Correspondence
Central Venous Catheterization
N Engl J Med 2007; 357:943-945August 30, 2007
- Article
To the Editor:
I have three concerns about the description of central venous catheterization in the video by Graham et al. (May 24 issue).1 First, it is misleading to describe the risk of hemothorax as “not applicable” when the internal jugular approach is used, since hemothorax is a known complication.2 Second, head rotation of 45 degrees increases the overlap of the carotid artery by the internal jugular vein,3 increasing the risk of arterial puncture.4 For this reason, most authors recommend a near-midline position of the head. Third, the manometer technique that is shown is inadequate. Blood rising more than 30 cm in the vertical tube indicates arterial catheterization; however, the absence of this increase does not exclude the possibility of arterial puncture if the needle tip abuts the artery wall. Arterial puncture can be excluded only by filling the horizontal catheter with more than 30 cm of blood and then holding it upright and observing a fall in the column. Finally, in light of the potential for serious or fatal complications, it is difficult to justify an attempt at central venous catheterization without an experienced operator present.
4 ReferencesMichael C. Reade, M.B., B.S., D.Phil.
University of Pittsburgh, Pittsburgh, PA 15261
mreade@doctors.net. uk 1
Graham AS, Ozment C, Tegtmeyer K, Lai S, Braner DAV. Central venous catheterization. N Engl J Med 2007;356:e21.
2
Eisen LA ,Narasimhan M ,Berger JS ,Mayo PH ,Rosen MJ ,Schneider RF . Mechanical complications of central venous catheters. J Intensive Care Med 2006;21:40-46
CrossRef | Medline3
Wang R ,Snoey ER ,Clements RC ,Hern HG ,Price D . Effect of head rotation on vascular anatomy of the neck: an ultrasound study. J Emerg Med 2006;31:283-286
CrossRef | Web of Science | Medline4
Sulek CA ,Gravenstein N ,Blackshear RH ,Weiss L . Head rotation during internal jugular vein cannulation and the risk of carotid artery puncture. Anesth Analg 1996;82:125-128
CrossRef | Web of Science | Medline
To the Editor:
We welcome the emphasis on sterility in the instructional video by Graham et al., given the association of central venous catheterization with bacteremia,1 including infection with methicillin-resistant Staphylococcus aureus.2 However, we wish to emphasize the significant variation in position of the jugular veins.
We undertook an audit of 100 patients who were awaiting coronary angiography and found that 11% of right internal jugular veins and 24% of left internal jugular veins were anterior and medial to the carotid artery (Figure 1Figure 1
Distribution of Internal Jugular Vein According to Quadrant.). With the use of the landmark technique described in the video, safe catheterization of these veins will probably be difficult, if not impossible. Therefore, it is not surprising that the landmark technique carries a 9% risk of arterial puncture.3 Furthermore, the degree of head rotation recommended can have a significant effect on the position of the vein.4 Ultrasonography accurately locates the target vein and also provides information about venous pressure and the presence of intravascular thrombus. Its use should therefore be an integral part of central venous catheterization.
4 ReferencesJames D. Newton, M.B., Ch.B.
David C. Sprigings, B.M., B.Ch.
Northampton General Hospital, Northampton NN1 5BD, United Kingdom
jdn1@le.ac. uk 1
Coello R ,Charlett A ,Ward V , et al. Device-related sources of bacteraemia in English hospitals -- opportunities for the prevention of hospital-acquired bacteraemia. J Hosp Infect 2003;53:46-57
CrossRef | Web of Science | Medline2
Carnicer-Pont D ,Bailey KA ,Mason BW ,Walker AM ,Evans MR ,Salmon RL . Risk factors for hospital-acquired methicillin-resistant Staphylococcus aureus bacteraemia: a case-control study. Epidemiol Infect 2006;134:1167-1173
CrossRef | Web of Science | Medline3
McGee DC ,Gould MK . Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-1133
Full Text | Web of Science | Medline4
Sulek CA ,Gravenstein N ,Blackshear RH ,Weiss L . Head rotation during internal jugular vein cannulation and the risk of carotid artery puncture. Anesth Analg 1996;82:125-128
CrossRef | Web of Science | Medline
To the Editor:
The video by Graham et al. shows a guidewire inducing premature ventricular contractions, illustrating a common problem during insertion of central venous catheters: overinsertion of guidewires. Intravenous guidewires, commercially available in kits, are generally twice as long as the catheters they guide, a length that easily allows entry into cardiac chambers and results in arrhythmias.1 We have observed transient right bundle-branch block and ventricular fibrillation when overinserted guidewires entered the right ventricle.
Overinsertion of guidewires occurs during the initial placement of the wire and during advancement of the catheter over the guidewire. We teach that the distal end of the guidewire should never be inserted past the top of the patient's head during catheterization of the right internal jugular vein and that the wire should be kept at this position during advancement of the catheter. If a guidewire requires withdrawal through the catheter for control of the distal end, the guidewire was inserted into the patient farther than necessary. Avoidance of guidewire overinsertion can be lifesaving in some patients.
1 ReferencesLisa T. Newsome, M.D.
Benjamin L. Antonio, D.O.
Roger L. Royster, M.D.
