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Usefulness of the carina as a radiographic landmark for central venous catheter placement in paediat
- Seung Z. Yoon, Chong S. Kim (14 March 2006)
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Usefulness of the carina as a radiographic landmark for central venous catheter placement in paediat
- Baljit Singh, Deepak K Tempe, Devesh Dutta (3 March 2006)
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Seung Z. Yoon, Clinical Professor Seoul National University Hospital, Chong S. Kim
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We would like to thank Singh and colleagues for their interest in our paper. The authors comment consists of three questions. We will answer one by one. We wondered how deep can we insert the central venous catheter (CVC) without complication. During literature search we found the article written by Andropoulos and colleagues (1) but realized that their work had some limitations.The main limitation was, as we described in the introduction of our article, that they used chest radiography to confirm that the tip of CVC was in the SVC-RA junction. With regards to the study by Aslamy and colleagues (2), a considerable portion of CVC tips which were in the cardiac silhouette on the chest radiograph may actually have been positioned in the SVC. Thus, the guidelines proposed by Andropoulos et al. for CVC placement could lead to an unintentional placement of a catheter tip in the mid SVC away from the SVC-RA junction, which may cause suboptimal catheter performance. So we designed and conducted a study to overcome the limitation for initial placement of CVC tip - this was subsequently published (3). As we mentioned in the method section, we routinely check the postoperative chest radiograph to confirm that the CVC tip is not in the right atrium (RA). Dr. CS Kim pointed out that there are no reliable radiographic landmarks to confirm that the tip of CVC is not in the RA. So we searched again to find out the radiographic landmark but failed. So Dr. Kim proposed that we report the radiographic landmark in pediatric chest radiograph for positioning the CVC tip. We investigated the postoperative chest radiograph and reported that carina is a useful radiographic landmark for central venous catheter tip in pediatric patients. We considered the CVC tip as a radiographic marker of SVC-RA junction because we placed the CVC tip at the SVC-RA junction by using TEE. So we think that the distance between the carina and the catheter tip by drawing two horizontal lines one at the level of carina and another at the level of CVC tip on the radiographic image can be considered as the longitudinal distance between the carina and SVC-RA junction. The legend in the scatter diagram is our mistake. The longitudinal distance from the level of carina to the level of CVC tip is correct. References 1.Andropoulos DB, Bent ST, Skjonsby B, Stayer SA.: The optimal length of insertion of central venous catheters for pediatric patients. Anesth Analg 2001; 93: 883-6 2.Aslamy Z, Dewald CL, Heffner JE. MRI of central venous anatomy. Implications for central venous catheter insertion. Chest 1998; 114: 820-6 3.Yoon SZ, Shin TJ, Kim HS, Lee J, Kim CS, Park CD et al. Depth of a central venous catheter tip: length of insertion guideline for pediatric patients. Acta Anesthesiol Scand 2006; 50:355-7 Conflict of Interest:None declared |
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Baljit Singh, Anaesthesiologist G B Pant Hospital, New Delhi, Deepak K Tempe, Devesh Dutta
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Letter to the Editor: Usefulness of the carina as a radiographic landmark for central venous catheter placement in paediatric patients. Editor - The report on the usefulness of the carina as a radiographic landmark for central venous catheter placement1 is very informative, however, we would like to take up certain issues. There is no mention as to how the catheter tip was positioned at the superior vena cava-right atrial (SVC-RA) junction before transoesophageal echocardiography (TOE) was performed. It is hard to imagine that all the catheters were found at the SVC-RA junction at initial placement without TOE. After identifying the tip of the catheter by the hyperechogenic microbubbles from the saline flush on TOE, was the catheter manipulated to reach the superior border of crista terminalis (SVC-RA junction)? Until and unless, the catheter is manipulated to reach the SVC-RA junction in cases where it was not there initially, we feel the two terms; the SVC-RA junction and the catheter tip should not be interchanged for determining the distance. In the intensive care unit, the authors determined the distance between the carina and the catheter tip by drawing two horizontal lines one at the level of carina and another at the level of CVC tip on the radiographic image. How can the distance between these two horizontal lines be considered as the longitudinal distance between the SVC-RA junction and CVC tip? Further, all the three scatter diagrams mention the longitudinal distance from the carina to the catheter, whereas the legend mentions it as the distance from the level of carina to the SVC-RA junction. Though the conclusion drawn by the authors is in order, there appears to be a gross error in the use of terminology with regard to the SVC-RA junction, the CVC tip and the carina. Reference: 1. Yoon SZ, Shin JH, Hahn S, et al. Usefulness of the carina as a radiographic landmark for central venous catheter placement in paediatric patients. Br J Anaesth 2005; 95: 514-7 Conflict of Interest:None declared |
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