All of us have placed central line before.  You enter the vein under ultrasound. The wire threads easily, or maybe there is a little resistance, but the wire passes anyway.  You dilate, place the catheter and suture it in place.  You then order a chest x-ray, already confident the line is in the right place.  Then you see this.

 

WTF?

You knew you were in the vein, so what happened?  You get a blood gas – venous.  Your patient is crashing and you need to use this line what do you do?

 

There are many instances of misplaced central lines.  Arterial, mediastinal, subarachnoid, anatomical variation of patients, but which can be safely used?  Obviously, lines placed outside the venous system are out, but what if the patient has a weird anatomical variation.

 

Consider the following

If all four are yes, then the catheter is likely safe to use.  But in the case above, the line does not line over the SVC, so can it be used if all other three conditions are met?

In this case yes, this patient has a Persistent Left Superior Vena, where a redunant SVC drains into the coronary sinus and then the RA.  While not ideal, with a good cvp waveform these lines can be used.  


Patient’s with a PLSVC may have other underlying abnormalities such a the PLSVC draining into the left atria, making the line unusable.  Also, because the PLSVC drains into the coronary sinus, there is an increased risk of arrhythmia when placing the line.  However, if you hook up the line to a CVP monitor and it shows this…

Then you are unlikely to have a problem.  Here’s a table for other line problems

 

  • F. Gibson and

  • A. Bodenham

Misplaced central venous catheters: applied anatomy and practical managementBr. J. Anaesth. first published online February 5, 2013 doi:10.1093/bja/aes497

THANK YOU DR SCOFI FOR THIS SUPER HELPFUL PEARL!