Safe placement of Central Venous Catheter via right Internal Jugular Vein: Calculation of insertion depth by individual body height

Abstract

Background: Cardiac tamponade is a serious complication of central venous catheter (CVC) placement. Current guidelines strongly suggest that CVC tip should lie in the superior vena cava (SVC) outside the pericardial sac. Various landmarks and sophisticated techniques such as right atrial electrocardiography (ECG) and transoesophageal echocardiography (TEE) have been recommended to decide a proper insertion depth (ID) of CVC. The purpose of this study was to devise a simple formula to determine the proper insertion depth based on an individual patient’s height when cannulation is via the right internal jugular vein (RIJV). Patients and Methods: We studied 100 patients. The right internal jugular vein was punctured by an anterior approach using the sternocleidomastoid muscle as a landmark midway between the mastoid process and the sternal notch. Insertion depth was theoretically determined as one-tenth of the patient’s height in cm. Post insertion bedside chest x-ray (CXR) was done to see the CVC tip position in relation to the level of the carina. Results: In 74.22% of the cases the tips of the CVCs were at or above the level of the carina. In the rest of the 25.78% patients the tips were within 2 cm below the level of carina. The standard error of proportion (SEP) between these two groups of observations was 4.4. It means the tip of the CVC will be positioned at or above the level of carina in 65% to 83% of the population (95% CI). Conclusion: Thus to place all the CVC tips above the pericardial reflection we propose a simple formula as: Insertion Depth in cm = (Patient’s height in cm/10) - 2cm, for cannulation via the right internal jugular vein when the puncture site is midway between the mastoid process and the sternal notch. Keywords: central venous catheter, internal jugular vein, insertion depth, carina