Correspondence

Central Venous Catheterization — Subclavian Vein

N Engl J Med 2008; 358:1758-1760April 17, 2008

Article

To the Editor:

In their video and accompanying article, Braner et al. (Dec. 13 issue)1 omit an important and common complication of subclavian central-venous-catheter placement — misplacement of the catheter tip in the internal jugular vein. This occurs in approximately 5% of patients, with the catheter tip most commonly misplaced in the ipsilateral internal jugular vein.2 Misplaced catheters increase the risk of thrombophlebitis, thrombosis, and inaccurate measurements of central venous pressure. There are a few excellent bedside maneuvers that may reduce the incidence of misplacement of the central venous catheter in the internal jugular vein. The Ambesh maneuver, which involves manual occlusion of the internal jugular vein during subclavian-vein cannulation, helps to determine whether the catheter tip is in the internal jugular vein.2 Another maneuver is to flush the catheter with 10 ml of normal saline and ask the patient whether there is a sensation of fluid gushing in the neck or a ringing in the ear. A positive response warrants withdrawal of the catheter tip and repositioning.3

Samar Harris, M.B., B.S.
Harris V.K. Naina, M.B., B.S.
Mayo Clinic College of Medicine, Rochester, MN 55905
harris.samar@mayo.edu

3 References

1. 1

   Braner DAV, Lai S, Eman S, Tegtmeyer K. Videos in clinical medicine: central venous catheterization. N Engl J Med 2007;357 (Web only). (Available at http://www.nejm.org.)
   

2. 2

   Ambesh SP, Pandey JC, Dubey PK. Internal jugular vein occlusion test for rapid diagnosis of misplaced subclavian vein catheter into the internal jugular vein. Anesthesiology 2001;95:1377-1379
   CrossRef | Web of Science | Medline

3. 3

   Naina HV, Harris S, Bharat A, Kuppachi S, Siddique S. Bedside localization of misplaced peripherally inserted central catheter. Oxford, England: British Journal of Anaesthesia, May 2006. (Accessed March 28, 2008, at http://bja.oxfordjournals.org/cgi/qa-display/short/brjana_el;781.)
   

To the Editor:

In the otherwise excellent video by Braner et al. on subclavian central venous catheterization, no mention is made of using the J end of the guidewire rather than the straight end. Inserting the J wire such that it points caudad is an excellent way of directing the wire so that it goes downward toward the heart rather than upward into a neck vein.

Francis C. Evans, M.D.
16 Ocean Ridge Blvd. N., Palm Coast, FL 32137
fcevansmd@mindspring.com

To the Editor:

Braner et al. make the important point that when high-volume intravenous fluid resuscitation is required, short, large-bore peripheral cannulas are usually more rapidly inserted and more effective than central venous lines. However, the video shows an illustration of a green peripheral cannula that appears to be an 18-gauge cannula, not a large-bore cannula.

Many health care professionals mistakenly believe that 18-gauge cannulas are adequate for rapid fluid resuscitation, despite international recommendations to use 14- or 16-gauge peripheral cannulas for this purpose. Flow rates for a green (18-gauge) cannula are significantly lower than those for a 16-gauge or larger cannula.1

Colin A. Graham, M.D., M.P.H.
Chinese University of Hong Kong, Hong Kong SAR, China
cagraham@cuhk.edu.hk

1 References

1. 1

   Barcelona SL, Vilich F, Cote CJ. A comparison of flow rates and warming capabilities of the Level 1 and Rapid Infusion System with various-size intravenous catheters. Anesth Analg 2003;97:358-363
   CrossRef | Web of Science | Medline

To the Editor:

We have some important concerns about the description of central venous catheterization of the subclavian vein in the video by Braner et al. We believe there are substantial discrepancies between the animation and the text regarding the anatomical landmarks. The course of the subclavian vein under the medial part of the clavicle is depicted as showing attachment through connective tissue to the clavicle, the subclavian muscle, the pretracheal fascia, and the first rib (Figure 1Figure 1Bottom View of the Apertura Thoracis Superior of a Cadaver, Horizontal Slice.).1-3 This explains why the vessel can never separate from the parietal pleura and why the vessel lumen is always open, even though its diameter is reduced when the shoulder is pulled downward, as would happen if a towel were placed between the shoulders.2 In addition, the video demonstrates a forward–backward movement of the guidewire through a cannula. This movement is associated with a high risk of damage to the wire and may result in fragmentation or even embolism.4 Therefore, one should refrain from retracting a guidewire through a cannula. Given its educational value, this video needs revision.

Wolfram Schummer, M.D.
Rosemarie Fröber, M.D.
Claudia Schummer, M.D.
Friedrich-Schiller University, 07747 Jena, Germany
cwsm.schummer@gmx.de

4 References

1. 1

   Lanz T, Wachsmuth W. Hals. Berlin: Springer, 2003.
   

2. 2

   Lechner P, Anderhuber F, Tesch NP. Anatomical bases for a safe method of subclavian venipuncture: clinical experience in 350 cases. Surg Radiol Anat 1989;11:91-95
   CrossRef | Web of Science | Medline

3. 3

   Loeweneck H, Schafer K, Pfeifer KJ. Anatomical directions for the placement of central venous catheters. Chirurg 1978;49:615-619
   Web of Science | Medline

4. 4

   Polos PG, Sahn SA. Complication of central venous catheter insertion: fragmentation of a guidewire with pulmonary artery embolism. Crit Care Med 1991;19:438-440
   CrossRef | Web of Science | Medline

Author/Editor Response

We agree with Harris and Naina that malposition of a catheter in the internal jugular vein is an important complication. The constraints of video production do not permit the inclusion of all possible complications, and we agree that the articles by Ambesh et al. and Naina et al. describe this complication and potential solutions quite well. Evans notes a technique that can be used to avoid internal-jugular-vein placement; we have no experience with this technique.

Graham points out an important consideration: it is clear that higher-bore, shorter catheters result in more rapid fluid flow. Without doubt, use of a 14- or 16-gauge catheter would result in more rapid fluid administration than use of the 18-gauge catheter pictured in the video. However, it is important to keep in mind the length of the peripheral catheter. In some cases, smaller catheters that are also shorter may have higher infusion rates.

In response to the comments by Schummer and colleagues, many standard texts refer to placement of a towel underneath the spine. The intent is not to pull the shoulder caudad but to allow the shoulder to relax posteriorly to move the head of the humerus out of the working plane. It is one option in optimizing the position. As for the forward–backward movement of the wire, the potential for damage to the wire is not zero, but in the context described, in which advancement of the wire leads to dysrhythmia, we believe it is important to pull the wire back quickly. The operator should be sure that the wire always moves freely; it should never be tugged or require anything but minimal effort. If more than minimal effort is required, the wire and needle should be withdrawn together. We believe that the incidence of wire damage is low enough that the practice should not be avoided at all costs, but learners should keep in mind that when aberrancies from normal procedure occur, the procedure should be modified appropriately.

Dana A.V. Braner, M.D.
Ken Tegtmeyer, M.D.
Oregon Health and Science University, Portland, OR 97229