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LETTER TO EDITOR
Year : 2012  |  Volume : 56  |  Issue : 2  |  Page : 205-207  

Malposition of internal jugular vein catheter into contralateral internal jugular vein: An uncommon position


Department of Neuroanaesthesiology, Neurosciences Center, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

Date of Web Publication17-May-2012

Correspondence Address:
Hemanshu Prabhakar
Department of Neuroanesthesiology, Neurosciences Center, 7th Floor, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.96317

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How to cite this article:
Singh GP, Prabhakar H, Reddy BK. Malposition of internal jugular vein catheter into contralateral internal jugular vein: An uncommon position. Indian J Anaesth 2012;56:205-7

How to cite this URL:
Singh GP, Prabhakar H, Reddy BK. Malposition of internal jugular vein catheter into contralateral internal jugular vein: An uncommon position. Indian J Anaesth [serial online] 2012 [cited 2019 Dec 6];56:205-7. Available from: http://www.ijaweb.org/text.asp?2012/56/2/205/96317

Sir,

Malposition of catheter is well known during central venous cannulation. An essential prerequisite for the use of central venous catheters (CVC) is its proper placement. [1] Incorrect positioning of CVC may lead to serious complications such as perforation of the heart or great vessels. A 62-year-old female patient weighing 73 kg was scheduled for excision of planum sphenoidal meningioma. After induction of general anaesthesia and preparing the site, the right internal jugular vein (IJV) was cannulated using the Seldinger technique. On locating the right IJV with the needle and free aspiration of blood, the guide wire was threaded freely through the needle without resistance and a 7F double lumen catheter (Centrofix Duo V720, B Braun, Germany) was passed over the guide wire again without any unusual resistance. The catheter was fixed at the 14 cm mark after free aspiration of blood from both the ports of the catheter. On attaching the invasive pressure monitor, it was found that the central venous pressure was high (18 mmHg) and continued to remain high (18-22 mmHg) throughout the intraoperative course. A suspicion of malposition of catheter tip was raised and flush test [2] was performed immediately after the surgery, which was positive on the contralateral side of the neck. This confirmed the catheter tip in the left IJV that was further substantiated by the post-operative chest X-ray [Figure 1]. The catheter was unfixed and gradually pulled out while simultaneously aspirating from the proximal port till the aspiration of blood just stopped. The distal port was then aspirated and aspiration of blood through it confirmed the tip to be within the lumen of the vein. As the distance between the proximal and the distal ports of the catheter is small (approximately 1 inch), the catheter should be pulled out very gradually and gently to prevent dislodgement of the catheter tip from the vessel. The guide wire was passed through the catheter with its "J" tip pointing forwards, taking utmost care not to dislodge the catheter from the vein. The guide wire was advanced slowly into the superior vena cava and the catheter was passed over it. The guide wire was then removed and blood was aspirated freely from both the ports. The flush test was negative and the catheter was fixed at the 13 cm mark. X-ray chest confirmed the catheter tip to be in the lower part of the superior vena cava. The usual malposition of CVC involves placement of catheter tip in larger tributaries of superior vena cava like IJV, subclavian vein and brachiocephalic vein or in the right atrium. Other rare malposition of catheter tip mentioned in the literature includes left superior intercostals vein, [3] left internal mammary vein, [4] azygous arch, [5] innominate vein and loop formation within the vessel. Flush test may be a useful bedside test to rule out the malposition of CVC tip into the IJV in situations where X-ray chest is not immediately available, such as intraoperative CVC placement. Flush test is carried out by palpating the neck over the region of IJV with the palmer aspect of the hand while flushing the CVC with 5-10 mL of normal saline using a syringe. If the tip of the CVC lies in the IJV, a fluid thrill felt by the palm or a bruit can be heard over the IJV using a stethoscope. This test has 100% sensitivity and specificity for detecting malpositioned CVC into the ipsilateral IJV. However, other malpositions may not be ruled out by this test as suggested by the authors. [2] Use of modalities such as intraluminal ECG guidance and flush test can guide the correct placement of CVC tip and prevent complications arising from malposition of CVCs.
Figure 1: Arrow showing the central venous catheter tip in the contralateral (left) internal jugular vein

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   References Top

1.Singh PK, Ali Z, Rath GP, Prabhakar H. Catheter malposition following supraclavicular approach for subclavian vein catheterisation - Case reports. Middle East J Anesth 2008;19:1405-10.  Back to cited text no. 1
    
2.Toshniwal GR, Rath GP, Bithal PK. Flush test-a new technique to assess the malposition of subclavian central venous catheter position in the internal jugular vein. J Neurosurg Anesthesiol 2006;18:268-9.  Back to cited text no. 2
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3.Ghosh S, Dewan H, Bhattacharyya S. A rare malposition of the thoracic venous catheter introduced via the left internal jugular vein. Indian J Crit Care Med 2008;12:201-3.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Sandroni C, Pirronti T, Tortora F, Santangelo S, Rinaldi P, Antonelli M. Unusual central venous catheter malposition into the left internal mammary vein: A case report. Intensive Care Med 2003;29:2338-9.  Back to cited text no. 4
    
5.Bankier AA, Mallek R, Wiesmayr MN, Fleischmann D, Kranz A, Kontrus M, et al. Azygos arch cannulation by central venous catheters: Radiographic detection of malposition and subsequent complications. J Thorac Imaging 1997;12:64-9.  Back to cited text no. 5
    


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