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Table of Contents  
LETTER TO EDITOR
Year : 2016  |  Volume : 10  |  Issue : 2  |  Page : 379-380  

Misplacement of subclavian vein catheter in a neonate: What went wrong?


1 Department of Anesthesiology and Critical Care Medicine, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
2 Department of Anesthesiology and Critical Care Medicine, Institute of Medical Sciences, Varanasi, Uttar Pradesh, India

Date of Web Publication26-Apr-2016

Correspondence Address:
Neeraj Kumar
Manvi Home, Ahead Shyamal Hospital, Urja Gram, Patna - 800 014, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0259-1162.176410

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How to cite this article:
Dubey PK, Kumar S, Kumar N, Sanjeev OP, Gupta BK. Misplacement of subclavian vein catheter in a neonate: What went wrong?. Anesth Essays Res 2016;10:379-80

How to cite this URL:
Dubey PK, Kumar S, Kumar N, Sanjeev OP, Gupta BK. Misplacement of subclavian vein catheter in a neonate: What went wrong?. Anesth Essays Res [serial online] 2016 [cited 2019 Nov 23];10:379-80. Available from: http://www.aeronline.org/text.asp?2016/10/2/379/176410



Sir,

Malpositioning is a known complication of central venous catheterization in neonates.[1] We describe a misplacement of the right subclavian vein (SCV) catheter into the contralateral SCV in an infant. Such misplacement not only can impede the venous return but also can distort the central venous pressure measurement [2] that may be significant in a neurosurgical patient. Repositioning also adds to the operating room cost and time. We present a hypothesis involving a possible anatomical factor contributing to the misplacement.

A 9-day-old child (body weight 2.5 kg, length 50.5 cm) was posted for decompressive craniotomy of subdural hematoma under general anesthesia. The baby was delivered normally at term. During the last week of her pregnancy, the mother has received electrical shock at home and had landed on her abdomen. The baby had presented with a swelling on the forehead. A computed tomography scan revealed a left temporal intracerebral hemorrhage and a left frontal subdural hematoma. The physical examination was unremarkable, and routine investigations were within normal limits.

A 5 Fr triple lumen central venous catheter (Certofix ® Trio Paed S 508, B. Braun Melsungen AG, Melsungen, Germany) was planned to be inserted via the right SCV using the anatomic landmark technique by infraclavicular approach, after administering general anesthesia. The J-tip guidewire got twisted during the insertion attempt. Fearing misplacement due to the twisted guidewire, it was decided to use the opposite straight end which is also flexible. The catheter was used uneventfully. A chest X-ray obtained next day showed misplacement in the opposite SCV [Figure 1]. The catheter was repositioned under image guidance using a Seldinger guidewire.
Figure 1: Chest X-ray showing the misplaced catheter (left) and a diagrammatic representation of the supracardial venous system in infants (right)

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It has been found by cadaveric dissection that the central venous anatomy in infants is slightly different as compared to that of children aged more than 1 year, which is similar to that of adults.[3] It is clear from the central venous anatomy in infants [Figure 1] that the SCV arch superiorly on both sides of its course, more on the right side than the left. In older children and adults, they become more horizontal.

During central venous access, the direction of the J-tip of the Seldinger wire influences the path taken by the guidewire and the consequently that of the catheter.[4] It appears from the anatomical relations that it is extremely difficult for the straight end of a right SCV guidewire to enter the opposite SCV as the left innominate vein joins the right at almost right angle. This makes the path very tortuous for such a placement. One possible explanation is that the anatomical position of these veins changed with the phases of respiration. We speculate that at the height of inspiration, both SCVs assumed a more horizontal position bringing them in alignment. Under the influence of neuromuscular blocking agents, a compliant chest wall and an inflated lung due to positive pressure ventilation had contributed to this change in anatomy. After needle puncture, the guidewire must have been negotiated into the vein at the height of inspiration. This misplacement did not produce any clinical problem due to the high rate of flow in the vein.[3]

Twisting of the guidewire during insertion is a known factor in contributing to misplacements.[5] That is why we decided to use the opposite straight end of the guidewire which is also flexible.

Difference in anatomical relationship of thoracic veins in infants as compared to older children should be kept in mind during central venous catheterization. We recommend ceasing of ventilation at end expiration for a few seconds during insertion of a straight guidewire in infants as this may influence the direction of the path taken by the guidewire during right SCV cannulation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Casado-Flores J, Valdivielso-Serna A, Pérez-Jurado L, Pozo-Román J, Monleón-Luque M, García-Pérez J, et al. Subclavian vein catheterization in critically ill children: Analysis of 322 cannulations. Intensive Care Med 1991;17:350-4.  Back to cited text no. 1
    
2.
Conces DJ Jr., Holden RW. Aberrant locations and complications in initial placement of subclavian vein catheters. Arch Surg 1984;119:293-5.  Back to cited text no. 2
    
3.
Cobb LM, Vinocur CD, Wagner CW, Weintraub WH. The central venous anatomy in infants. Surg Gynecol Obstet 1987;165:230-4.  Back to cited text no. 3
[PUBMED]    
4.
Tripathi M, Dubey PK, Ambesh SP. Direction of the J-tip of the guidewire, in Seldinger technique, is a significant factor in misplacement of subclavian vein catheter: A randomized, controlled study. Anesth Analg 2005;100:21-4.  Back to cited text no. 4
    
5.
Dubey PK. Beware of the twisted guidewire. J Clin Anesth 2008;20:70-1.  Back to cited text no. 5
[PUBMED]    


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