Wake Forest University School of Medicine, Winston-Salem, NC 27157-10091
Royster RL ,Johnston WE ,Gravlee GP ,Brauer S ,Richards D . Arrhythmias during venous cannulation prior to pulmonary artery catheter insertion. Anesth Analg 1985;64:1214-1216
CrossRef | Web of Science | Medline
To the Editor:
Sometimes ultrasonographic guidance is not available for central venous catheterization, so the operator must rely on surface landmarks alone. In this situation it may be safer if the patient's head is in the neutral position. Head rotation can cause the internal jugular vein to move laterally in relation to surface landmarks and become more difficult to locate.1 Furthermore, the vein can lie directly above the carotid artery,2 increasing the risk of arterial puncture. Using a 22-gauge needle to find and anchor the vein is also useful.3 This needle can be left in the vein to guide the insertion of the introducer needle.
Another recognized complication is damage to the guidewire.4 This is avoided by nicking the skin while the needle is in place and by retracting the skin while inserting the dilator.
Finally, use of an introducer cannula rather than the introducer needle minimizes the risk of laceration of the vein if the needle moves. This is particularly useful if pressure transduction is required to check location before insertion of the catheter.
4 ReferencesShaumik Adhya, M.B., B.S.
Conquest Hospital, St. Leonards-on-Sea TN37 7RD, United Kingdom
shaumik@doctors.org. uk Shondipon K. Laha, M.A., F.R.C.A.
Lancashire Teaching Hospitals NHS Foundation Trust, Preston PR1 9HT, United Kingdom1
Khatri VP ,Wagner-Sevy S ,Espinosa MH ,Fisher JB . The internal jugular vein maintains its regional anatomy and patency after carotid endarterectomy: a prospective study. Ann Surg 2001;233:282-286
CrossRef | Web of Science | Medline2
Sulek CA ,Gravenstein N ,Blackshear RH ,Weiss L . Head rotation during internal jugular vein cannulation and the risk of carotid artery puncture. Anesth Analg 1996;82:125-128
CrossRef | Web of Science | Medline3
Tripathi M ,Pandey M . Anchoring of the internal jugular vein with a pilot needle to facilitate its puncture with a wide bore needle: a randomised, prospective, clinical study. Anaesthesia 2006;61:15-19
CrossRef | Web of Science | Medline4
Monaca E ,Trojan S ,Lynch J ,Doehn M ,Wappler F . Broken guide wire -- a fault of design? Can J Anaesth 2005;52:801-804
CrossRef | Web of Science | Medline
Author/Editor Response
We regret that although our video stresses not over-rotating the head, our text refers to the classic teaching of positioning the patient with the head rotated away from neutral.1 It has become clear that as the head rotates away from neutral, there is an increase in both the overlap and proximity of the internal jugular vein and carotid artery,2 which increases the risk of carotid puncture.
We agree that ultrasonography enhances the rate of success of internal jugular venous catheterization, speeds the process, demonstrates important anatomical variations, demonstrates vessel thromboses, and decreases complications, including catheter-related bloodstream infections.3 We appreciate Reade's comment that hemothorax is a rare but potentially serious complication of internal jugular venous catheterization. Ultrasonographic guidance may reduce the risk of hemothorax from 1.7% to zero.3 Unfortunately, ultrasonography is not universally available and ultrasound devices may fail to operate; therefore, knowledge of the landmark technique remains essential.
We agree with Newsome et al. that guidewire overinsertion can be dangerous. The wire needs to be advanced only far enough to maintain reliable control of the tract from the skin surface to the intravascular space.
Adhya and Laha suggest nicking the skin while the needle remains in place, which may prove useful as long as the operator takes care not to cause damage by inadvertent movement of the indwelling needle during the process. They also refer to an interesting study that describes the use of a small-gauge pilot needle to locate the internal jugular vein and an innovative technique to then stabilize it.4 This small-gauge pilot needle may be particularly useful when patients have coagulopathy or when ultrasonography is not available.
We agree that, ideally, an experienced operator should be present for all central venous catheterization procedures. This is especially important for patients with known risk factors for difficult catheterization.
4 ReferencesAlan S. Graham, M.D.
Ken Tegtmeyer, M.D.
Dana Braner, M.D.
Oregon Health and Science University, Portland, OR 97239
grahamal@ohsu.edu 1
McGee DC ,Gould MK . Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-1133
Full Text | Web of Science | Medline2
Wang R ,Snoey ER ,Clements RC ,Hern HG ,Price D . Effect of head rotation on vascular anatomy of the neck: an ultrasound study. J Emerg Med 2006;31:283-286
CrossRef | Web of Science | Medline3
Karakitsos D ,Labropoulos N ,De Groot E , et al. Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients. Crit Care 2006;10:R162-R162
CrossRef | Web of Science | Medline4
Tripathi M ,Pandey M . Anchoring of the internal jugular vein with a pilot needle to facilitate its puncture with a wide bore needle: a randomised, prospective, clinical study. Anaesthesia 2006;61:15-19
CrossRef | Web of Science | Medline
- Citing Articles (1)
Citing Articles
1
Sun Young Park, Min Jung Kim, Mun Gyu Kim, Se Jin Lee, Sang Ho Kim, Si Young Ok, Soon Im Kim. (2011) Changes in the relationship between the right internal jugular vein and an anatomical landmark after head rotation. Korean Journal of Anesthesiology 61:2, 107
CrossRef
