The incidence and risk of central venous catheter malpositioning: a prospective cohort study in 1619 patients.
Article Type: Clinical report
Subject: Central venous catheters (Complications and side effects)
Central venous catheters (Usage)
Medical errors (Research)
Authors: Pikwer, A.
Baath, L.
Davidson, B.
Perstoft, I.
Ayeson, J.
Pub Date: 01/01/2008
Publication: Name: Anaesthesia and Intensive Care Publisher: Australian Society of Anaesthetists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2008 Australian Society of Anaesthetists ISSN: 0310-057X
Issue: Date: Jan, 2008 Source Volume: 36 Source Issue: 1
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: Sweden Geographic Code: 4EUSW Sweden
Accession Number: 188796717
Full Text: SUMMARY

Central venous catheters are used in various hospital wards. An anterior posterior chest X-ray is usually obtained soon after cannulation to assess the location of the catheter tip. This prospective clinical study was designed to determine the radiographic catheter tip position after central venous cannulation by various routes, to identify clinical problems possibly associated with the use of malpositioned catheters and to make a cost-benefit analysis of routine chest X-ray with respect to catheter malposition. A total 1619 central venous cannulations were recorded during a three-year period with respect to patient data, information about the cannulation procedures, the radiographic catheter positions and complications during clinical use. The total incidence of radiographic catheter tip malposition, defined as extrathoracic or ventricular positioning, was 3.3% (confidence interval 2.5 to 4.3%). Cannulation by the right subclavian vein was associated with the highest risk of malposition, 9.1111b, compared with 1.4% by the right internal jugular vein. Six of the 53 malpositioned catheters were removed or adjusted. No case of malposition was associated with vascular perforation, local venous thrombosis or cerebral symptoms. We conclude that the radiographic incidence of central venous catheter malpositioning is low and that clinical use of malpositioned catheters is associated with few complications. However, determination of the catheter position by chest X-ray should be considered when mechanical complications cannot be excluded, aspiration of venous blood is not possible, or the catheter is intended for central venous pressure monitoring, high flow use or infusion of local irritant drugs.

Key Words: catheterisation, central venous, clinical protocols, costs, cost analysis, diagnostic tests, questionnaires, radiography, unnecessary procedures

**********

Central venous catheters are mainly used for reliable infusion of fluids, for total parenteral nutrition, for administration of potentially irritant drugs and for assessment of systemic haemodynamics. A standard anterior-posterior chest X-ray is often obtained to assess the location of the catheter tip. The traditionally preferred position of the catheter tip is within the caudal third of the superior caval vein (SCV). This position is believed to minimise the risk of complications during clinical use such as vascular perforation, local venous thrombosis, catheter dysfunction and cranial retrograde injection (1).

Small- and medium-sized clinical studies have reported a 3.6 to 14% incidence of catheter malposition (defined as extrathoracic or ventricular positioning) (2-9), but to our knowledge no previous major study has thoroughly addressed this topic although catheter malposition has been claimed to be associated with mechanical complications (10-13).

This prospective clinical study was designed to determine the radiographic catheter tip positions after central venous cannulation by various routes, to identify clinical problems possibly associated with the use of malpositioned catheters and to make a cost-benefit analysis of routine chest X-ray with respect to catheter malposition.

PATIENTS AND METHODS

Setting

The study was approved by the Human Ethics Committee at the Medical Faculty, Lund University, Lund, Sweden.

All 2048 central venous cannulations made by the internal jugular, external jugular or subclavian routes at Malmo University Hospital, Lund University, Malmo, Sweden, between January 1, 2003, and December 31, 2005, were recorded prospectively in study protocols according to criteria reported below.

A total of 429 cannulations (21%) were excluded due to lack of information on the procedures (8.1%) or insufficient control chest X-ray reports (13%). Complete information was thus obtained in 1619 cannulations.

Clinical methods

The puncture site and cannulation technique were chosen by the anaesthesiologist according to the patient's individual needs and the catheter was introduced over a guidewire inserted percutaneously as guided by anatomical landmarks.

Information was obtained on patient age, patient gender and physician's experience of anaesthesia and intensive care at the time of cannulation together with corresponding information on the procedure (clinical indication, hospital area and time of cannulation, puncture site, type of catheter, number of veins punctured and technical difficulty) recorded in the study protocol by the anaesthesiologist.

Clinical information on indwelling time and problems possibly associated with clinical use of malpositioned catheters (catheter dysfunction, vascular perforation, local venous thrombosis and cerebral symptoms) was recorded prospectively in study protocols by nurses in the wards and obtained retrospectively by the main investigator (AP) from patient charts.

