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MISPLACEMENT OF SUBCLAVIAN VENOUS CATHETERS: IMPORTANCE OF HEAD POSITION AND CHOICE OF PUNCTURE SITE
British Journal of Anaesthesia 1990; 64: 632-633
MISPLACEMENT OF SUBCLAVIAN VENOUS CATHETERS IMPORTANCE OF HEAD POSITION AND CHOICE OF PUNCTURE SITE R. SANCHEZ, S. HALCK, S. WALTHER-LARSEN AND L. HESLET
Two hundred patients admitted to the Intensive Care Unit for central venous catheterization via a subclavian vein were included after informed consent was obtained. The procedure was approved by the Regional Ethics Committee. Patients were excluded if they were receiving anticoagulants, undergoing mechanical ventilation or if randomization to the left or right side was impossible. Patients were allocated randomly to four groups: Group 1: Right side, head turned towards the puncture side. Group 2: Right side, head turned away from the puncture side. KEY WORDS Group 3: Left side, head turned towards the Complications: catheter misplacement. Veins: subclavian. puncture side. cannulation. Group 4: Left side, head turned away from the puncture side. Catheterization was performed by the Intensive Care Unit medical staff, all levels of training being Catheterization of the superior vena cava permits represented. Local anaesthetic solution was monitoring of central venous pressure (CVP) in infiltrated 2 cm below and medial to the midpoint addition to administration of parenteral nutrition, of the clavicle with the patient in a 15—20° drugs and fluid therapy. Misplacement of the Trendelenburg position. A 16-gauge, 20-cm central venous catheter to a cranial position in the catheter (Secalon Seldy, Viggo) was placed using internal jugular vein may impair reliable measure- a Seldinger technique by a conventional approach ment of CVP and increase the risk of chemical or [5]. Intravascular placement was confirmed by bacterial thrombophlebitis [1,2]. Pybus, Poole free reflux of blood and correct position of the and Crawford [3] suggested ihat misplacement in catheter tip verified by chest x-ray. children was less likely when the head was turned The catheterization was recorded as easy or towards the puncture side. However, Rosen [4] difficult. A procedure was considered easy if recommended that the head be turned away from the side of puncture. The present study was designed to investigate the effects of head position R.SANCHEZ, M.D.; S. HALOC, M.D.; S. WALTHER-LARSEN, and side of puncture on the likelihood of suc- M.D.; Department of Anaesthesia, Gentofte Hospital, 2900 Hellerup, Denmark. L. HESLET M.D., Department of Ancessful cannulation and misplacement following aesthesia, Odense Hospital, 5000 Odense, Denmark. Accepted subclavian vein puncture. for Publication: December 16, 1989. We have investigated the frequency of misplacement of subclavian catheters in 200 consecutive patients admitted to the intensive Care Unit. The patients were allocated randomly to an attempt at infraclavicular cannulation of the right or left subclavian vein with the head turned either towards or away from the selected side, giving four groups. Catheterization was successful in 185 (92.5%) patients. Misplacement into the internal jugular vein occurred in 10 (5.4%) patients. No statistically significant difference (P < 0.05) was demonstrated between the four groups.
Downloaded from http://bja.oxfordjournals.org/ at Indiana University Library on July 13, 2015
METHOD AND RESULTS
SUMMARY
MISPLACEMENT OF SUBCLAVIAN CATHETERS
633
TABLE I. Complications and misplacement following subclavian vein catheterization. RS, LS = Right, left side; HT/HA = head towards, away from puncture side. SVC = Superior vena cava; IJ = internal jugular vein
IJ Unsuccessful Complications Pneumothorax Arterial puncture
Group 2 (RS, HA)
Group 3 (LS, HT)
Group 4 (LS, HA)
50 55 (21-85) 26/24
50 57 (20-88) 23/27
50 57 (27-87) 24/26
50 58 (20-89) 29/21
102/98
29 21
34 16
36 14
32 18
131 69
41 5 4
44 1 5
44 2 4
46 2 2
175 10 15
0 3
0 4
1 3
1 2
2 12
catheterization was successful at the first attempt and without difficulty. Complications such as pneumothorax, arterial puncture and catheter misplacement were recorded. Results were analysed with a chi-square test with a significance level of 0.05. The four groups were comparable regarding age and sex (table I). Successful catheterization of the subclavian vein was achieved in 185 (92.5%) patients, and the intended position of the catheter tip in the superior vena cava achieved in 175 (94.6%). Misplacement into the internal jugular vein occurred in 10 (5.4%) patients. The procedure was regarded as easy in 131 (65.5%) patients. Pneumothorax occurred in two subjects (1%); minor complications occurred in 22 (11%). No significant difference {P > 0.05) was demonstrated between the four groups regarding misplacement, ease of procedure, complications or unsuccessful attempts. COMMENT
The position of the head during infraclavicular subclavian vein puncture might be expected to alter the relationship between the subclavian and jugular veins and thus the likelihood of successful cannulation or misplacement. Conflicting advice has been given as to whether the head should face towards or away from the site of puncture [3, 4]. Similarly, differences in venous anatomy between the right and left side might also be expected to influence subclavian vein puncture.
