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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2014  |  Volume : 25  |  Issue : 5  |  Page : 1011-1016
The role of routine chest radiography for detecting complications after central venous catheter insertion

Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran

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Date of Web Publication2-Sep-2014


Chest radiographs are obtained routinely after central venous catheter (CVC) insertion in many institutions, although it consumes time and money. The purpose of this study was to evaluate the role of post-procedural chest X-ray in detecting complications of CVC insertion; we performed CVC insertion without using ultrasonography guidance. A total of 454 patients who required an emergency vascular access for hemodialysis between February 2008 and March 2010 were included in this study. In cases where three to five unsuccessful attempts were encountered to place the CVC or pierce the artery, we used another site for CVC placement or we placed the CVC under ultrasonographic guidance. Both the internal jugular and the subclavian veins were used as routes for catheter insertion. All the catheters were dual lumen and were inserted by the same vascular access surgeon. All the catheters were inserted using the same protocol. This protocol consists of five stages including position, percutaneous anesthesia, puncture, pull out and placement. Chest radiography was obtained after the procedure and patients were interviewed for the presence of any unusual symptoms. The X-rays were reviewed by a radiologist who was unaware of the patients' symptoms. Complications occurred in two patients who had unusual symptoms after the placement of the catheter. Although immediate postprocedural chest radiography is recommended for tip position confirmation, it should not be considered a reliable procedure for detecting complications in the absence of clinical symptoms. It is recommended to monitor patients after catheter insertion and perform delayed chest X-ray in the presence of any unusual symptoms.

How to cite this article:
Zadeh MK, Shirvani A. The role of routine chest radiography for detecting complications after central venous catheter insertion. Saudi J Kidney Dis Transpl 2014;25:1011-6

How to cite this URL:
Zadeh MK, Shirvani A. The role of routine chest radiography for detecting complications after central venous catheter insertion. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2023 Feb 2];25:1011-6. Available from: https://www.sjkdt.org/text.asp?2014/25/5/1011/139895

   Introduction Top

Placement of a central venous catheter (CVC) is a common method of vascular access. Catheter malposition (defined as any CVC tip position outside the superior vena cava) [1] and other complications such as arterial puncture, injury to great vessels and nerves, neck hematoma, arrhythmia, cardiac tamponade, pneumothorax or hemothorax may be associated with catheter insertion, some of them requiring immediate intervention.

These days, CVCs are inserted with sonogra-phic guidance and confirmed by intraoperative fluoroscopy, electrocardiography (ECG) [2] and/or chest X-ray (CXR). Malposition of catheter tip into the right atrium could lead to dysrhyth-mias, possible erosion through the cardiac chamber or thrombus formation. [3],[4],[5] Further­more, the catheter tip must not lie at a per­pendicular angle against the superior vena cava because this generates a risk for vascular erosion. [6] While intra-atrial ECG was consi­dered unreliable for confirming the position of left internal jugular CVCs by Schummer et al, [7] post-procedural CXR is widely used to detect the presence of any complication.

Apart from the cost and radiation exposure, post-procedural chest radiography delays utili­zation of the catheter, which could be vital in the lack of additional intravenous lines. Some studies recommend CXR after CVC insertion to exclude complications, [1],[8],[9] while others pre­fer to eliminate post-procedural chest radio-graphy. [10],[11],[12],[13],[14],[15],[16] In this prospective study, we eva­luated the role of routine post-procedural CXR taken immediately after the insertion of CVC.

   Materials and Methods Top

The patients were selected based on their need for temporary CVC for hemodialysis (HD). The following protocol (We named it the 5P's Protocol) was used to place CVCs in 454 patients undergoing HD from February 2008 to March 2010. Informed consent was obtained from all the patients. In our study, all the CVCs were placed by the same expe­rienced vascular access surgeon to minimize the chance of bias as it has been shown that the incidence of complications is associated with the level of training of the physician placing the line. [8] A CXR was taken after catheter placement in all the patients. Moreover, the patients were monitored by intermittent inter­views and physical examinations for the pre­sence of any unusual symptoms after the procedure. Internal jugular and subclavian veins were used as routes of catheter insertion in all these cases. The internal jugular vein was catheterized in 330 patients and, in 124 patients, the subclavian vein was used. All the catheters used in this study were dual lumen catheters. In cases of three to five unsuccessful attempts or piercing the artery, we used another site for CVC placement or we placed the CVC under ultrasonography guidance. Cases in whom ultrasonography guidance was used for catheter insertion were excluded from the study (15 patients).

