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Central Venous Catheter Placement: Where Is the Tip?

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George Ibrahim at SickKids
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The insertion of central venous catheters is a common bedside procedure performed in intensive care units. Here, we present a case of an 82-year-old man who underwent insertion of a central venous catheter in the internal jugular vein without perceived complications. Postprocedural radiographs showed rostral migration of the catheter, and computed tomography performed coincidentally showed cannulation of the jugular bulb at the level of the jugular foramen. To our knowledge, this is the first report to document migration of a central venous catheter from the internal jugular vein into the dural sinuses, as confirmed by computed tomography. The case highlights the importance of acquiring postprocedural radiographs for all insertions of central venous catheters to confirm catheter placement.
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CENTRAL VENOUS CATHETER
PLACEMENT: WHERE IS THE TIP?
Cases of Note
By George M. Ibrahim, MD
Abstract The insertion of central venous catheters is a common bedside proce-
dure performed in intensive care units. Here, we present a case of an 82-year-old
man who underwent insertion of a central venous catheter in the internal jugular
vein without perceived complications. Postprocedural radiographs showed ros-
tral migration of the catheter, and computed tomography performed coinciden-
tally showed cannulation of the jugular bulb at the level of the jugular foramen.
To our knowledge, this is the first report to document migration of a central venous
catheter from the internal jugular vein into the dural sinuses, as confirmed by
computed tomography. The case highlights the importance of acquiring post-
procedural radiographs for all insertions of central venous catheters to confirm
catheter placement. (American Journal of Critical Care. 2012;21:370-371)
T
he insertion of central venous catheters
(CVCs) is a common bedside procedure
performed in intensive care units. Here,
an uncommon complication of inser-
tion of a CVC is described. The case
involves cannulation of the internal jugular vein of
an 82-year-old man admitted to the general surgical
care area for management of an episode of severe,
acute pancreatitis. The patient had an episode of
confusion, during which he removed his intra-
venous catheters, and a decision to insert a CVC
was made.
By using sterile technique and anatomical land-
marks without ultrasound assistance, the internal
jugular vein was successfully located and punctured
on the first attempt. The Seldinger technique was
used to cannulate the vein by using a guidewire,
and a triple-lumen CVC was advanced easily
approximately 12 cm into the vessel before being
secured. The procedure was not perceived to be dif-
ficult, and the patient tolerated the procedure well.
In addition to routine postprocedural films
(see Figure, A) to confirm catheter placement, the
patient underwent computed tomography of the
brain (see Figure, B) to investigate his prior episode
of confusion. The radiograph showed unexpected
rostral migration of the catheter, and the computed
tomography scan confirmed cannulation of the
right jugular bulb at the level of the jugular fora-
men. Once the problem was identified, the catheter
was removed with no sequelae.
The insertion of CVCs at the bedside is a routine
procedure in intensive care units as well as in many
surgical and medical care areas. The rate of catheter
tip malposition is estimated to be 14% in the litera-
ture, with the tip most commonly in the right atrium
(55%), followed by the left brachiocephalic vein
(14%), the inferior vena cava, and the right pulmonary
artery.1To our knowledge, no cases of cannulation
of the jugular bulb at the level of the jugular foramen,
Cases of Note features peer-reviewed case reports and case series that document clinically relevant findings from critical and high acuity care environ-
ments. Cases that illuminate a clinical diagnosis or a management issue in the treatment of critically and acutely ill patients and include discussion of
the patient’s experience with the illness or intervention are encouraged.
