Introduction: Although placement of the central venous catheter is a routine procedure carried out by anesthesiologists, it carries a certain risk of complications. One of the complications is malposition, or inadequate catheter position.

Case report: We present a case of the patient who was admitted to an intensive care unit due to head injury and blood vomiting. The central venous catheter was inserted through the right internal jugular vein. Due to hemodynamic instability and the need for fluid and blood infusion, a chest x-ray examination was not immediately performed to evaluate the position of the catheter. After the patient was stabilized, the test was performed and revealed that the tip of the catheter was not located in the superior vena cava but in the right subclavian vein.

Conclusion: This case has shown that the misplacement of the central venous catheter tip is not unusual. Once in the venous system, even when it is not located in the superior vena cava, it can be used for initial fluid replacement and drug administration and after the patient is stabilized, the repositioning or placement of a new catheter should be considered.

INTRODUCTION

Central venous catheter (CVC) placement is a procedure that is almost without exception used in the pre-operative treatment of critically ill and patients in intensive care units (ICU). CVC can be placed centrally or peripherally, and the preferred sites for insertion are internal jugular vein (IJV) and subclavian vein (SV). CVC is widely used in administration of fluids, blood products, parenteral nutrition or drugs; placement of temporary pacemakers etc. Arguably, the role of CVC in central venous pressure (CVP) measurement is irreplaceable.

Although relatively safe, numerous complications occurring during CVC placement as well as maintenance have been reported. Complications are estimated to occur in 2-26% of cases [1]. Complications of insertion of CVCs include mechanical, infectious and thrombotic complications [2]. The most common complications are hematoma, infection, and pneumothorax [3]. Other complications are rare.

In order to reduce the incidence of complications, this procedure is usually carried out by well-trained physicians. However, complications are sometimes inevitable despite all precautionary measures. One of the complications not dependent on the performer's experience is malposition or inadequate CVC position [4]. Interestingly, although the use of ultrasound significantly increases the success rate of vein cannulation, it does not diminish the possibility of catheter tip malposition [5].

We present a case report of a misplaced CVC from right internal jugular vein to right subclavian vein.

CASE REPORT

DISCUSSION

For accurate CVP measurement, the tip of the central venous catheter (CVC) should lie within the SVC, above its junction with the right atrium. Malposition CVC refers to a catheter whose tip does not lie in the ‘ideal’ position. The incorrect positioning leads not only to inaccurate CVP values but can also lead, depending on localization, to erosion of the vein wall, vein perforation, local venous thrombosis, catheter dysfunction, etc. [6].

Right-sided subclavian access carries a higher risk of malposition (9.1%), compared to IJV access (1.4%) [7]. The incidence of malposition depends on the site of insertion and the used material, the type of material used, but not on the experience of the physician who inserted the catheter[4] and innate and acquired anomalies of the blood vessels. Some of the innate factors are: persistent left SVC, SVC variations, dextrocardia, varicella of the IVC, variations of the azygous venous system [8]. Acquired factors are much more common causes of malposition and can be of internal or external origin. Venous thrombosis or stenoses are the most common internal causes. External causes are mainly tumor formations causing external pressure on the vein (lungs or breast tumors, lymphomas, thymomas, etc.) [9].

Internal jugular vein access has the advantage of direct access to the superior vena cava. Malposition can be of two types, intracaval and extracaval, according to the location of the catheter [10]. It is described in almost all possible anatomical locations: arterial system, mediastinum, pleura, pericardium, trachea, esophagus, subarachnoid space and other sites [11,12].

It may occur during catheter placement or later as a result of spontaneous migration due to anatomical positioning or changes in pressure in the thoracic cavity. Therefore, routine chest x-ray examination is recommended for the evaluation of catheter position and recording of possible complications [13]. There are authors who do not recommend a routine radiographic testing due to the low incidence of malposition [14].

We assume that the reason for malposition in our case was rotating the guide wire to the right when it met resistance at the second marker. At that point, the guide wire tip advancing through right brachiocephalic vein changed the direction and turned to the right subclavian vein. As venous blood was aspirated, we did not suspect the malposition. However, aspiration of blood after placement of the catheter does not guarantee correct catheter positioning [13]. Although the tip of the catheter was not in the SVC, it was still in the venous system, thus we used it to administer fluids and drugs and stabilize the patient.

CONCLUSION

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13.    Ghatak T, Azim A, Baronia AK, Muzaffar SN (2011) Malposition of central venous catheter in a small tributary of left brachiocephalic vein. J Emerg Trauma Shock 4: 523-525.

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