We divided the classic technique for CVC insertion into five steps for better remembering the stages of cannulating the internal jugular and subclavian veins. The 5P's protocol to place a CVC in the internal jugular or sub-clavian vein is as follows:

  1. Position: Place the patient in the Trendelenburg position.
    1. Internal jugular approach: The patient must look away from the site of cathe­ter placement.
    2. Subclavian approach: The patient must look at the ceiling.
  2. Percutaneous anesthesia: There is no need for sedation or general anesthesia. Only skin and subcutaneous tissue should be locally anesthetized using 3-5 mL of lidocaine 2%. Do not inject lidocaine deeply because it would numb the arterial wall and the patient will not feel any pain if the tip of the needle pierces the arterial wall.
    1. Internal jugular approach: Anesthetize the superior carotid triangle.
    2. Subclavian approach: Anesthetize the deltopectoral space.
  3. Puncture:
    1. Internal jugular approach: Palpate the carotid artery with the non-dominant hand and push it to the midline. Insert a 21 or 23 gauge pathfinder into the skin at an angle of 45-60 degrees and insert it 1 inch below the tip of the anterior triangle of the neck. The tip of the pathfinder must face the ipsilateral nipple. Insert the pathfinder while aspirating until the internal jugular vein is reached and venous blood is aspirated. If the internal jugular vein is not found initially, it would probably lie further laterally. Slide an 18 gauge introducer needle alongside the path­finder needle until free blood return is confirmed. Unfortunately, the path of the wire cannot be predicted. The use of fluoroscopy is recommended unless it is unavailable or in emergencies.
    2. Subclavian approach: Palpate the deltopectoral space and use it as a landmark and advance below it. Insert the 18 gauge pathfinder directed 90 degrees from the skin and advance to a depth of the thickness of the clavicle. Then, point the tip of the pathfinder toward the suprasternal notch and advance while aspirating to reach the subclavian vein and venous blood is aspi­rated.

    • If the venous blood flow is not adequate or if it has a poor flow, discontinue the procedure and start all over again.
    • If the patient complains of pain during the procedure or if the needle pierces the artery even once, discontinue the procedure.
    • Choose another site for catheter placement after an unsuccessful procedure or insert the catheter under ultrasonography guidance.
  4. Pull out: Insert the guide wire and advance it softly to a depth of 20-25 cm. There must be no feeling of resistance. Presence of resistance indicates an unsuccessful procedure and must be terminated. After placing the guide wire, pull out the 18 gauge needle. Incise the skin about 2-3 mm and insert a dilator to about half its length. Do not continue the procedure if the patient encounters any kind of pain. Remove the dilator.
  5. Placement: Lock the red line of the cathe­ter and fill the blue line with normal saline and advance the catheter through the guide wire. It is generally recommended that CVCs be inserted to a depth of 13-16 cm on the right and 15-20 cm on the left. [3] Peres criteria [17] for catheter insertion depth may also be employed for determining the depth of CVC insertion. No resistance should be felt during catheter insertion. After the catheter placement is completed, remove the guide wire and aspirate blood from both lines with a 10 cc syringe. The blood must come easily and be pushed back without any difficulty or pain. Now, fill both lines with normal saline and hepa-rin in a way that 2500-5000 IU of heparin remains in each line.