Radiographic methods

The catheter tip positions were determined by different radiologists as part of their regular clinical work based on a routine chest X-ray in anterior-posterior supine view according to local guidelines. The junction between the SCV and right atrium was considered to be located at the intersection of the right lateral margin of the SCV (principally defining the right lateral border of the mediastinum) and the superior border of the right atrium (cardiac silhouette). Routine examinations in lateral view were not made.

Possible radiographic catheter tip positions were divided according to Figure 1 into eight zones--(1) right atrium, (2) caudal third of SCV, (3) cranial two thirds of SCV or brachiocephalic veins, (4) intrathoracic part of right subclavian vein, (5) intrathoracic part of left subclavian vein, (6) right internal jugular vein, (7) left internal jugular vein and (8) other position. Radiographic malposition was defined as extrathoracic or ventricular positions of the catheter tip.

Cost analysis

Actual charges for normal and bedside chest X-ray examinations at Mahn6 University Hospital were used to approximate, in U.S. dollars, the cost for detection of each malpositioned central venous catheter from the number of radiographic malpositions found and the total number of chest X-ray examinations carried out.

Statistical methods

Numeric data is given as mean [+ or -] standard deviation (SD) and proportions are reported with 95% confidence intervals (CI). The modified Wald method (14) was used to calculate CI for complication ratios. Proportions were compared by Fisher's exact test or Chi square test. A P value of 0.05 or less was considered as statistically significant.

RESULTS

Patients The age of the patients was 61.4 [+ or -] 9.8 years at the time of cannulation and 823 (51%) were females.

Physicians

Approximately half (52%) of the cannulations were made by specialists. The remaining cannulations were made by residents of anaesthesia and intensive care with less or more than two years' experience of the specialty (both 24%).

Clinical indications, hospital areas and time

The most common clinical indications for central venous cannulation were venous access (52.3%) or total parenteral nutrition (18.3%). Others were measurement of central venous pressure, administration of irritant drugs, renal replacement therapy or plasma separation.

The cannulations were carried out in operating theatres (51%), intensive care units (17%), postoperative (14%) or preoperative (13%) units, emergency departments (0.1%) or other wards (2.5%).

Three quarters (72%) of the cannulations were made during regular office hours and mainly in non-emergency situations.

[FIGURE 1 OMITTED]

Puncture sites

The puncture site was adequately recorded and a control chest X-ray made after each cannulation. Eighty-nine percent cannulations (89%) were made from the right side. The right internal jugular vein was the most common puncture site (63%), followed by the right subclavian (18%) and right external jugular (8.0%) veins.

Catheters

The type of catheter was not reported in 6.7% of the cannulations. Single-, double- or triple-lumen catheters all made of polyurethane were used in 558 (37%), 734 (49%) and 218 (14%), respectively, of the remaining 1510 cannulations. Most catheters (90%) were 20 cm or shorter. There were no pulmonary artery catheters.

One vein was punctured in 1447 cannulation procedures (89%), two veins were punctured in 155 (9.6%) and three or more veins were punctured in the remaining 17 procedures (1.1%).

Almost one fifth (17%) of the cannulations were reported as technically difficult. The right subclavian approach was significantly more often reported as technically difficult than was the right internal jugular approach (20% vs. 15%, P=0.0435), but the right subclavian vein was not significantly more often cannulated after failed attempts at other sites than was the right internal jugular vein (12% vs. 8.5%; P=0.132).

Catheter positions

As shown in Table 1 and Figure 1, the right internal jugular or subclavian approaches were associated with a similar incidence of catheter tip positioning within the caudal third of the SCV (33% vs. 35%; P >0.300).

The incidence of atrial placement after internal jugular cannulation was two thirds of that after subclavian cannulation (11% vs. 15%; P=0.0321). No catheter tip was positioned within the right ventricle.

The total incidence of radiographic malposition of the catheter tip was 3.3% (CI 2.5 to 4.3%) as shown in Table 2.

Malpositioning was found to be more than five times as common after subclavian cannulation than after internal jugular cannulation (8.3% vs. 1.6%; P <0.0001) and more than six times as common after cannulation by the right subclavian than by the right internal jugular vein (9.1% vs. 1.4%; P <0.0001).

There was no significant difference in the incidence of catheter malpositioning between the right and left external jugular (P >0.300), internal jugular (P=0.0762) or subclavian (P >0.300) approaches.

