RARE COMPLICATIONS?
SECONDARY CATHETER MALPOSITION
DISCLOSURE
Timothy R. Spencer, RN, DipAppSc, BHSc, ICCert,
APRN, VA-BC™
Vascular Access Specialist – 27yrs Australia
Australian Vascular Access Society – Founding President
(2009–2015)
Herbst Award Recipient – for Excellence in Vascular
Access, AVA (2019)
INTRODUCTION
Malpositioned central venous access device
(CVAD) tip locations can cause significant
mechanical and chemical vessel-related injuries
and complications if left in inappropriate
positions.
Discovery of a malposition, when not using
navigation or tip positioning systems, can often
be frustrating during the post-insertion x-ray
review period.
MALPOSITION CATEGORIES
Primary – occurs during the
insertion process, can be
corrected during procedure,
does not compromise sterile
technique/field.
Secondary – occurs
post-procedure, often from large
pressure changes in thoracic
cavity, can be problematic, has
long-term implications, can be
corrected either bedside or
EARLY SECONDARY
MALPOSITION REPORTS
•
Lang-Jensen et al, (1980) 102 catheters studied – 27 primary (8
corrected) and 2 secondary malpositions. Determined the IJV
had
lowest risk and malposition rate. Determined CXR not required
daily.
•
Vasquez & Brodski (1985) reported on 459 silicone CVCs placed
from 1979 to 1984 w/ special attention was given to the
complications of malposition.
•
From 1981–1984, 116 consecutive percutaneous silicone central
venous catheters (CVC) were inserted using a peel away sheath
introducer. No primary catheter malpositions using this
INCIDENCE
•
Misplaced catheters have been reported in almost every possible
anatomical position including the arterial system, the mediastinum, pleura, pericardium, trachea,
esophagus, subarachnoid space and other aberrant places (Gibson & Bodenham, 2013), even in
the peritoneum (John & Lagoo, 2016).
•
Can occur from coughing/sneezing/hyperemesis, tumor growth, pressure injection procedures,
central venous stenosis, pulmonary diseases, cardiomyopathies, changes in arm/body positions.
•
With the large number of devices placed throughout institutions today, the potential for device
malposition is almost guaranteed at some point.
INCIDENCE
•
Several clinical studies have reported rates of 3.6 – 14% (Pikwer et al, 2008; Roldan & Paniagua, 2015)
•
Accurate reporting of rates are unclear and most likely under-reported.
•
Choice of device length can impact catheter malposition – too short can lead to chemical related
injuries, including thrombosis, extravasation (Spencer, 2019).
•
Spontaneous correction has occurred in pediatrics within 24hrs (usually) Rastogi et al, 1998)
There are still frequent reports of
Organization
Guidelines
INS, (SOP 2016)
LOWER PORTION OF THE VESSEL
(SVC) AT OR NEAR THE CAJ
GAVECELT
IN THE LOWER PART OF THE
SVC OR IN THE UPPER PART OF
THE RA
ONS, 2011
DISTAL THIRD OF SVC
NKF, 2006
SVC OR RA
AVA
DISTAL SVC CLOSE TO CAJ
FDA/CDC
LOWER ONE-THIRD OF SVC
ASPEN, 2004
LOWER SVC ADJACENT TO RA
IS IT A PROBLEM?
•
Malpositioned catheter tips cause significant mechanical
and chemical related injury if left in inappropriate
positions.
•
Most reported complications of
catheter malposition are;
•
venous thrombosis
•
catheter dysfunction – flow-related issues
•
vessel-related trauma/damage/perforation
AZYGOS PERFORATION
•
Approx 1.2% azygos vein cannulation occurs.
•
a) Fernando et al (2016) PICC left in azygos vein for 9 days while
receiving PN.
•
Small R) pleural effusion (white arrow) and cephalad directed catheter
tip (black arrows).
•
b) Same patient 24hr, deteriorated, became tachycardic, tachypnoeic and
hypoxic. A repeat CXR was obtained that showed large bilateral pleural
effusions.
•
PICC removed and patient required a chest drain and 2L of PN drained
from chest.
•
Highlights importance of (?) regular CXR if the patient experiences
sneezing, coughing or vomiting with a CVAD insitu.
a)
COMPARISON WITH FEMORAL
CATHETERS
•
Malposition of femoral venous catheters is (almost) virtually unheard of.
•
Why? Because they often are not checked.
•
If routine X-ray performed after every femoral catheter, likely to discover that
these devices are not where intended - (Göcze et al, 2012) suggested that 4.5% lie
in the lumbar vein!).