   Results Top

This prospective study included 439 patients with a mean age of 56 ± 16 years (SD = 14-93 years). All patients underwent CVC placement using the above protocol by the same surgeon. All the catheters were placed in an emergency setting. One patient had chest pain after right subclavian CVC insertion but had normal CXR. She later developed dyspnea and her chest pain increased. A second CXR was taken about 3 h post-procedure, which showed a right-sided pneumothorax. Another patient in whom the CVC was placed in the left subclavian vein developed right ear pain. Fluoroscopy revealed that the tip of the catheter was in the right jugular vein and the catheter was translocated under fluoroscopy. None of the other patients had any unusual symptoms and their CXRs were normal. Overall, two of 439 cases (0.45%) presented with complications inclu­ding pneumothorax or malposition after CVC placement. In both cases, CVCs had been inserted through the subclavian vein.

   Discussion Top

It is well known that CVCs should be placed under ultrasonography guidance; moreover, such a procedure requires a well trained sur­geon and is not available in every medical center. In these conditions, the 5P's protocol is ideal for catheter placement. However, CXR, ECG or fluoroscopy has been recommended to be performed after catheter insertion for cathe­ter tip confirmation. While routine immediate post-procedural CXR is a way of confirmation of position of the catheter tip, it seems insuf­ficient to predict the upcoming complications as some of them may be delayed.

A study performed by Chang et al [11] showed that CXR can miss delayed pneumothorax in about 0.5% (2 of 424 cases) of patients with right internal jugular lines. In their study, routine inspiratory and expiratory post-procedural CXR did not reveal any evidence of pneumothorax, and pneumothorax was identified on delayed CXR obtained because of the presence of unusual symptoms. Similar results have been reported by Brown et al. [14] This validates the importance of monitoring clinical symptoms after CVC insertion. Accordingly, in a study of 358 patients by Bailey et al, [10] complications included three cases of pneumothorax that were not seen on the initial CXR. It can be seen that post-procedural pneumothorax cannot always be detected by an early CXR.

The necessity of post-procedural CXR after CVC placement is controversial in different studies [Table 1]. Some of these studies used a single route for catheter insertion and, in most of them, catheters were placed by different surgeons, which could have an adverse impact on the rate of malposition. In most cases with the presence of complications, the patient had symptoms after the CVC placement. [10],[11],[14]
Table 1: A comparison of various studies carried out to evaluate the necessity of obtaining chest radiography after central venous catheter insertion.

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In our study, both pneumothorax and catheter malposition occurred after insertion of the catheter through the subclavian vein, and there were no complications associated with the internal jugular vein route. Moreover, it has been shown that long-term subclavian vein catheterization may lead to venous stenosis. [18],[19],[20],[21],[22],[23] It has also been shown that the internal jugular approach carries a lower risk of pneu-mothorax as compared with the subclavian approach. [3],[24],[25],[26],[27],[28] Makau et al [29] and Walshe et al [30] reported left-sided subclavian catheters to be risk factors for vascular erosion. Additio­nally, in a case report by Inaba et al, [31] left-sided subclavian CVC was associated with delayed vascular wall injury of the superior vena cava and subsequent bilateral pleural effusion. Therefore, we suggest internal jugu­lar vein as the primary site for CVC insertion, whenever possible. Subclavian vein catheteri-zation should remain as an alternative option when the internal jugular vein is obstructed or if there is contraindication to catheterize the internal jugular vein.

In this study, the inclusion of a single expe­rienced operator limits the applicability of the data reported to other practices and centers; however, further studies are needed to prove this statement.

   Conclusion Top

While fluoroscopy and ultrasonography are preferred procedures for CVC insertion, the classic technique is still used in the absence of such facilities. Post-procedural CXR is taken for confirmation of position of the catheter tip and to detect any early complications, but de­layed complications can occur after catheteri-zation. Thus, the patient should be monitored carefully and managed appropriately according to the presenting signs and symptoms. We also recommend the internal jugular vein as the primary site of catheterization when there is no contraindication.

Conflict of interest: None

   References Top

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31.Inaba K, Sakurai Y, Furuta S, et al. Delayed vascular injury and severe respiratory distress as a rare complication of a central venous catheter and total parenteral nutrition. Nutrition 2009;25:479-81.  Back to cited text no. 31

Correspondence Address:
Dr. Amir Shirvani
Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.139895

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