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The carina as a radiological landmark for detection of accidental arterial placement of left sided c
- Umesh Goneppanavar, Sathyajith Karanth Airody (22 April 2007)
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Central venous catheter safety
- Simon P Young (11 September 2006)
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Twelve and a half is luckier than thirteen?
- William C Russsell, John L. Parker (28 March 2006)
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Umesh Goneppanavar , Sathyajith Karanth Airody
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Title: The carina as a radiological landmark for detection of accidental arterial placement of left sided central venous catheter To the Editor, We read with interest Stonelake and Bodenham’s paper about using the carina as a radiological landmark for central venous catheter tip position. Most commonly adapted technique for central venous catheter placement is the palpation technique where one relies mainly on the anatomical landmarks and feel of the vascular pulsations. However, there always exists a possibility of accidental arterial puncture. Usually, arterial puncture can easily be recognised by the bright red colour of the blood and the pulsatile nature of blood flow from the artery. However, it might be extremely difficult to judge arterial puncture by these means while performing central venous cannulation in patients with diseased lungs having circulatory arrest or hypovolaemic shock. Though, ultrasound guided technique of central venous cannulation is ideal in such patients, it is not available in all the institutions. Therefore, there is a need to have an alternative means to detect accidental arterial insertion of central venous catheters in such situations. We would like to draw your attention to Fig 5 of the article.(1)The Zone C in this stylized anatomical figure represents the left innominate vein proximal to the superior vena cava. Whether the approach for left central venous cannulation is through internal jugular vein, subclavian vein or cubital vein; the catheter has to pass through the common path ‘Zone C’ above the level of carina prior to entering superior vena cava. Therefore we can conclude that in a chest X ray, if a central venous catheter placed through left side is crossing the midline below the level of the carina, it is unlikely to be in a vein. Reference 1. Stonelake PA, Bodenham AR. The carina as a radiological landmark for central venous catheter tip position. Br J Anaesth 2006; 96: 335 – 40 Conflict of Interest:None declared |
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Simon P Young, Anaesthetic SPR/Lecturer
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I read with interest your article regarding central venous catheter (CVC) tip positioning (1). I beleive this provides an important contribution to the safe placement on CVCs. Additional simple measures that may arguably improve the safety of CVC placement should not be forgotten, namely use of a soft cannula-over needle (rather than hard needle) for initial puncture of the vessel, transducing the pressure waveform prior to 'wiring' through this cannula, and checking for free aspiration/injection of all ports. In addition I would argue against the mannipulation of CVC position once in situ if vasoactive medicines are being infused, as the risk of subcutaneus infusion and cardiovascular collapse is ever present. 1. P. A. Stonelake and A. R. Bodenham. The carina as a radiological landmark for central venous catheter tip position Br. J. Anaesth. 2006; 96: 335-340 S. P. Young, Leicester Conflict of Interest:None declared |
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William C Russsell, Consultant Nil, John L. Parker
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Editor- We read with interest the paper by Stonelake and Bodenham [1], and agree with their conclusions. Having a range of catheters is important and some thought should be applied to the length used for particular routes. For right sided access, we suggest that a 12.5 cm catheter should be used. 'Vygon' have produced such a catheter as a result of previous observations [2]. In 100% of cases they are positioned within the arbitrarily satisfactory position in Stonelakes’ paper. In fact in an audit of 35 consecutive right-sided insertions only two have had catheter tips greater than 1 cm below the carina (1.1 and 1.5 cm). This length catheter means as well as certainty of an extra cardiac position, they are easily fixed without any catheter protruding from the neck of the patient. Left sided lines are more difficult, we found the shorter catheters often abut the SVC at an acute angle and are probably not suitable for this approach. Looking at 24 lines inserted to 12.5-13 cm, half were less than a centimetre from the lateral wall of the SVC and only a fifth had an angle of incidence to the SVC of less than 10 degrees. Therefore we agree that with a the left-side approach longer 16-20cm catheters should probably be placed juxta atrial and pulled back only as required. References 1 Stonelake PA, Bodenham AR. The carina as a radiological landmark for central venous catheter tip position. Br J Anaesth 2006; 96:335-40 2 Russell WC, Parker JL. Thirteen centimetre central venous catheters, lucky for all? Anaesthesia 2003; 58:388 Conflict of Interest:None declared |
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