![]() Stonelake and Bodenham in their retrospective audit of the position of the CVC tip on routine post-procedure CXRs of ICU patients suggested three different zones for safe catheter placement. The carina is radiologically identifiable in about 96% of all CXRs at the interspace between the fourth and fifth thoracic vertebrae. All these necessitate a radiographic confirmation of the CVC tip, which can easily be accomplished with a simple CXR. This might explain the higher risk of perforation with left-sided catheters. An in vitro study has shown that an acute angle of >40° with the wall of the SVC results in a markedly increased risk of vessel perforation. Many authors are of the opinion that a right-sided IJV catheter is better placed up in the SVC or in the innominate vein, whereas a left-sided one is safer in the lower part of the SVC or RA. Catheters passed through the left IJV must traverse the left brachiocephalic vein and enter the SVC perpendicularly, and their distal tip may impinge on the right lateral wall of the SVC, thereby increasing the potential for vascular injury. The right IJV has been the route preferred by anesthesiologists for CVC placement for various reasons, like fewer complications with a success rate of approximately 90-99%. It should be recognized that the length of the catheter inserted through right IJV to position the tip properly in the SVC will vary according to the height of the patient and puncture site, and is about 3-5 cm more when it is passed from the left IJV compared with the right. The junction of the SVC and RA was considered to be located at the intersection of the right lateral margin of the SVC and the superior border of the RA (cardiac silhouette). The traditionally preferred position of the catheter tip is in the distal third of the SVC to minimize complications such as catheter migration, extravasation of irritant agents, vascular perforation, local vein thrombosis, catheter malfunction and cranial retrograde injection. It was corrected by withdrawing the catheter by 1-2 cm. 8: One PICC line inserted for chemotherapy by the cut down method probably went straight into the thoracic duct as chyle could be aspirated. ![]() Thus the catheter was salvaged and additional cost burden to the patient was avoided.Ĭase no. A repeat CXR revealed the tip of the catheter in the SVC. The guide wire was removed and blood was aspirated from all three lumens. The catheter was fully withdrawn over the guide wire and was reinserted again. ![]() Now the guide wire could be freely advanced up to 15 cm. The catheter was pulled out by 4 cm to undo the kink. The catheter was pulled out slowly while simultaneously pushing in the guide wire in a similar way. Under strict aseptic precautions, the proximal straight end of an ethylene oxide-sterilized J tip guide wire was inserted into the distal end of the triple-lumen catheter until resistance was felt-probably the site of the kink. We decided to correct the kink using a “push pull” improvised technique. A check CXR revealed a kinked catheter with its tip in the left IJV. 7: A triple-lumen CVC was inserted into the left IJV by Seldinger technique but blood could not be aspirated from the most proximal lumen.
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