Towards Optimal Central Venous Catheter Tip Position

  • W. Schummer
  • Y. Sakr
  • C. Schummer


Central venous catheters (CVCs) are required in many critically ill patients. They are usually inserted through the subclavian or internal jugular veins. As with most invasive procedures, central venous catheterization is associated with numerous potential complications, many of which are associated with the access procedure. The use of ultrasound guidance during CVC placement is among the top 10 evidence-based tools that health care providers can use to improve patient safety [1]. However, serious complications may also occur due to catheter tip malposition. Generally, these complications have only been reported in small studies or case reports, thus underreporting is likely. As a result, exact figures regarding the magnitude of risk of specific complications are not available. Venous or right heart perforations, causing pericardial tamponade or hemothoraces, are associated with a high mortality rate of 65 to 91% [2]. Despite the low incidence of severe complications, there is a wide range of clinically relevant drawbacks related to catheter tip malposition (e.g., venous thrombosis, catheter dysfunction).


Central Venous Catheter Superior Vena Cardiac Tamponade Vein Wall Pericardial Tamponade 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. 1.
    Rothschild J (2001) Ultrasound guidance of central vein catheterization. In: Markowitz A (ed) On Making Health Care Safer: A critical analysis of patient safety practices. AHRQ Publications, Rockville, MD, pp 245–255Google Scholar
  2. 2.
    Booth SA, Norton B, Mulvey DA (2001) Central venous catheterization and fatal cardiac tamponade. Br J Anaesth 87: 298–302PubMedCrossRefGoogle Scholar
  3. 3.
    Fletcher SJ, Bodenham AR (2000) Safe placement of central venous catheters: where should the tip of the catheter lie? Br J Anaesth 85: 188–191PubMedCrossRefGoogle Scholar
  4. 4.
    Kim FM, Burrows PE, Hoffer FA, Chung T (1996) Interpreting the results of pediatric central venous catheter studies. Radiographics 16: 747–754PubMedGoogle Scholar
  5. 5.
    Puel V, Caudry M, Le Metayer P, et al (1993) Superior vena cava thrombosis related to catheter malposition in cancer chemotherapy given through implanted ports. Cancer 72: 2248–2252PubMedCrossRefGoogle Scholar
  6. 6.
    Pithie A, Soutar JS, Pennington CR (1988) Catheter tip position in central vein thrombosis. JPEN J Parenter Enterai Nutr 12: 613–614CrossRefGoogle Scholar
  7. 7.
    Luciani A, Clement O, Halimi P, et al (2001) Catheter-related upper extremity deep venous thrombosis in cancer patients: a prospective study based on Doppler US. Radiology 220: 655–660PubMedCrossRefGoogle Scholar
  8. 8.
    Food and Drug Administration (1989) Precautions necessary with central venous catheters. FDA Task Force. FDA Drug Bulletin: 15–16Google Scholar
  9. 9.
    Vesely TM (2003) Central venous catheter tip position: a continuing controversy. J Vasc Interv Radiol 14: 527–534PubMedGoogle Scholar
  10. 10.
    Schummer W, Schummer C, Bayer O, Muller A, Bredle D, Karzai W (2005) Extravasation injury in the perioperative setting. Anesth Analg 100: 722–727PubMedCrossRefGoogle Scholar
  11. 11.
    Wu X, Studer W, Skarvan K, Seeberger MD (1999) High incidence of intravenous thrombi after short-term central venous catheterization of the internal jugular vein. J Clin Anesth 11: 482–485PubMedCrossRefGoogle Scholar
  12. 12.
    Domino KB, Bowdle TA, Posner KL, Spitellie PH, Lee LA, Cheney FW (2004) Injuries and liability related to central vascular catheters: a closed claims analysis. Anesthesiology 100: 1411–1418PubMedCrossRefGoogle Scholar
  13. 13.
    Schummer W, Schummer C, Rose N, Niesen WD, Sakka SG (2007) Mechanical complications and malpositions of central venous cannulations by experienced operators: A prospective study of 1794 catheterizations in critically ill patients. Intensive Care Med 33: 1055–1059PubMedCrossRefGoogle Scholar
  14. 14.