Radiographic malpositioning of the catheter tip was found not to be significantly associated with patient age (P >0.300) or gender (P >0.300), physician's experience of anaesthesia and intensive care (P=0.102), length >20 cm (P=0.257) or design (P >0.300) of catheter, number of punctured veins (P >0.300), time of cannulation (P >0.300) or technical difficulty (P=0.0850). Furthermore, there was no significant correlation between radiographic malposition and removal of the catheter because of catheter dysfunction (P=0.218).

Catheter use

The catheters were used for 8 [+ OR -] 8 days and 5.5% were removed because of catheter dysfunction.

Six of the 53 malpositioned catheters were adjusted or removed due to initial positions in small intrathoracic or cervical veins and intended administration of local irritant drugs. There were no clinical signs of vascular perforation or local venous thrombosis during clinical use in the remaining 47 malpositioned catheters (Table 2) or in those 184 catheters (11%) with atrial position, of which none was adjusted.

No cerebral symptoms were reported during clinical use for 5 [+ or -] 5 days (until adjustment or removal) in seven patients with cranially directed catheters, or in the remaining 12 patients with cranially directed catheters removed immediately after X-ray control.

[FIGURE 2 OMITTED]

Cost analysis

The current charge at Malmo University Hospital is approximately US$117 for a normal and US$181 for a bedside chest X-ray examination. A total number of 31 chest X-ray examinations, corresponding to a total cost of approximately US$5400, were required to detect each catheter malposition.

DISCUSSION

This prospective study reports clinically relevant aspects on central venous cannulation with respect to radiographic catheter tip positioning. To our knowledge no previous study on this subject has been carried out in such detail and in so many patients.

The present study indicates that the right internal jugular approach should normally be preferred for central venous cannulation to reduce the incidence of extrathoracic positioning. Our lower incidence of catheter malposition compared with previous smaller studies (2-8) might have resulted from higher differences in statistical power and accuracy as well as from more frequent use of the right internal jugular approach in the present study. Lower incidence of malpositioning including atrial placement after internal jugular than after subclavian cannulation might have anatomical reasons but could also have resulted from more personal experience of the internal jugular approach for central venous cannulation, in agreement with recent findings (8), and from slightly more frequent, though statistically nonsignificant, use of the subclavian route when other routes have failed. The low total number of left internal jugular cannulations might partly explain why the right internal jugular route was associated with a lower, though not statistically significant, incidence of malpositioning (15).

Transoesophageal echocardiography has been suggested for determination of the guide wire position during central venous cannulation (16) and anaesthesiologists have been reported to be able to identify catheter malposition bedside by transthoracic ultrasonic evaluation (17).

The catheter tip position has also been proposed to be predictable from clinical judgements in adults, and intravascular distances from the cannulation site to the SCV-atrial junction have been determined and reported for both the internal jugular and subclavian veins (18,19).

Radiographic catheter malposition, although subjected to methodological inaccuracy (20,21), anatomical variation (22)' and interobserver variability (22), has been proposed to be associated with vascular perforation, local venous thrombosis, catheter dysfunction and cranial retrograde injection (10-12).

The risk of vascular perforation during clinical use of modern softer catheters made of polyurethane is low (23) in agreement with our findings. Four cases of cardiac tamponade have been reported two to 24 hours after central venous catheterisation in patients subjected to major orthopaedic surgery (24) where the catheter tip had been either maintained in the atrium (in one patient) or repositioned into the SCV (in two patients) after initial chest X-ray control. The rapid progress of clinical symptoms in these patients suggests that the complications could have resulted from the cannulation procedures rather than from clinical use (24,25). Moreover, it cannot be excluded that the cardiac tamponade resulted from high-energetic thoracoabdominal trauma in the fourth patient (where no radiographic catheter position was reported). It has been suggested, since cardiac tamponade has been reported in patients with a radiographic catheter tip position within the cardiac silhouette (26), that the optimal tip position is within the SCV outside the pericardium and that the carina can be used as a landmark on a frontal chest X-ray (27). However, a catheter tip within the SCV (on a chest X-ray) may also erode the vessel and cause either mediastinal haematoma, pleural infusion or pericardial tamponade (28). A radiographic catheter tip positon close to the carina increases the possibility of the catheter not being aligned with the long axis of the SCV, particularly after introduction from the subclavian or left jugular veins (29), thereby possibly increasing the risk of vascular perforation on long-term use (30). Most cardiac tamponades result from pericardial infusion of fluid (26), which like pleural infusion (23) could be avoided by careful aspiration of blood or (if no blood can be obtained) chest X-ray with intravenous contrast injection before clinical use. Five cases of pleural infusion were recently reported to be associated with total parenteral nutrition by polyethylene or polyurethane catheters inserted from the left side, but no radiographic tip positions were reported (23). To summarise, any central venous catheter adequately positioned within the SCV could be associated with vascular perforation (Figure 2), indicating that there is no safe or optimal catheter position and that knowledge about the radiographic position has no clinical value in these aspects. Furthermore, these complications are probably associated with the cannulation procedure rather than with short-term catheter use.

