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The clavicular landmark for bedside prediction of the central venous catheter insertion depth
- Jae-Hyon Bahk (3 May 2007)
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Re: Bedside prediction of the central venous catheter insertion depth
- raman sikka (26 April 2007)
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Bedside prediction of the central venous catheter insertion depth
- Johann N Emmanuel (26 February 2007)
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Bedside prediction of central venous catheter insertion depth
- Jae-Hyon Bahk, Jin-Tae Kim (5 February 2007)
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Bedside prediction of the central venous catheter insertion depth
- Muhammad Farooq (29 January 2007)
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Jae-Hyon Bahk Seoul National University Hospital
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SIR- Dr. Sikka correctly pointed out my mistake about description of the notch on the superior surface of the medial end of the clavicle. So I would like to appreciate Dr. Sikka’s comment on my article (1) and apologize for my lack of vigilance. As shown in my article (1), I think it an important surface landmark for central venous catheterization. Rao et al (2) described it as being consistently palpated 0.25-1 cm lateral to the sternal head of the clavicle on the superior surface of the clavicle and easily identified on the chest radiography. On both sides, the brachiocephalic (innominate) vein lies beneath this notch on the clavicle (3). Thus, the course of central venous catheters placed via the internal jugular and subclavian veins run under the notch on the clavicle. Therefore, I suggest for the future reference that the notch on the clavicle may be named as brachiocephalic (innominate) notch of the clavicle. Jae-Hyon Bahk Seoul National University Hospital, Seoul, Korea References 1. Ryu HG, Bahk JH, Kim JT, Lee JH. Bedside prediction of the central venous catheter insertion depth. Br J Anaesth 2007; 98: 225-7 2. Rao TLK, Wong AY, Salem MR. A new approach to percutaneous catheterization of the internal jugular vein. Anesthesiology 1977; 46: 362 -4 3. Cardiovascular system. In: Williams PL, ed. Gray’s Anatomy, 38th Edn. New York: Churchill Livingstone, 1995; 1589-90 Conflict of Interest:None declared |
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raman sikka
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Editor- We read with great interest and appreciate the study by Ryu HG et al1 regarding the prediction of the central venous catheter insertion depth. The authors have revealed a simple formula using a landmark which is consistently palpated 0.25-1cm lateral to the sternal head of the clavicle on the superior surface of the clavicle and they have named it as “clavicular notch”. However we would like to emphasize that clavicular notch anatomically is a structure on the manubrium sterni as oval fossae which are directed up and postereolaterally for articulation with the sternal ends of the clavicle.2Clavicular notch is thus not a part of clavicle as was described by the authors.Rao et al3 who first used this landmark named it as an easily identifiable “notch” located just above the medial end of the clavicle. Though we are sure this will not dilute the outcome of the study we just endeavour to get the anatomical prespective right. References: 1. Ryu GH, Bahk JH, Kim JT, Lee JH. Bedside prediction of the central venous catheter insertion depth.Br J Anaesth 2007;98:225-7 2.David Johnson. Thorax-Chest wall.Gray,s Anatomy.39th Edn.New York:Churchill Livingstone 2005:952 3.RaoTLK,Wong AY, Salem MR. A new approach to percutaneous catheterization of the internal jugular vein. Anesthesiology1977;46:362-4 Conflict of Interest:None declared |
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Johann N Emmanuel
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Editor, I read the article on bedside tool for central venous catheter depth prediction with interest. At first glance any tool that improves catheter positioning should be commended. However this would be only useful if it were to be compared against standard practice, ie clinician's estimation. Sadly I believe the authors have missed out on what would have been an easy modification to the study, that may then have showed benefit from standard practice. The presence of outliers may reflect artefact due to parallax and portable x-ray beam position, however this would still leave a reliance on post- operative chest radiographs with this technique. Therefore, rather than reducing demand on radiology services, this would increase demand and time, with no obvious benefit to standard practice. Conflict of Interest:None declared |
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Jae-Hyon Bahk Seoul National University Hospital, Jin-Tae Kim
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Sir We would like to thank Dr Farooq for his interest on our article [1]. However, there seems to be some misunderstanding. The practical purpose of my article was not to prove the possibility that chest x-ray (CRX) may be omitted after central venous catheterization, but to minimize post- procedural adjustments of central venous catheter insertion depth. We agree that our technique is not so helpful for patients without prior CRX. Intuitively, the patients indicated for central venous catheterization might have their CRX already taken preoperatively or before admitted to intensive care unit. Besides, though it was not studied, it is highly probable that at least optimal central venous catheter insertion depth should depend on the insertion point to clavicular notch distance. It is possible that very tall patients would have their claviclular notch appeared more peripherally on the CRX augmenting the clavicular notch to carina distance because parallax effect would be greater peripherally. However, because routine posterior-anterior CRX is taken at a fixed distance between x-ray tube and film (72 inch), we think such kind of bias negligible in most cases. If we measure the insertion point to clavicular notch distance after insertion of a guidewire or catheter, there is no reason to introduce any serious error during simple distance measurements. 1. Ryu HG, Bahk JH, Kim JT, Lee JH: Bedside prediction of the central venous catheter insertion depth. Br J Anaesth 2007; 98(2): 225-7 Conflict of Interest:None declared |
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Muhammad Farooq, spr anaesthesia AMNCH, DUBLIN
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Sir I read this article with keen interest [1].Because it may change practice of routine chest x-ray after central line insertion in ICU patients. This practice can lead to decrease in cost of patient care and radiation exposure. But his technique of checking line tip position is not suitable for those patients who have no chest x-ray before central line insertion. So, it is not suitable for that sub group of patients. But, if patient is getting chest x-ray just for carina position to measure length from clavicle notch to carina, then why not x-ray after central line insertion. By doing x-ray after insertion of line, we can see tip of line and serious complications like pneumothorax. Other point is that length from insertion site, clavicular notch and carina is subjective measure, may lead to bias and erroneous results. Dr Muhammad Farooq Spr anaesthesia AMNCH, DUBLIN Reference 1.H.-G. Ryu, J.-H. Bahk, J-T. Kim and J.-H. Lee. Bedside prediction of the central venous catheter insertion depth. British Journal of Anaesthesia 2007 98(2):225-227 Conflict of Interest:None declared |
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