CORRECTIVE OPTIONS
•
It is strongly recommended to use non-invasive repositioning techniques to PICC malposition in
infants & children.
•
High Flow Flush Technique (HFFT) (Spencer, 2017; Ruegg, 2019) or Simultaneous Rapid Saline Flush
Technique (SRSFT) (Natividad & Rowe, 2016) w/ correct patient positioning - quick results, cost
effective, good success rates (68 - 86% FTS) - good first option alternative, lower radiation exposure
•
Bedside guidewire exchanges (+/- ECG) – effective, adds time / cost (Pittiruti et al, 2012), Trerotola et
al (2007) – higher costs, greater reposition rate (IR) bedside 68% success
AVOIDING MALPOSITION –
PREVENTION STRATEGIES
•
Always verify correct tip position first – use of ECG positioning
•
May sometimes be unavoidable due to time/disease/pathophysiological changes
•
Needs corrective repositioning performed once diagnosed
•
Several lo-fi to hi-fi techniques available (HFFT/SRSFT), guidewire exchange,
fluoroscopy (increase in cost/time/radiation exposure)
REFERENCES
Lang-Jensen, T., Nielsen, R., Sørensen, M. B., & Jacobsen, E. (1980). Primary and secondary displacement of central venous catheters. Acta Anaesthesiologica Scandinavica, 24(3), 216-218. Vazquez, R. M., & Brodski, E. G. (1985). Primary and secondary malposition of silicone central venous catheters. Acta Anaesthesiologica Scandinavica, 29, 22-25.
Gibson, F., & Bodenham, A. (2013). Misplaced central venous catheters: applied anatomy and practical management. BJA: British Journal of Anaesthesia, 110(3), 333-346. John, L., & Lagoo, J. (2016). Accidental intraperitoneal malpositioning of femoral central venous catheter: Learning from mistakes. Sri Lankan Journal of Anaesthesiology, 24(1).
Imakiire, Y., Yanaru, T., Kumano, H., Nakamori, E., & Yamaura, K. (2018). Malposition of Peripherally Inserted Central Catheter Into the Right Inferior Thyroid Vein: A Case Report. The American journal of
case reports, 19, 491.
Spencer, T. R. (2019). Subclavian Vein Catheter Extravasation—Insufficient Catheter Length as a Probable Causal Factor. Journal of the Association for Vascular Access, 24(1), 46-51.
Rastogi, S., Bhutada, A., Sahni, R., Berdon, W. E., & Wung, J. T. (1998). Spontaneous correction of the malpositioned percutaneous central venous line in infants. Pediatric radiology, 28(9), 694-696. Wang, Y., Egan, A., & Hoskote, S. (2019). 995: Where Is That Line? An Unusual Case Of A Malpositioned Central Venous Catheter. Critical Care Medicine, 47(1), 476.
Almanzar, A., & Danckers, M. (2019). 997: An Unusual Misplacement Of A Central Venous Catheter Into The Superior Mediastinum. Critical Care Medicine, 47(1), 477. Fletcher, J., Gaines, L., & Meredith, C. (2019). 1005: Where Is My Central Line?. Critical Care Medicine, 47(1), 481.
Fernando, R., Lee, Y. J., Khan, N., & Kazmi, F. (2016). Delayed migration of a peripherally inserted central venous catheter to the azygos vein with subsequent perforation. BJR| case reports, 20150315. Göcze, I., Müller-Wille, R., Stroszczynski, C., Schlitt, H. J., & Bein, T. (2012). Accidental cannulation of the left ascending lumbar vein through femoral access—still often unrecognized. Asaio Journal, 58(4), 435-437.
Ruegg L. Repositioning a peripherally inserted central catheter (PICC) using a high-flow flush technique (HFFT) in an adult patient with non-Hodgkin’s lymphoma. Vascular Access 2019; 5(2):49-50. Natividad, E., & Rowe, T. (2015). Simultaneous rapid saline flush to correct catheter malposition: a clinical overview. Journal of the Association for Vascular Access, 20(3), 159-166.
Pittiruti, M., Bertollo, D., Briglia, E., Buononato, M., Capozzoli, G., De Simone, L., ... & Sette, P. S. (2012). The intracavitary ECG method for positioning the tip of central venous catheters: results of an Italian multicenter study. The journal of vascular access, 13(3), 357-365.
Trerotola, S. O., Thompson, S., Chittams, J., & Vierregger, K. S. (2007). Analysis of tip malposition and correction in peripherally inserted central catheters placed at bedside by a dedicated nursing team.