    Robinson JF, Robinson WA, Cohn A, Garg K, Armstrong JD 2nd (1995) Perforation of the great vessels during central venous line placement. Arch Intern Med 155: 1225–1228PubMedCrossRefGoogle Scholar
  15. 15.
    Mukau L, Talamini MA, Sitzmann JV (1991) Risk factors for central venous catheter-related vascular erosions. JPEN J Parenter Enteral Nutr 15: 513–516PubMedCrossRefGoogle Scholar
  16. 16.
    Xiang DZ, Verbeken EK, Van Lommel AT, Stas M, De Wever I (1998) Composition and formation of the sleeve enveloping a central venous catheter. J Vasc Surg 28: 260–271PubMedCrossRefGoogle Scholar
  17. 17.
    Müller K (1981) Komplikation durch Kava-Katheter und ihr pathologisch-anatomisches Substrat. In: Lawin P, Hartenauer U (eds) Der intravasale Katheter. Thieme, Stuttgart, pp 73–81Google Scholar
  18. 18.
    Hoshal VL, Jr., Ause RG, Hoskins PA (1971) Fibrin sleeve formation on indwelling subclavian central venous catheters. Arch Surg 102: 253–258Google Scholar
  19. 19.
    Winn MP, McDermott VG, Schwab SJ, Conlon PJ (1997) Dialysis catheter’ fibrin-sheath stripping’: a cautionary tale! Nephrol Dial Transplant 12: 1048–1050PubMedCrossRefGoogle Scholar
  20. 20.
    Borow M, Crowley JG (1985) Evaluation of central venous catheter thrombogenicity. Acta Anaesthesiol Scand Suppl 81: 59–64PubMedCrossRefGoogle Scholar
  21. 21.
    Gault DT (1993) Extravasation injuries. Br J Plast Surg 46: 91–96PubMedCrossRefGoogle Scholar
  22. 22.
    Upton J, Mulliken JB, Murray JE (1979) Major intravenous extravasation injuries. Am J Surg 137: 497–506PubMedCrossRefGoogle Scholar
  23. 23.
    Yosowitz P, Ekland DA, Shaw RC, Parsons RW (1975) Peripheral intravenous infiltration necrosis. Ann Surg 182: 553–556PubMedCrossRefGoogle Scholar
  24. 24.
    Wallenborn J, Kuhnert I (2002) [Do position control methods for central venous catheters prevent complications? Hydromediastinum caused by an initially correctly placed tri-lumen subclavian catheter by using intra-atrial ECG recording — a case report]. Anaesthesiol Reanim 27: 131–137PubMedGoogle Scholar
  25. 25.
    Walker C, Jackson D, Dolan S (1997) The potential for extravasation using a new five lumen catheter. Anaesthesia 52: 716–717PubMedGoogle Scholar
  26. 26.
    Chalkiadis GA, Goucke CR (1998) Depth of central venous catheter insertion in adults: an audit and assessment of a technique to improve tip position. Anaesth Intensive Care 26: 61–66PubMedGoogle Scholar
  27. 27.
    Stuart RK, Shikora SA, Akerman P, et al (1990) Incidence of arrhythmia with central venous catheter insertion and exchange. JPEN J Parenter Enteral Nutr 14: 152–155PubMedCrossRefGoogle Scholar
  28. 28.
    Morris D, Mulvihill D, Lew WY (1987) Risk of developing complete heart block during bedside pulmonary artery catheterization in patients with left bundle-branch block. Arch Intern Med 147: 2005–2010PubMedCrossRefGoogle Scholar
  29. 29.
    Sprung CL, Elser B, Schein RM, Marcial EH, Schrager BR (1989) Risk of right bundle-branch block and complete heart block during pulmonary artery catheterization. Crit Care Med 17: 1–3PubMedCrossRefGoogle Scholar
  30. 30.
    Garden AL, Laussen PC (2004) An unending supply of ‘unusual’ complications from central venous catheters. Paediatr Anaesth 14: 905–909PubMedCrossRefGoogle Scholar
  31. 31.
    Forßmann W (1929) Die Sondierung des rechten Herzens. Klin Wochenschr 8: 2085–2087CrossRefGoogle Scholar
  32. 32.
    Webb W (2005) Pulmonary edema, the acute respiratory distress syndrome and radiology in the intensive care unit. In: Webb W (ed) Thoracic imaging: Pulmonary and cardiovascular radiology. Lippincott Williams & Wilkins, Philadelphia, pp 331–355Google Scholar
  33. 33.
    Aslamy Z, Dewald CL, Heffner JE (1998) MRI of central venous anatomy: implications for central venous catheter insertion. Chest 114: 820–826PubMedCrossRefGoogle Scholar
  34. 34.
    Defalque RJ, Campbell C (1979) Cardiac tamponade from central venous catheters. Anesthesiology 50: 249–252PubMedCrossRefGoogle Scholar
  35. 35.
    Greenall MJ, Blewitt RW, McMahon MJ (1975) Cardiac tamponade and central venous catheters. BMJ 2: 595–597PubMedGoogle Scholar