©2012 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ajcc2012925
370
AJCC
AMERICAN JOURNAL OF CRITICAL CARE, September 2012, Volume 21, No. 5 www.ajcconline.org
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which was confirmed in the current case on com-
puted tomography, have been reported. The jugular
bulb receives drainage from the sigmoid and inferior
petrosal sinuses as well as other neighboring veins
and venous plexi.2The anatomical relationships
between the jugular foramen, jugular bulb, and
internal jugular vein are reviewed by Rhoton.2
It can be predicted that cannulation of the
jugular bulb may potentially lead to dural sinus
thrombosis or vascular injury. The association
between dural sinus thrombosis and jugular throm-
bosis after catheterization is well described.3Dural
sinus thrombosis should be suspected if the patient
has headaches, unilateral hemispheric symptoms
(eg, hemiparesis, aphasia), seizures, behavioral
signs and symptoms (eg, delirium, amnesia, or
mutism), or a depressed level of consciousness.3
Although it is impossible to know with cer-
tainty, the use of ultrasound is unlikely to have pre-
vented this complication, because the internal
jugular vein was cannulated without difficulty on
the first attempt by using anatomical landmarks.4
The mainstay of treatment is early identification of
central catheter malposition and removal of the
catheter. This case therefore demonstrates the
importance of routine postprocedural imaging after
all central catheter insertions to confirm placement.
The CVC was easily removed in this case at the bed-
side with gentle traction, but should there be any
perceived or actual difficulty, or resistance to trac-
tion, consultation of an interventional radiologist
and/or neurosurgeon would be prudent.
FINANCIAL DISCLOSURES
None reported.
REFERENCES
1. Gladwin MT, Slonim A, Landucci DL, Gutierrez DC, Cun-
nion R. Cannulation of the internal jugular vein: is postpro-
cedural chest radiography always necessary? Crit Care
Med. 1999;27(9):1819-1823.
2. Rhoton AL Jr. Jugular foramen. Neurosurgery. 2000;47(3
Suppl):S267-S285.
3. Stam J. Thrombosis of the cerebral veins and sinuses. N
Engl J Med. 2005;352(17):1791-1798.
4. Keenan SP. Use of ultrasound to place central lines. J Crit
Care. 2002;17(2):126-137.
About the Authors
George M. Ibrahim is a neurosurgery resident in the
Division of Neurosurgery, University of Toronto,
Ontario, Canada.
Corresponding author: George M. Ibrahim, MD, Hospital
for Sick Children, Suite 1503, 555 University Avenue,
Toronto ON, M5G 1X9, Canada (e-mail: george.m.ibrahim
@gmail.com).
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AMERICAN JOURNAL OF CRITICAL CARE, September 2012, Volume 21, No. 5 371
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Figure Plain radiographs (A) shows rostral
migration of central venous catheter (arrow),
and computed tomography scan (B) of the
head shows catheter tip within right jugular
bulb at the level of the jugular foramen (arrow).
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... Rates of malposition vary depending upon experience and type of insertion. Ibrahim (2012) identifies a bedside malposition rate for nontunnelled CVCs of 14%, with 55% of these tips being misplaced into the RA and 14% into the left brachiocephalic vein. Other studies have shown that CVCs have 6.7% malposition rate (Roldan and Paniagua 2015) and PICC malposition rates of 9.3% both without guidance technology, confirmed by Hill (2012) whose combined PICC and CVC non-guided malposition rates were reported at 8%. ...
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Fetal electrocardiogram signal extraction and analysis method combining fast independent component analysis algorithm and convolutional neural network
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Fetal electrocardiogram (ECG) signals provide important clinical information for early diagnosis and intervention of fetal abnormalities. In this paper, we propose a new method for fetal ECG signal extraction and analysis. Firstly, an improved fast independent component analysis method and singular value decomposition algorithm are combined to extract high-quality fetal ECG signals and solve the waveform missing problem. Secondly, a novel convolutional neural network model is applied to identify the QRS complex waves of fetal ECG signals and effectively solve the waveform overlap problem. Finally, high quality extraction of fetal ECG signals and intelligent recognition of fetal QRS complex waves are achieved. The method proposed in this paper was validated with the data from the PhysioNet computing in cardiology challenge 2013 database of the Complex Physiological Signals Research Resource Network. The results show that the average sensitivity and positive prediction values of the extraction algorithm are 98.21% and 99.52%, respectively, and the average sensitivity and positive prediction values of the QRS complex waves recognition algorithm are 94.14% and 95.80%, respectively, which are better than those of other research results. In conclusion, the algorithm and model proposed in this paper have some practical significance and may provide a theoretical basis for clinical medical decision making in the future.