No clinical signs of venous thrombosis were found in our patients with catheter malposition, probably due to relatively short indwelling times. Symptomatic local venous thrombosis is considered to be associated with long-term catheter use, especially with tip positions within the cranial part of the SCV (31), but also within the caudal part of the SCV (32) or in the right atrium (32,33). Surface deposition of thrombotic material at the catheter tip is probably not uncommon during clinical use but has little clinical relevance in a short-term perspective as long as the catheter function is normal. It cannot be excluded that investigation by ultrasound or phlebography in our patients with catheter dysfunction could have revealed subclinical venous thromboses.

As also found here, clinical use is not affected by moderate catheter dysfunction due to suboptimal position unless high flow rates are required, e.g. during haemodialysis (12,34).

A cranial course of a catheter is often adjusted to avoid local venous thrombosis or retrograde cerebral injection, although these complications have never been reported in patients. Cerebral retrograde injection has even been shown to be impossible in humans (35), in agreement with the lack of cerebral symptoms during clinical use of cranially directed catheters in the present study.

Another main purpose of the study was to make a cost-benefit analysis of routine chest X-ray with respect to catheter malposition after central venous cannulation. This analysis was made without considering complications possibly associated with clinical use of malpositioned catheters or the cannulation procedure, since no specific catheter position has to our knowledge been shown to be associated with such complications during short-term catheter use.

There are two possible limitations of the study. First, it is a single-centre study, which could (although it is large) limit the generalisability. Secondly, the low incidence of malpositioning reported does not include atrial placement. The risk associated with atrial positioning of central venous catheters particularly for prolonged periods of time remains uncertain, since the absolute number of atrial placements in this study was small and the catheters were used for short periods of time.

CONCLUSIONS

Taking all these aspects into consideration, we conclude that the radiographic incidence of central venous catheter malpositioning is low and that clinical use of malpositioned catheters is associated with few complications. However, determination of the catheter position by chest X-ray should be considered when mechanical complications cannot be excluded, aspiration of venous blood is not possible, or the catheter is intended for central venous pressure monitoring, high flow use or infusion of local irritant drugs.

Accepted for publication on September 5, 2007.

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A. PIKWER *, L. BAATH ([dagger]), B. DAVIDSON ([double dagger]), I. PERSTOFT ([section]), J. AYESON **

Departments of Anaesthesiology and Intensive Care Medicine, and of Diagnostic Radiology, Lund University, Malmo University Hospital, Malmo, Sweden

* M.D., Resident Anaesthesiologist, Department of Anaesthesiology and Intensive Care Medicine.

[dagger] M.D., Ph.D., Consultant Radiologist, Department of Diagnostic Radiology.

[double dagger] M.D., Consultant Anaesthesiologist, Department of Anaesthesiology and Intensive Care Medicine.

[section] Nurse Anesthetist and IT Technician, Department of Anaesthesiology and Intensive Care Medicine.

** M.D., Ph.D., Associate Professor and Consultant Anaesthesiologist, Department of Anaesthesiology and Intensive Care Medicine.

Address for reprints: Dr A. Pikwer, Department of Anaesthesiology and Intensive Care Medicine, Lund University, Malmo University Hospital, SE-205 02 Malmo, Sweden.
TABLE 1
Puncture sites and corresponding radiographic catheter tip positions of
central venous catheters inserted at Malmo University Hospital during
the three-year study period 2003 to 2005

Puncture site (%)      Radiographic catheter tip positions (%)
                     with 95% confidence intervals within region

                     1          2          3          4

UV      1127 (70)    123 (11)   356 (32)   615 (55)   11 (1.0)
                     9.2-13     29-34      52-58      0.5-1.8

right   1023 (63)    118 (12)   334 (33)   543 (53)   10 (1.0)
                     9.7-14     30-36      50-56      0.5-1.8

left    104 (6.4)    5 (4.8)    22 (21)    72 (69)    1 (1.0)
                     1.8-11     14-30      60-77      0-5.8

