Central line placement left IJ

BelgianRN · Jun 10, 2012

Very limited information so it's mostly guessing as to the cause.

Hmmm when concerned with placement in an artery just hook up the pressure transducer and look at the waveform. A measured CVP of 40 means little if the measurement was incorrect (e.g. partly occluded lumen, wrongly zeroed) and if the used monitor is anything like our monitoring system if you have a CVP of 40 you will see a blue line along the maximum scale line because we only display CVP's in the range of 0 - 30 mmHg. If below or above you will see a straight line until you adjust the scaling. Also with our monitoring system we have to adjust the measurement of CVP to show diastolic and systolic pressures if we want to know if it is arterial in origin otherwise we get only a mean pressure.

If you look at the waveform having a CVP-like pressure trace is more likely to be in a vein if you have a highly pulsatile arterial trace it's in an artery.

High CVP-values could also result from canon A waves due to A-V dyssynchrony that leads to increased automatically calculated values for your CVP but again the waveform is more important.

Reason for the increased CVP and high pO2 could be the effect of the AV fistula that creates a direct shunt and higher venous pressures. It also depends on the amount of oxygen the patient is receiving say he is mechanically ventilated and receiving an FiO2 of 1,0 with quasi normal lungs the arterial pO2 could easily be in the 200 - 500 mmHg reach a high venous pO2 is not abnormal in that case.

If you patient is sedated or not using his oxygen in the peripheral tissues (e.g. CO intoxication, sepsis with failing microcirculation, decreased metabolism) the arterial-venous oxygen pressure difference reduces. Since you don't use a lot of your oxygen it could be that if you offer a pO2 of 150 mmHg (SO2 - 100ish%) on the arterial side, you'll measure a pO2 of 100 mmHg on the venous side (SO2 - 98ish %).

The above is my reason for pleading against using blood gasses as indicators of right placement of intravascular lines but I prefer pressure tracings.

Advanced Practice Columnist / Guide · Jun 10, 2012

The pO2 number is concerning in this case but given the presence of an AV Fistula in the ipsilateral arm, the high pO2 could be attributed to it. When an AV Fistula is created especially in more proximal vessels (ie, brachiocephalic fistula created above the elbow), the flow in the vein increases to the point that it becomes "arterialized" as it pulls blood from the artery. The involved upper arm vein empties blood into the cavo-atrial junction where the tip of the catheter lies. This raises the possibility of a higher pO2 if the line is on the same side of the fistula.

I don't know what to make of the CVP number that was quoted. How was this obtained? In most if not all ICU's in the US, CVP's are measured by transducing the CVP port of the catheter to a monitor. You will not only find a number corresponding to the CVP but also a waveform that should look like a venous waveform. If the waveform has arterial upstrokes, then the line is misplaced in the artery. A crude way to evaluate this is to assess flow at the tip of the catheter by lowering the bag of solution infusing through it below the level of the heart being careful not to allow air to enter. In patients with normal cardiac anatomy, the tip would be squirting blood out in a pulsatile manner especially in a high pressure artery like the aorta.

As someone who routinely places central venous catheters, there are many ways a provider can be confident that a line is placed in the correct vessel prior to, during, and after insertion. At the institutions I've worked in, we never place lines without ultrasound guidance (even in an emergency). You have to be able to visualize your target vein and the artery next to it with ultrasound prior to cannulating and making sure one distinguishes which one is which. We cannulate with real time ultrasound guidance, meaning you have to see your needle entering the vein as you poke.

We also use a fluid column that we attach to the catheter used to cannulate the vein prior to inserting the guide wire. Venous cannulation will cause fluid to enter the vessel as you raise the level of the column, arterial cannulation will not and will pulsate blood out regardless of the height of the column. I also make a practice of visualizing that my guide wire is in the vein using the ultrasound probe as an extra precaution. In these modern times, a chest film after placement is really only helpful in determining where the tip of the catheter lies and whether or not a pneumothorax was inadvertently caused by the line placement.

detroitdano · Jun 14, 2012

I've seen IJ and fem lines placed in arteries a billion times. Usually the dead giveaway is blood pulsating in one of the three tubing ports.

I have also seen art line-appearing waveforms on CVP lines and it was definitely in the IJ. Usually you see this with dehydrated patients. I've never seen this with fem central lines that were placed properly though.

Your numbers will tell you whether it's actually in the artery though. Set the box to transduce an art line, not CVP, and if you get numbers correlating to a cuff pressure, chances are yeah it's in the wrong place.

The AVF thing will make drawing a guess a somewhat worthless effort as mentioned.

CABGx4, ASN, BSN, MSN, CRNA · Jun 23, 2012

Just take the cap off and if blood squirts across the room you'll have your answer. But seriously it sounds venous ESP with the fistula in that arm. On X-ray, the central line would not reach the right atrium and may appear to be in the aorta. Just my 2 cents?

clozad1 · Jul 1, 2012

Yes I had a resident place a right subclavian catheter into the artery instead of a vein. Easy way to figure out with my patient was that the patient had an arterial line so the cvp was pretty much the same as the MAP and blood was pulsating from one of the lumens as someone already stated.

biancocm · Jul 2, 2012

I didn't have this happen with an IJ, but they placed an introducer into my patient's groin and it went into the femoral artery instead of the vein. We had to go based off gases, the patient had an a-line and another central line (verified in the vein) so we had to compare to see which it matched up best with. We also used ultrasound to see if they could see where it was and also tried to transduce a waveform. It did end up being in her artery and we couldn't remove it because she was in DIC so it ended up really bad.

iluvivt, BSN, RN · Jul 2, 2012

Oh yes it can happen from any number of approaches. We got a patient from another ED recently and just happened to find that the right subclavain placed a few hours ago was actually in the artery...usually the bright red blood and the pulsating blood shooting from the cannula or dilator is a big clue but not always b/c it happens. They had get a vascular surgeon and take him to the OR and get it removed under anesthesia. I myself have accessed an artery a few times before we had Ultrasound..once when we did (old machine with crappy picture) but had a high degree of suspision and the line was only in about 45 min. Unfortuntely, the CXR was not too valuable so I had an ABG drawn and that told me I needed to go pull it.