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hrombosis of the cerebral veins and sinuses is a distinct cere- brovascular disorder that, unlike arterial stroke, most often affects young adults and children. The symptoms and clinical course are highly variable. A teenag- er who has had recent headaches after starting oral contraception, a woman who has had seizures after delivery in the obstetrical ward, and a comatose man with a dilated pupil in the emergency room all may have sinus thrombosis. The estimated annual in- cidence is 3 to 4 cases per 1 million population and up to 7 cases per 1 million among children. About 75 percent of the adult patients are women. During the past decade, in- creased awareness of the diagnosis, improved neuroimaging techniques, and more ef- fective treatment have improved the prognosis. More than 80 percent of all patients now have a good neurologic outcome. This review summarizes recent insights into the pathogenesis of sinus thrombosis, risk factors, and clinical and radiologic diagnosis and discusses the current evidence and controversies about the best treatment. To understand the symptoms and signs of sinus thrombosis, two different mechanisms should be distinguished: thrombosis of the cerebral veins, with local effects caused by venous obstruction, and thrombosis of the major sinuses (Fig. 1), which causes intra- cranial hypertension. In the majority of patients, these two processes occur simulta- neously. The first mechanism, occlusion of the cerebral veins, can cause localized edema of the brain and venous infarction. Pathological examination shows enlarged, swollen veins, edema, ischemic neuronal damage, and petechial hemorrhages (Fig. 2). The latter can merge and become large hematomas, which have a characteristic appearance on com- puted tomographic (CT) scans (Fig. 3). Two different kinds of cerebral edema can devel- op. The first, cytotoxic edema, is caused by ischemia, which damages the energy-depen- dent cellular membrane pumps, leading to intracellular swelling. The second type, vasogenic edema, is caused by a disruption in the blood-brain barrier and leakage of blood plasma into the interstitial space. Vasogenic edema is reversible if the underlying condition is treated successfully. Magnetic resonance imaging (MRI) has shown that both cytotoxic and vasogenic edema occur in cerebral vein thrombosis. 3,4 The second mechanism is the development of intracranial hypertension as the result of occlusion of the major venous sinuses. Normally, the cerebrospinal fluid is transport- ed from the cerebral ventricles through the subarachnoid spaces at the base and surface of the brain to the arachnoid villi, where it is absorbed and drained into the superior sagittal sinus. Thrombosis of the sinuses leads to increased venous pressure, impaired absorption of cerebrospinal fluid, and consequently, increased intracranial pressure. The obstruction to the drainage of cerebrospinal fluid is located at the end of its trans- port pathway, and no pressure gradient develops between the subarachnoid spaces at the surface of the brain and the ventricles. Hence, the ventricles do not dilate, and hydro- t
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Canulation of the internal jugular vein: Is postprocedural chest radiography always necessary?