Total 200
However, the present study has shown no statistically significant difference in the success or misplacement rate for the different head positions or side of puncture. Failure and misplacement rates are small and thus a much larger group of patients should be studied to be certain that no difference exists. The incidences of minor complications and difficulty of cannulation in the present study were greater than those in other studies [6], and reflect the relative inexperience of some of the operators. We conclude that the position of the head during infraclavicular subclavian vein cannulation does not have a clinically important effect on the likelihood of successful cannulation or misplacement of the catheter.
REFERENCES 1. Conces DJ, Holden RW. Aberrant locations and complications in initial placement of subclavian vein catheters. Archives of Surgery 1984; 119: 293-295. 2. Dunbar RD, Mitchell R, Lavine M. Aberrant locations of centra] venous catheters. Lancet 1981; 1: 711-715. 3. Pybus DA, Poole JL, Crawford MC. Subclavian venous catheterization in small children using the Seldinger technique. Anaesthesia 1982; 37: 451. 4. Rosen M. Handbook of Percutaneous Central Venous Catheterization. London: Saunders, 1981: 51. 5. Aubaniac R. L'injection intraveineuse sub-claviculaire. La Presse Midicalc 1952; 60: 1456. 6. Eerola R, Kautinen L, Kautinen S. Analysis of 13800 subclavian vein catheterizations. Acta Anaesthesiologica Scandinavica 1985; 29: 193-197.
Downloaded from http://bja.oxfordjournals.org/ at Indiana University Library on July 13, 2015
Number Mean age (yr) (range) Sex (F/M) Procedure Easy Difficult Position SVC
Group 1 (RS, HT)
MISPLACEMENT OF SUBCLAVIAN VENOUS CATHETERS IMPORTANCE OF HEAD POSITION AND CHOICE OF PUNCTURE SITE R. SANCHEZ, S. HALCK, S. WALTHER-LARSEN AND L. HESLET
Two hundred patients admitted to the Intensive Care Unit for central venous catheterization via a subclavian vein were included after informed consent was obtained. The procedure was approved by the Regional Ethics Committee. Patients were excluded if they were receiving anticoagulants, undergoing mechanical ventilation or if randomization to the left or right side was impossible. Patients were allocated randomly to four groups: Group 1: Right side, head turned towards the puncture side. Group 2: Right side, head turned away from the puncture side. KEY WORDS Group 3: Left side, head turned towards the Complications: catheter misplacement. Veins: subclavian. puncture side. cannulation. Group 4: Left side, head turned away from the puncture side. Catheterization was performed by the Intensive Care Unit medical staff, all levels of training being Catheterization of the superior vena cava permits represented. Local anaesthetic solution was monitoring of central venous pressure (CVP) in infiltrated 2 cm below and medial to the midpoint addition to administration of parenteral nutrition, of the clavicle with the patient in a 15—20° drugs and fluid therapy. Misplacement of the Trendelenburg position. A 16-gauge, 20-cm central venous catheter to a cranial position in the catheter (Secalon Seldy, Viggo) was placed using internal jugular vein may impair reliable measure- a Seldinger technique by a conventional approach ment of CVP and increase the risk of chemical or [5]. Intravascular placement was confirmed by bacterial thrombophlebitis [1,2]. Pybus, Poole free reflux of blood and correct position of the and Crawford [3] suggested ihat misplacement in catheter tip verified by chest x-ray. children was less likely when the head was turned The catheterization was recorded as easy or towards the puncture side. However, Rosen [4] difficult. A procedure was considered easy if recommended that the head be turned away from the side of puncture. The present study was designed to investigate the effects of head position R.SANCHEZ, M.D.; S. HALOC, M.D.; S. WALTHER-LARSEN, and side of puncture on the likelihood of suc- M.D.; Department of Anaesthesia, Gentofte Hospital, 2900 Hellerup, Denmark. L. HESLET M.D., Department of Ancessful cannulation and misplacement following aesthesia, Odense Hospital, 5000 Odense, Denmark. Accepted subclavian vein puncture. for Publication: December 16, 1989. We have investigated the frequency of misplacement of subclavian catheters in 200 consecutive patients admitted to the intensive Care Unit. The patients were allocated randomly to an attempt at infraclavicular cannulation of the right or left subclavian vein with the head turned either towards or away from the selected side, giving four groups. Catheterization was successful in 185 (92.5%) patients. Misplacement into the internal jugular vein occurred in 10 (5.4%) patients. No statistically significant difference (P < 0.05) was demonstrated between the four groups.
