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Catheter-Induced Cardiac Tamponade: A Preventable Complication

Schummer, Wolfram MD, DEAA, EDIC

doi: 10.1213/ANE.0b013e3182330d7a
Letters to the Editor: Letters & Announcements

Jena and SRH Zentralklinikum Suhl Department of Anesthesiology and Intensive Care Medicine Friedrich Schiller University Jena, Germany (Schummer)

Conflicts of Interest: Wolfram Schummer received honoraria from B. Braun, Melsungen, Germany and consulted for B. Braun, Melsungen, Germany.

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To the Editor

The recent editorial by Shamir and Bruce1 comments on ways to prevent cardiac tamponade associated with insertion of a central venous catheter (CVC). The optimal position of the CVC tip remains the subject of debate because no position is absolutely safe.2 The United States Food and Drug Administration strongly advises that the CVC tip should not be placed in the heart. However, pericardial tamponade may also occur with perforation of the superior vena cava below the pericardial reflection, which is not visible on chest radiographs. Schuster et al.3 suggested placement of the tip of the CVC above the carina as a reliable landmark for the pericardial reflection. However, the cephalic limit of the pericardial reflection is highly variable, and accordingly, it is difficult to ensure placement outside the pericardium.4

In patients with sinus rhythm, electrocardiogram (ECG) guidance is a reliable bedside method to site the CVC tip in a proper position (during the insertion procedure!), which should at least have been mentioned by Shamir and Bruce.5,6 With an intraluminal wire or saline as electroconductive medium, the tip of the CVC serves as an electrode (Einthoven lead II) to obtain the intravascular ECG. An adapter allows the operator to switch from a surface (Einthoven lead II) to an intravascular ECG. The first increase in P-wave amplitude relates to the pericardial reflection.7 The P-wave amplitude increases to its maximum once the catheter tip levels with the superior vena cava/right atrial junction.8 Further advancement of the catheter tip results in a decrease in P-wave amplitude or biphasic P wave.6,8 We suggest placing the CVC tip at the maximal P-wave amplitude.6,8

Wolfram Schummer, MD, DEAA, EDIC

Jena and SRH Zentralklinikum Suhl

Department of Anesthesiology and Intensive Care Medicine

Friedrich Schiller University

Jena, Germany

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1. Shamir MY, Bruce LJ. Central venous catheter-induced cardiac tamponade: a preventable complication. Anesth Analg 2011;112:1280–2
2. Fletcher SJ, Bodenham AR. Safe placement of central venous catheters: where should the tip of the catheter lie? Br J Anaesth 2000;85:188–91
3. Schuster M, Nave H, Piepenbrock S, Pabst R, Panning B. The carina as a landmark in central venous catheter placement. Br J Anaesth 2000;85:192–4
4. Bayer O, Schummer C, Richter K, Fröber R, Schummer W. Implication of the anatomy of the pericardial reflection on positioning of central venous catheters. J Cardiothorac Vasc Anesth 2006;20:777–80
5. Gebhard RE, Szmuk P, Pivalizza EG, Melnikov V, Vogt C, Warters RD. The accuracy of electrocardiogram-controlled central line placement. Anesth Analg 2007;104:65–70
6. Schummer W, Schummer C, Schelenz C, Schmidt P, Frober R, Huttemann E. Modified ECG-guidance for optimal central venous catheter tip positioning: a transesophageal echocardiography controlled study [in German]. Anaesthesist 2005;54:983–90
7. Schummer W, Schummer C, Schelenz C, Brandes H, Stock U, Müller T, Leder U, Hüttemann E. Central venous catheters: the inability of ‘intra-atrial ECG’ to prove adequate positioning. Br J Anaesth 2004;93:193–8
8. Chu KS, Hsu JH, Wang SS, Tang CS, Cheng KI, Wang CK, Wu JR. Accurate central venous port-A catheter placement: intravenous electrocardiography and surface landmark techniques compared by using transesophageal echocardiography. Anesth Analg 2004;98:910–4
© 2011 International Anesthesia Research Society