Article
  • Oct 1999
  • CRIT CARE MED
To determine whether clinical features can be used in a decision rule to prospectively identify a subgroup of internal jugular catheter placements that are correctly positioned and free from mechanical complications, thus obviating the need for routine postprocedural chest radiographs in selected patients. Prospective cohort study. Tertiary care teaching hospital. A total of 107 consecutive patients who presented to our catheter service for internal jugular catheter insertion because of clinical indications between November 1995 and April 1996. Exclusion criteria were mechanical ventilation, an altered mental status, an age of <15 years, and a height of <152 cm. Right or left internal jugular vein catheter placement followed by a postprocedural chest radiograph. The operating physician completed a detailed questionnaire for each catheter insertion, designed to detect potential complications and to predict the necessity, or lack of necessity, for a postprocedural chest radiograph. The questionnaire documented patient characteristics, the number of needle passes, difficulty establishing access, operator experience, poor anatomical landmarks, number of previous catheter placements, resistance to wire or catheter advancement, resistance to aspiration of blood or flushing of the catheter ports, sensations in the ear, chest, or arm, and development of signs or symptoms suggestive of pneumothorax. After catheter insertion, chest radiographs were obtained to assess for mechanical complications and malpositioned catheters. In 46 cases, the decision rule predicted either a complication or a malposition and, thus, the need for a chest radiograph. In 61 cases, neither was predicted (no chest radiograph was needed). Radiographs confirmed one complication (pneumothorax) and 15 catheter tip malpositions (nine in the right atrium and six in the right axillary vein). Among the 46 cases predicted to have a potential complication or malposition, there were one actual complication (pneumothorax) and six actual malpositions (three axillary vein malpositions and three right atrial malpositions). The positive predictive value of this decision rule is 15%. Among the 61 cases predicted to be free from complications or malpositions and not to require a postprocedural chest radiograph, there were nine unexpected malpositions (three axillary vein malpositions and six right atrial malpositions). The negative predictive value is 85%. The overall sensitivity of the decision rule for detecting complications and malpositions is 44%, and the specificity is 55%. In experienced hands, internal jugular venous catheterization is a safe procedure. However, the incidence of axillary vein or right atrial catheter malposition is 14%, and clinical factors alone will not reliably identify malpositioned catheters. Chest radiographs are necessary to ensure correct internal jugular catheter position.
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Use of ultrasound to place central lines
Article
  • Jul 2002
  • J CRIT CARE
Placement of central venous catheters (CVCs) is an integral part of care for the critically ill patient but is associated with significant morbidity when using the traditional landmark method. The use of real-time ultrasound to guide line placement has been developed in hopes of avoiding this morbidity. The objectives of this article are 2-fold. The first is to determine the relative effectiveness of the use of real-time ultrasound to place CVCs compared with the use of landmarks alone. The second is to discuss the merits of future study to increase the use of this technology. Medline from 1966 to 2001, personal files, 2 prior systematic reviews, and reference lists of selected articles. Studies were included if: (1) study design was a controlled trial, (2) patients required placement of a CVC, (3) the interventions were real-time ultrasound versus standard landmark-guided line placement, and (4) outcomes included at least 1 of failure to place catheter, success of first attempt, number of attempts, time to catheter placement, or complication rate. Eighteen trials were identified. Pooled results showed a significant reduction in failure rate (risk difference, -.12, 95% confidence interval [CI], -.18 to -.06), number of attempts (risk reduction, 1.41, 95% CI, 1.15-1.67), and arterial puncture rate (risk difference, -.07, 95% CI, -.10 to -.03). The number of successful venous cannulations on first attempt were higher using ultrasound (risk difference,.24, 95% CI,.08-.39). No difference was found in time to insertion. Significant heterogeneity of study results was found for most analyses. Subgroup analyses suggested that ultrasound improved outcomes most convincingly using external probes, for internal jugular vein cannulation, and when used by clinicians less experienced at line placement. Adoption of real-time ultrasound to guide CVC placement has the potential to improve successful line placement and minimized complications. It can improve patient safety. However, there are significant cost concerns and the reported adverse events are generally minor and easy to treat. Before creating study protocols to increase usage of this technology, both current usage and cost effectiveness should be determined.
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  • Phone
Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.
  • Jan 2000
  • Al Rhoton
  • Jr
  • Jugular Foramen
Rhoton AL Jr. Jugular foramen. Neurosurgery. 2000;47(3
Ibrahim is a neurosurgery resident in the Division of Neurosurgery
  • M George
George M. Ibrahim is a neurosurgery resident in the Division of Neurosurgery, University of Toronto, Ontario, Canada.
  • Jan 2000
  • NEUROSURGERY
  • 267-285
  • A L Rhoton
  • Jugular Foramen
Rhoton AL Jr. Jugular foramen. Neurosurgery. 2000;47(3 Suppl):S267-S285.