  36. 36.
    Collier PE, Blocker SH, Graff DM, Doyle P (1998) Cardiac tamponade from central venous catheters. Am J Surg 176: 212–214PubMedCrossRefGoogle Scholar
  37. 37.
    Hobbs G, Mahajan R (2000) Radiology for Anesthesia. Churchill Livingstone, New YorkGoogle Scholar
  38. 38.
    Vail CM, Ravin CE (1992) Cardiovascular monitoring devices. In: Goodman LR, Putman CE (eds) Critical Care Imaging. W. B. Saunders, Philadelphia, pp 3–12Google Scholar
  39. 39.
    Schuster M, Nave H, Piepenbrock S, Pabst R, Panning B (2000) The carina as a landmark in central venous catheter placement. Br J Anaesth 85: 192–194PubMedCrossRefGoogle Scholar
  40. 40.
    Stonelake PA, Bodenham AR (2006) The carina as a radiological landmark for central venous catheter tip position. Br J Anaesth 96: 335–340PubMedCrossRefGoogle Scholar
  41. 41.
    Hsu JH, Wang CK, Chu KS, et al (2006) Comparison of radiographic landmarks and the echocardiographic SVC/RA junction in the positioning of long-term central venous catheters. Acta Anaesthesiol Scand 50: 731–735PubMedCrossRefGoogle Scholar
  42. 42.
    Gravenstein N, Blackshear RH (1991) In vitro evaluation of relative perforating potential of central venous catheters: comparison of materials, selected models, number of lumens, and angles of incidence to simulated membrane. J Clin Monit 7: 1–6PubMedCrossRefGoogle Scholar
  43. 43.
    Reynolds N, McCulloch AS, Pennington CR, MacFadyen RJ (2001) Assessment of distal tip position of long-term central venous feeding catheters using transesophageal echocardiology. JPEN J Parenter Enterai Nutr 25: 39–41CrossRefGoogle Scholar
  44. 44.
    Andropoulos DB, Stayer SA, Bent ST, et al (1999) A controlled study of transesophageal echocardiography to guide central venous catheter placement in congenital heart surgery patients. Anesth Analg 89: 65–70PubMedCrossRefGoogle Scholar
  45. 45.
    Chu KS, Hsu JH, Wang SS, et al (2004) Accurate central venous port-A catheter placement: intravenous electrocardiography and surface landmark techniques compared by using transesophageal echocardiography. Anesth Analg 98: 910–914PubMedCrossRefGoogle Scholar
  46. 46.
    Jeon Y, Ryu HG, Yoon SZ, Kim JH, Bahk JH (2006) Transesophageal echocardiographic evaluation of ECG-guided central venous catheter placement. Can J Anaesth 53: 978–983PubMedCrossRefGoogle Scholar
  47. 47.
    Schummer W, Schummer C, Schelenz C, Schmidt P, Frober R, Huttemann E (2005) [Modified ECG-guidance for optimal central venous catheter tip positioning. A transesophageal echocardiography controlled study]. Anaesthesist 54: 983–990PubMedCrossRefGoogle Scholar
  48. 48.
    McGee WT, Ackerman BL, Rouben LR, Prasad VM, Bandi V, Mallory DL (1993) Accurate placement of central venous catheters: a prospective, randomized, multicenter trial. Crit Care Med 21: 1118–1123PubMedCrossRefGoogle Scholar
  49. 49.
    Schummer W, Schummer C, Paxian M, Stock U, Richter K, Bauer M (2005) [Extravasal position of central venous catheters despite unsuspicious ECG-guidance]. Anasthesiol Intensivmed Notfallmed Schmerzther 40: 91–96PubMedCrossRefGoogle Scholar
  50. 50.
    Schummer W, Schummer C, Schelenz C, et al (2004) Central venous catheters — the inability of’ intra-atrial ECG’ to prove adequate positioning. Br J Anaesth 93: 193–198PubMedCrossRefGoogle Scholar
  51. 51.
    Oliver WC Jr, Nuttall GA, Beynen FM, Raimundo HS, Abenstein JP, Arnold JJ (1997) The incidence of artery puncture with central venous cannulation using a modified technique for detection and prevention of arterial cannulation. J Cardiothorac Vasc Anesth 11: 851–855PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science + Business Media Inc. 2008

Authors and Affiliations

  • W. Schummer
    • 1
  • Y. Sakr
    • 2
  • C. Schummer
    • 1
  1. 1.Dept of Anesthesiology and Intensive CareFriedrich-Schiller UniversityJenaGermany
  2. 2.Dept of Anesthesiology and Intensive CareFriedrich-Schiller UniversityJenaGermany

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