|LETTER TO EDITOR
|Year : 2013 | Volume
| Issue : 1 | Page : 100-101
Optimal length of central venous catheter insertion in infants
Bikash Ranjan Ray, Dalim Kumar Baidya
Department of Anaesthesia and Intensive Care, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||14-Mar-2013|
Dalim Kumar Baidya
Department of Anaesthesia and Intensive Care, 5th Floor, Teaching Block, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ray BR, Baidya DK. Optimal length of central venous catheter insertion in infants. Indian J Anaesth 2013;57:100-1
We have read the article "Catheter malposition in infants: A preventable complication" by Dr. Balakrishnan et al. with great interest. We congratulate the authors for their sincere effort in emphasising the importance of optimal length of catheter insertion in infants. However, we have certain concerns regarding the management of misplaced catheter and the optimal length of catheter insertion, detailed as follows:
- Misplacement of the catheter into the right subclavian vein due to over-insertion of the catheter may be due to anatomical variations, presence of valves, thrombus, or stenosis. 
The authors have cannulated the left internal jugular vein (IJV) because repositioning of the right IJV catheter was difficult. But left IJV cannulation is associated with higher rate of complications than right cannulation.  Repositioning could have been attempted after withdrawing the catheter >2.5 cm and re-advancing it over a fresh guide wire. Directing the J tip of the guidewire toward the left during repositioning could prevent re-entry of the catheter into the right subclavian vein. Moreover, fluoroscopy guided advancement can help in proper positioning in such cases; however, it is associated with radiation exposure.
- The authors mentioned that the optimal length of the catheter insertion in the child would have been 4.5 cm according to height and 5 cm according to weight, as per the formula described by Andropoulus and co-workers.  However, this statement does not have any relevance without mentioning the point-of-entry. Andropoulus and co-workers  derived the formula with the point-of-entry being exactly halfway between the tip of the mastoid process and the sternal notch. However, the authors used the landmark technique and, hence, we presume that the point-of-entry was different. In order to use the formula with a different point-of-entry, the corresponding distance should be subtracted or added if a lower or higher point of entry is selected. Another concern with the use of this formula is that the original study was performed in American patients and it may not be valid in Indian patients. For routine use of this formula in Indian patients, it should be validated with a properly designed study. In fact, the optimal length of catheter in this patient could have been calculated from the first chest X-ray using the same methodology as in the study by Andropoulus and co-workers. 
- We disagree with the authors regarding the statement that long term venous patency can be improved with the use of ultrasound guided cannulation technique. Ultrasound definitely increases the success rate and decreases the rate of complications, but it has no significance with long term patency.
To conclude, determining optimal length of insertion of central venous catheter in paediatric population is crucial in preventing serious complications. Routine chest X-ray or fluoroscopy in the operating room to determine the optimum length of insertion may not be always feasible. Hence, we suggest that a properly designed study in Indian paediatric patients is warranted for formulating some equation based on weight or height for routine use.
| References|| |
|1.||Balakrishnan I, Kaur M, Sawhney C, D'Souza N. Catheter malposition in infants: A preventable complication. Indian J Anaesth 2012;56:427-8. |
|2.||Patel RY, Friedman A, Shams JN, Sliberzweiq JE. Central venous catheter tip malposition. J Med Imaging Radiat Oncol 2010;54:35-42. |
|3.||Sulek CA, Blas ML, Lobato EB. A randomized study of left versus right internal jugular vein cannulation in adults. J Clin Anesth 2000;12:142-5. |
|4.||Andropoulus DB, Bent ST, Skjonsby B, Stayer SA. The optimal length of insertion of central venous catheters for pediatric patients. Anesth Analg 2001;93:883-6. |