Malposition Of Internal Jugular Vein Cannula Into Ipsilateral Subclavian Vein In Reverse Direction- Unusual Case Report
D Malhotra, S Gupta, S Gupta, B Kapoor
D Malhotra, S Gupta, S Gupta, B Kapoor. Malposition Of Internal Jugular Vein Cannula Into Ipsilateral Subclavian Vein In Reverse Direction- Unusual Case Report. The Internet Journal of Anesthesiology. 2008 Volume 22 Number 1.
Malpositioning of CVC inserted into the subclavian vein and IJV is a known and dreaded complication. The most common misplacement of the subclavian vein catheter is into the IJV (5.4%) and does not vary with the side of insertion or whether the head is turned towards or away from the side of insertion.1 Our case report is about misplacement of catheter in the reverse direction towards the axillary vein (reverse direction) inserted through IJV.
Percutaneous cervical central venous cannulation is now common during perioperative care of major surgical patients, in intensive care monitoring, for long-term hyper alimentation and also for securing a central vein for rapid restoration of blood volume in a case of unexpected acute blood loss. Advantages of internal jugular vein cannulation relate to its consistent, predictable, anatomic location, its valve less course to the superior vena cava and right atrium, the possibility of repeated cannulation and low incidence of complications in experienced hand.
Placement of CVC is technically challenging procedure. Reported incidence of malpositioning of CVC varies extremely wide range <1% to >60%
A 26 year old male, a case of road traffic accident with head injury and CTscan proved Right temporo-parietal contusion with midline shift with GCS 7(E2V2M3) was admitted in ICU for elective ventilation. Patient was hemodynamically stable with pulse 90b/m BP 126\70 .After putting patient on A/C mode ,CVC inserted through right sided internal jugular vein approach in single go. Guide wire went freely. Adequate backflow of blood and free inflow of normal saline confirms IV position of Central Vein Catheter. CVP recorded was zero. CVP was not rising even after adequate crystalloid and blood administration. Check chest X-ray was done which showed to our surprise that catheter tip was placed in retrograde position in subclavian vein as shown in
The patient was shifted to the Neurosurgical OT for evacuation of contusion. Immediately under fluoroscopy, guide wire was reinserted and the CVC was withdrawn .The guide wire was pulled out to some extent and redirected and the CVC was inserted and tip of catheter was being seen at junction of the SVC and Right Atrium under fluoroscopy. The CVP recorded was 6cm H2O. Surgery was done and the patients shifted back to the ICU for elective ventilation.
Central venous catheter insertion is a common procedure used in monitoring CVP, administration of some drugs, blood and blood products, antineoplastic treatment, Parenteral nutrition, and bone marrow transplantation. Central venous catheters can be centrally or peripherally inserted; however, the commonly referred technique is the internal jugular or subclavian veins. These complications can be listed as arterial puncture, pneumothorax, chylothorax, Vein and nerve damage, infection, thrombosis, malposition, folding of the catheter, hemothorax, cardiac tamponade, air embolism, arrhythmia, and death
Catheter malpositioning is a known complication of central venous catheterization
In a randomized controlled study authors suggest that keeping the guidewire J tip directed caudad increase correct placement of CVC towards atrium.