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Patient Safety: Case Report

Anterior Mediastinal Central Line Malposition

Turi, Guido, MD; Tordiglione, Paolo, MD; Araimo, Fabio, MD

Author Information
doi: 10.1213/ANE.0b013e31824e2d37

Central venous catheters (CVCs) are used on a daily basis to provide venous access, especially in critically ill patients who require long-term IV access. Among its many uses, a CVC can be used for central venous pressure monitoring and for administration of IV fluids, inotropic drugs, parenteral nutrition, and blood products.4

Central venous access can involve the internal jugular, the subclavian, or the femoral veins. There are many significant complications related to insertion and maintenance of a CVC: unintended arterial puncture, pneumothorax, and chylothorax (especially during left subclavian vein access) during insertion; catheter malposition, tethering, accidental dislodgment, occlusion, extravasation, thrombosis, infection, and catheter fracture; or neurologic sequelae,5 arrhythmia, air embolism, cardiac perforation, cardiac tamponade, and death.6,7

The jugular vein is the approach used most frequently, because access is considered easier compared to the subclavian vein.7 Cannulation of the subclavian vein can also be associated with more complications, is more time-consuming, and requires greater dexterity, considering the close anatomical relationship between the clavicle and first rib, which may impede guidewire advancement. The most common complications associated with the subclavian vein approach are pneumothorax or hemothorax, with a reported frequency of 0%–12%, depending on operator experience.7

Despite these recognized risks, during head and neck surgery the subclavian vein approach is usually the first choice, particularly when a long postoperative recovery time is expected, because of its lower risk of infection,8 greater patient acceptance, and easier nursing care.

To reduce complications and assure appropriate placement of the tip of the catheter, several techniques have been introduced clinically: ultrasound-guided cannulation9 and continuous electrocardiographic (ECG) monitoring of changes in shape and size of the P wave as the catheter is advanced centrally. Despite the use of these techniques, the National Kidney Foundation Disease Outcomes Quality Initiative guidelines still consider the radiologic examination of the chest (chest radiograph) mandatory after subclavian and internal jugular vein insertion before catheter use.10

Unintended placement of the CVC tip in a smaller vein (mammary vein, intercostal vein, etc.) increases the risk of thrombosis significantly. Moreover, the catheter tip can perforate the vessel wall, leading to extravasation of fluids into the surrounding tissue. We report an unusual case of CVC malposition.

A 38-year-old healthy male presented with a ruptured cerebral aneurysm and underwent emergency craniotomy for drainage of cerebral hemorrhage.

At the conclusion of the surgical procedure due to the patient’s critical condition and expectation for a prolonged hospital stay, we placed a CVC in the right subclavian vein. Routine standards of care included sterile preparation of the site and sterile draping, Trendelenburg position, caudal traction of the right upper extremity, and temporary discontinuation of mechanical ventilation during needle insertion and venous cannulation. Once the subclavian vein was cannulated, a triple-lumen, 7-F diameter catheter and kink-proof guidewire with a flexible J-tip were inserted. The cannulation proceeded smoothly except for the insertion of the dilator, due to the thickness of the patient’s clavicle (Fig. 1). As the guidewire was advanced centrally, brief and self-limited periods of arrhythmia were observed on the ECG. Once the catheter was advanced to the correct position, the three lumens were tested by noting no resistance to saline flushes and by aspiration of venous blood. The catheter was then sutured to the skin at a depth of 15 cm. There was no indication at this time that the CVC may have been malpositioned.

Figure 1
Figure 1:
The curve of the central venous catheter due to the thickness of the clavicle.

Despite convincing clinical evidence of correct CVC placement, during the routine postoperative head computed tomography (CT) scan, a thoracic “scout” radiographic examination was performed to confirm correct CVC placement. The scout film revealed a misplacement of the CVC tip outside of the superior vena cava (Fig. 2); to obtain a clearer image, a thoracic CT scan was performed, which revealed, presence of CVC with right subclavian access and its tip deforming and raising left innominate vein in which the catheter is still placed, although its distal point resides outside of the superior vena cava in the anterosuperior mediastinal fatty tissue (Fig. 3).

Figure 2
Figure 2:
The misplacement of the central venous catheter tip out of the superior vena cava as viewed on the thoracic “scout” radiographic examination.
Figure 3
Figure 3:
The central venous catheter distal tip protrudes out of the superior vena cava into the anterosuperior mediastinal fatty tissue.

At this point, we tested all 3 lumens again; blood could be aspirated only from the proximal and medial lumens, whereas the distal lumen had no blood return.

The catheter was immediately removed, with no bleeding complications, to avoid the risk of an incorrect use.11 A new CVC was placed, in the left subclavian vein, with no complications. The patient fully recovered from the cerebral hemorrhage and had no complications from the CVC misplacement.

We experienced no technical difficulties during the initial catheter insertion, such as bending of the guidewire, need for reversed use of the J-wire, resistance to wire or catheter upon insertion, nor difficulties in blood draw from all three lumens; these difficulties have all been reported to be harbingers of catheter malpositioning.12

Even though none of these difficulties was experienced and the procedure was technically very smooth, the use of the thoracic CT scan allowed us to detect the catheter malposition and immediately remove the CVC, avoiding further complications.

It is important to note that even if we had used an ultrasound-guided procedure, we would not have had any indication of catheter malpositioning. The only method that might have alerted us of the potential misplacement of the catheter would have been the use of continuous ECG monitoring of the tip of the catheter during advancement centrally as long as it was a primary, and not a secondary, dislocation of the CVC.

In light of the current report, the clinician may wish to consider the need for radiographic confirmation of appropriate CVC placement, even if the insertion proceeded smoothly and without apparent complications, and particularly before the start of IV infusions.2

DISCLOSURES

Name: Guido Turi, MD.

Contribution: This author helped write the manuscript.

Attestation: Guido Turi approved the final manuscript.

Name: Paolo Tordiglione, MD.

Contribution: This author helped write the manuscript.

Attestation: Paolo Tordiglione approved the final manuscript.

Name: Fabio Araimo, MD.

Contribution: This author helped write the manuscript.

Attestation: Fabio Araimo approved the final manuscript.

This manuscript was handled by: Sorin J. Brull, MD, FCARCSI (Hon).

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