insertion is still a blind process. Although use of ultrasoundguided insertion has advantage in terms of improved accuracy of insertion site, assessing the location of the tip of the catheter is still a challenge during insertion. Transoesophageal echocardiography can detect the location of the tip of the catheter in relation to the Superior Vena Cava (SVC) and Right Atrium (RA), but its availability as a bedside tool is very limited [2]. Most commonly a chest radiography is performed after the procedure to confirm the tip [3]. We report here a case of mispositioning of the catheter into the contralateral subclavian vein.

Case report
A 40-year-old female patient with a diagnosis of acute intestinal obstruction was admitted to the ICU for postoperative care. The patient became drowsy and developed fever on second postop day. It was decided to insert a central venous line for fluid management. A CVC was placed into the right subclavian vein by infraclavicular approach using Sledinger technique. The catheter was threaded over a guide wire and fixed at the recommended depth of 15 cm. All three lumens were flushed, and intravenous fluid was started. Post procedural radiography confirmed insertion of the catheter tip into the contralateral subclavian vein (Figure 1). We decided to correct the tip position by pulling the catheter over the guide wire. The catheter was reinserted, and a radiograph was taken subsequently confirmed the tip position into the SVC above the RA.

Discussion
Subclavian vein catheterization is a very commonly performed procedure in the ICU and anaesthesia practice. In normal course, the guide wire passes through the right subclavian vein, proceeds along the inside of the right brachiocephalic, and then toward the RA. The path taken by the guide wire is also dependent on the

Journal of Anesthesia & Intensive Care Medicine
orientation of its tip [4,5]. During subclavian vein catheterization, the most common misplacement of the catheter happens in the ipsilateral internal jugular vein. Incidence of up to 60% is noted in some series [6]. Other mentioned sites are the thymic vein, the left superior intercostal vein, and the azygous vein. Complications associated with guidewire and catheter insertion are due to mechanical erosions arrythmia due to cardiac wall stimulation. Over insertion of the catheter into the heart chambers can be avoided by inserting the catheter at 16-17 cm [7].
Avoiding a bevelled or hard-tipped catheter and immobilization of the catheter have been recommended [8]. Placement of the tip in the extracardiac position in the SVC and confirming it by radiography is the most effective method. For catheter tip location three different zones have been mentioned with respect to the SVC [9]. Zone A suitable area for placement of a right-sided catheter, represents the lower SVC and upper RA. The catheter lies parallel to the vessel wall in this zone. Zone B represents the area around the junction of the left and right innominate vein and upper SVC. It is the most suitable area for placement of a right-sided catheter Zone C represents the left innominate vein proximal to the SVC. This zone is suitable for short-term therapy and central venous pressure monitoring (Figure 2). Site of insertion and the patient's height and body built are important factors that influence the catheter length. [10]

Financial Support and Sponsorship
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Conflicts of Interest
There are no conflicts of interest.  [9].