SV      324 (20)     50 (15)    114 (35)   127 (39)   3 (0.9)
                     12-20      30-40      34-45      0.2-2.8

right   287 (18)     47 (16)    100 (35)   109 (38)   2 (0.7)
                     12-21      30-40      33-44      0-2.7

left    37 (2.3)     3 (8.1)    14 (38)    18 (49)    1 (2.7)
                     2.1-22     24-54      34-64      0-15

EJV     168 (10)     11 (6.5)   58 (34)    90 (54)    1 (0.6)
                     3.8-12     28-42      46-61      0-3.6

right   130 (8.0)    9 (6.9)    52 (40)    63 (48)    1 (0.8)
                     3.5-13     32-49      40-57      0-4.7

left    38 (2.3)     2 (5.3)    6 (16)     27 (71)    0 (0.0)
                     0.5-18     7.1-31     55-83      0-11

Total   1619 (100)   184 (11)   528 (33)   832 (51)   15 (0.9)
                     9.9-13     30-35      49-54      0.6-1.5

Puncture site (%)      Radiographic catheter tip positions (%)
                     with 95% confidence intervals within region

                     5         6          7         8

UV      1127 (70)    4 (0.4)   4 (0.4)    1 (0.1)   13 (1.2)
                     0.1-0.9   0.1-0.9    0-0.6     0.7-2.0

right   1023 (63)    4 (0.4)   4 (0.4)    0 (0)     10 (1.0)
                     0.1-1.0   0.1-1.0    0-0.5     0.5-1.8

left    104 (6.4)    0 (0.0)   0 (0)      1 (1.0)   3 (2.9)
                     0-4.3     0-4.3      0-5.8     0.6-8.5

SV      324 (20)     3 (0.9)   5 (1.5)    3 (0.9)   19 (5.9)
                     0.2-2.8   0.6-3.7    0.2-2.8   3.7-9.0

right   287 (18)     3 (1.0)   5 (1.7)    2 (0.7)   19 (6.6)
                     0.2-3.2   0.6-4.1    0-2.7     4.2-10

left    37 (2.3)     0 (0)     0 (0)      1 (2.7)   0 (0)
                     0-11      0-11       0-15      0-11

EJV     168 (10)     0 (0)     1 (0.6)    2 (1.2)   5 (3.0)
                     0-2.7     0-3.6      0.1-4.5   1.1-7.0

right   130 (8.0)    0 (0)     1 (0.8)    2 (1.5)   2 (1.5)
                     0-3.5     0-4.7      0.1-5.8   0.1-5.8

left    38 (2.3)     0 (0)     0 (0)      0 (0)     3 (7.9)
                     0-11      0-11       0-11      2.0-22

Total   1619 (100)   7 (0.4)   10 (0.6)   6 (0.4)   37 (2.3)
                     0.2-0.9   0.3-1.2    0.2-0.8   1.7-3.1

IJV=internal jugular vein, SV=subclavian vein, EJV=external jugular
vein, 1=right atrium, 2=caudal third of superior caval vein, 3=cranial
two thirds of superior caval or brachiocephalic vein, 4=intrathoracic
part of right SV, 5=intrathoracic part of left SV, 6=right UV, 7=left
IJV, 8=other position.

TABLE 2
Central venous catheter malposition (defined as extrathoracic or
ventricular radiographic catheter tip positions) and reported multiple
or difficult punctures (in numbers and percent of catheters introduced
from that site) at Malmo University Hospital during the three-year
study period 2003 to 2005

Puncture site                   Malposition         >1 punctured vein

                               n     %    CI        n      %    CI

Internal jugular vein, right   14   1.4   0.8-2.3   87    8.5   6.9-10
Internal jugular vein, left    4    3.8   1.2-9.8   21    20    14-29
Subclavian vein, right         26   9.1   6.2-13    33    12    8.3-16
Subclavian vein, left          1    2.7   0-15      3     8.1   2.1-22
External jugular vein, right   5    3.8   1.4-8.9   18    14    8.9-21
External jugular vein, left    3    7.9   2.0-22    7     18    8.9-34

All                            53   3.3   2.5-4.3   169   10    9.0-12

Puncture site                  Difficult puncture

                               n     %     CI

Internal jugular vein, right   149   15    12-17
Internal jugular vein, left    31    30    22-39
Subclavian vein, right         56    20    15-24
Subclavian vein, left          7     19    9.2-34
External jugular vein, right   12    9.2   5.2-16
External jugular vein, left    6     16    7.1-31

All                            261   16    14-18

CI=95% confidence interval, n=number of catheters.
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