Downloaded from http://bja.oxfordjournals.org/ at Indiana University Library on July 13, 2015
METHOD AND RESULTS
SUMMARY
MISPLACEMENT OF SUBCLAVIAN CATHETERS
633
TABLE I. Complications and misplacement following subclavian vein catheterization. RS, LS = Right, left side; HT/HA = head towards, away from puncture side. SVC = Superior vena cava; IJ = internal jugular vein
IJ Unsuccessful Complications Pneumothorax Arterial puncture
Group 2 (RS, HA)
Group 3 (LS, HT)
Group 4 (LS, HA)
50 55 (21-85) 26/24
50 57 (20-88) 23/27
50 57 (27-87) 24/26
50 58 (20-89) 29/21
102/98
29 21
34 16
36 14
32 18
131 69
41 5 4
44 1 5
44 2 4
46 2 2
175 10 15
0 3
0 4
1 3
1 2
2 12
catheterization was successful at the first attempt and without difficulty. Complications such as pneumothorax, arterial puncture and catheter misplacement were recorded. Results were analysed with a chi-square test with a significance level of 0.05. The four groups were comparable regarding age and sex (table I). Successful catheterization of the subclavian vein was achieved in 185 (92.5%) patients, and the intended position of the catheter tip in the superior vena cava achieved in 175 (94.6%). Misplacement into the internal jugular vein occurred in 10 (5.4%) patients. The procedure was regarded as easy in 131 (65.5%) patients. Pneumothorax occurred in two subjects (1%); minor complications occurred in 22 (11%). No significant difference {P > 0.05) was demonstrated between the four groups regarding misplacement, ease of procedure, complications or unsuccessful attempts. COMMENT
The position of the head during infraclavicular subclavian vein puncture might be expected to alter the relationship between the subclavian and jugular veins and thus the likelihood of successful cannulation or misplacement. Conflicting advice has been given as to whether the head should face towards or away from the site of puncture [3, 4]. Similarly, differences in venous anatomy between the right and left side might also be expected to influence subclavian vein puncture.
Total 200
However, the present study has shown no statistically significant difference in the success or misplacement rate for the different head positions or side of puncture. Failure and misplacement rates are small and thus a much larger group of patients should be studied to be certain that no difference exists. The incidences of minor complications and difficulty of cannulation in the present study were greater than those in other studies [6], and reflect the relative inexperience of some of the operators. We conclude that the position of the head during infraclavicular subclavian vein cannulation does not have a clinically important effect on the likelihood of successful cannulation or misplacement of the catheter.
REFERENCES 1. Conces DJ, Holden RW. Aberrant locations and complications in initial placement of subclavian vein catheters. Archives of Surgery 1984; 119: 293-295. 2. Dunbar RD, Mitchell R, Lavine M. Aberrant locations of centra] venous catheters. Lancet 1981; 1: 711-715. 3. Pybus DA, Poole JL, Crawford MC. Subclavian venous catheterization in small children using the Seldinger technique. Anaesthesia 1982; 37: 451. 4. Rosen M. Handbook of Percutaneous Central Venous Catheterization. London: Saunders, 1981: 51. 5. Aubaniac R. L'injection intraveineuse sub-claviculaire. La Presse Midicalc 1952; 60: 1456. 6. Eerola R, Kautinen L, Kautinen S. Analysis of 13800 subclavian vein catheterizations. Acta Anaesthesiologica Scandinavica 1985; 29: 193-197.
Downloaded from http://bja.oxfordjournals.org/ at Indiana University Library on July 13, 2015
Number Mean age (yr) (range) Sex (F/M) Procedure Easy Difficult Position SVC
Group 1 (RS, HT)