CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 5, November/December 2023 AFRICA 323 considered for CVC in the absence of a contra-indication. Besides, it was found in the study by Marik et al. involving 113 652 catheter days that there was no difference between femoral, subclavian and internal jugular interventions regarding catheter-related haematogenous reproductions, in contrast to general belief.16 The length of the catheter should also be adjusted according to the selected localisation. Incorrect length of catheter increases the probability of malposition or displacement of the catheter through the vein via migration.17 The commonly used method after catheterisation for detection of localisation and complications is anterior–posterior lung radiography. However, this is postponed to the postoperative period in routine clinical practice if no complication has been experienced with regard to puncture and forwarding of the pre-operatively inserted catheter. Use of ultrasonography (USG) during catheterisation facilitates accurate identification of the veins and puncture site, however, it does not prevent malposition.18 Some authors recommend use of USG to confirm the accurate intravascular position of the catheter and detect possible complications early on.19,20 Bedside USG has some practical benefits to the conventional radiological examination, such as much faster application, more comfortable to use in different environments andprotectionof patients against radiation exposure. Researchers recommend the use of USG not only during puncture, but also for accurate orientation of the guide-wire by visualising it during the rest of the procedure.21 In some studies, echocardiography has been used during insertion of the guide-wire. The guide-wire was forwarded and localised as a hyperechogenic line in the right atrium for confirmation of the position, then it was withdrawn under control until its ‘J’ tip disappeared into the right atrium and was fixed in the correct position.21,22 In addition, CVC can be visualised through the right supraclavicular fossa and forwarding of the guide-wire towards this field after puncture can easily be monitored and its localisation can be confirmed.23 According to a meta-analysis, the best confirmation of the location of CVC can be achieved by a combination of vascular USG and a transthoracic echocardiogram.20,24 Briefly, it is possible to reduce the malposition rate to zero by implementing certain protocols. In our clinic we now use USG mandatorily for puncture and forwarding of the guide-wire in catheterisations performed in the operating theatre and intensive care unit. We also perform anterior–posterior lung radiography after completion of the procedure. In the case of suspected catheter malposition, we perform lateral radiograpy in addition to these routine studies and also venography using a little diluted radiopaque agent. Furthermore, we carry out imaging with C-armed endoscopy in the operating theatre in case of ongoing suspicion.25 Localisation of the CVC tip in a vessel other than the SVC may result in consequences such as haemorrhage due to abrasion or rupture of the vessel wall, local venous thrombosis, dysfunction of the catheter due to folding in on itself, and entry of the administered drugs to the cerebral circulation by cranial retrograde injection instead of the systemic circulation.2 Localisation of the catheter in a small vessel increases the risks.26 Infusion of hyperosmolar solutions or vasopressors through the catheter, as is frequently performed in cardiovascular surgery, increases the possibility of complications.2 Besides, the localisation of the catheter in the atrium instead of a side-vessel branch may cause arrhythmia or result in atrial perforation.27 The use of this route should not be attempted intentionally. Early detection and repositioning of the malpositioned central venous catheter may prevent serious complications. We experienced no serious complications in our cases since the malposition was detected early in the intra-operative stage. However, probable malposition could not be detected if dissection of the LIMA was not performed since no difficulty was experienced during catheterisation and blood could easily be aspirated. Consequently the patient could be subject to complications. The only clinical symptom reported in the literature of other IMV malpositions was development of chest and/or shoulder pain due to administration of fluid.28,29 In all our cases, clinical symptoms could not be evaluated since catheterisation was performed after induction of anaesthesia. However, no complication was experienced during puncture or forwarding of the catheter and our experienced practitioner described the intervention as an ordinary procedure. CVP of only two of our cases was not correlated with clinical results. Conclusion Central venous catheter positioning should be considered as a procedure that may develop complications, even when performed by the most experienced practitioners. Easy aspiration of blood through the catheter and monitoring the CVP trace do not guarantee the correct position of the catheter. Since the central venous catheter is inserted after anaesthetic induction in cardiovascular surgery, no clinical symptoms can be detected in a case of malposition. The probability of complications is high because of the fragility of particularly the IMV walls. In the case of unnoticed malposition during the operation, peri/postoperative CVP will be inaccurate and it will lead to misdiagnosis and false treatment in cases of rupture. Our suggestion is the implementation of central catheterisation through the RIJV, which produces the lowest complication rates, and under the guidance of bedside USG as an easily applicable non-invasive method to confirm the position after puncture. Additionally, lung radiography should be performed immediately after the procedure, and lateral radiography and venography also should be carried out in the case of suspicion related to positioning of the catheter. References 1. Lennon M, Zaw NN, Pöpping DM, Wenk M. Procedural complications of central venous catheter insertion. Minerva Anestesiol 2012; 78(11): 1234–1240. 2. Roldan CJ, Paniagua L. Central venous catheter ıntravascular malpositioning: causes, prevention, diagnosis, and correction. West J Emerg Med 2015; 16(5): 658–664. 3. Gibson F, Bodenham A. Misplaced central venous catheters: applied anatomy and practical management. Br J Anaesth 2013; 110(3): 333–346. 4. Park HP, Jeon Y, Hwang JW, Han SH, Bahk JH, Oh YS. Influence of orientations of guidewire tip on the placement of subclavian venous catheters. Acta Anaesthesiol Scand 2005; 49(10): 1460–1463. 5. Nazarian GK, Bjarnason H, Dietz CA Jr, Bernadas CA, Hunter DW. Changes in tunneled catheter tip position when a patient is upright. J
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