Malposition of central venous catheter from right internal jugular vein into ipsilateral subclavian-Axillary vein: Report of a rare case

Abstract

Central venous catheters (CVCs) are placed for many different indications in cardiac, non-cardiac surgery and ICUs. These include inadequate peripheral venous access, administering of medications, (anaesthetic and vasoactive agents, antibiotics, chemotherapy), and central venous pressure (CVP)or hemodynamic monitoring, measurement of central venous oxygen saturation, dialysis, and administration of hypertonic saline, blood and its products, and for cardiac catheterization, and even for transvenous cardiac pacing, ECMO therapy, and plasmapheresis and repeated blood sampling [1, 2, 3]. Normally, the tip of CVC is placed, where the SVC and RA merge. Even with the highest level of skill of the operator and the use of ultrasound guidance, CVC placement can result in various malpositions. Easy and uncomplicated catheterisation, free aspiration of blood and monitoring of catheterisation do not guarantee correct placement of the internal jugular vein (IJV) catheter. Though, placement of a catheter through the RIJV is associated with the lowest incidence of malposition. Ultrasound, ECG guidance, real-time X-ray imaging, confirmation either by palpation in SVC or visualized in the RA during open heart surgery, and saline injection test are definite confirmation and dramatically increase the successful placement of needles, guidewires, and catheters, but significant numbers of catheter misplacements can still occur, particularly if operators are not fully proficient in such techniques. Ruesch et al. have reported the catheter malposition rates as 5.3% and 9.3% for IJV and subclavian vein respectively [4]. Mispositioning of the RIJV insertion into ipsilateral subclavian vein is an extremely unusual event. Here, A case of RIJV inserted CVP catheter malposition into the Right subclavian vein and further into right axillary vein has been reported in a 65 years old male, weighing 70 kg, admitted in emergency department with 67% first degree burns, who deteriorated over the 24 hrs and had cardiac arrest. The malposition was confirmed on the routine check Chest X-Ray.