Internal Jugular Catheterization Research Articles

Two Cases of Malpositioning of Internal Jugular Central Venous Catheters: A Review of Literature and Current Treatment Recommendations

Two Cases of Malpositioning of Internal Jugular Central Venous Catheters: A Review of Literature and Current Treatment Recommendations

Complications of femoral access for hemodialysis: A surgical perspective

Background: Vascular access, especially arteriovenous fistula (AVF), is critical for patients requiring haemodialysis. Due to delayed diagnosis, late referral, poverty and limited availability of competent access surgeons, many patients commence haemodialysis without an AVF, hence the frequent use of venous catheters. Objectives: To assess the pattern of complications associated with repeated femoral punctures for haemodialysis. Materials and Methods: This is a multicentre prospective study conducted at the Cardiovascular units of the University of Port Harcourt Teaching Hospital, Port Harcourt and Federal Medical Centre, Umuahia between January 2017 and December 2022. 66 patients were recruited for the study. Data obtained were patients’ demography, complications of femoral access, surgical approach and outcome. Results: 15 patients presented with severe lower limb pains and inability to walk, 10 with fibrosis/ hardening of the skin of both groins, 8 with skin infection at the repeated puncture sites, 12 had Pseudoaneurysm of the superficial femoral artery (SFA), 6 had iatrogenic femoro-femoral Arteriovenous Fistula (AVF) of the SFA and superficial femoral vein (SFV), 5 had groin abscess. All the patients had internal jugular venous catheters inserted. Some patients had Fogarty catheter thrombectomies and interposition Great Saphenous Vein (GSV) graft repairs, while some others had successful takedown of the AVF, Fogarty thrombectomy and direct prolene 6/0 repair of the vein & arterial wall defects. All those that underwent surgical treatment had successful recovery. Conclusion: Femoral vein cannulation, apparently easy to perform, should not be used as the vascular access of choice for chronic haemodialysis.

An Enigmatic Discovery - Accidental Insertion of Internal Jugular Haemodialysis Catheter into the Vertebral Vein

A 40-year-old male was admitted to the medical ward with chronic kidney disease with uremic symptoms and a decision was made to initiate the patient on haemodialysis. It was decided to catheterize the right internal jugular vein directly as the patient would require an A-V fistula in the near future which would be created in the left arm subsequently.
 Procedure
 During the time of right internal jugular vein catheterization using the anterior landmark technique, the right carotid artery was punctured leading to hematoma formation on the right side of the neck, despite adequate haemostatic measures.
 It was decided to catheterize the left internal jugular vein subsequently. Using the anterior landmark technique again, venipuncture was performed on the left side of the neck and in the first attempt itself the guide wire was inserted without any difficulty or resistance.
 Safe back-flow of venous blood was achieved through all ports of the catheter; that is, the catheter tip was presumed to be well positioned in the left internal jugular vein (IJV), as seen on the chest X-ray taken following the procedure.
 Clinical Course
 The patient complained of numbness over the left shoulder and weakness of the left upper limb following the procedure and was evaluated for the same. Under the clinical suspicion of left vertebral artery catheterization, a vascular surgeon opinion was sought and a CT angiogram of the neck was advised.
 The CT angiogram revealed the catheter entering the left vertebral vein at the level of C6 vertebra, coursing anteroinferiorly reaching the left brachiocephalic vein with its tip noted at the confluence of subclavian vein with internal jugular vein.
 After the CT angiogram, the misplaced catheter was promptly extracted to prevent the onset of additional complications.
 No excessive resistance was encountered during the catheter removal, and there were no signs of hematoma formation.
 Over the next few days, the patient’s symptoms of numbness and weakness resolved spontaneously.
 The patient had no neurological complaints and deficits on examination during follow-up in the outpatient department.

No contraindication to internal jugular central venous catheter insertion in patients at increased risk of bleeding: Results from a prospective observational study in a internal medicine department.

Implantation of centrally inserted central venous catheter (CICC) may be complicated by bleedings particularly in patients with severe coagulopathy or taking antithrombotic drugs. It has been shown that the application of the Italian Group for Venous Access Devices (GAVeCeLT) bundle reduces the incidence of bleeding in patients admitted to intensive care units (ICU), but its effectiveness has never been demonstrated in different contexts. In this study we evaluated the incidence of bleeding after urgent internal jugular CICC (J-CICC) implantation in patients with increased or no risk of bleeding complications when recommended preventive strategies are applied systematically. We included 185 patients admitted to Internal Medicine Units who underwent urgent J-CICC implantation from April 2016 to December 2018. The incidence of major and minor bleeding immediately after the procedure and in the following 30 days was recorded. None of the enrolled patients showed major bleeding. The incidence of minor bleedings was 2.1% (95% IC: 0.03-4.2) with two patients requiring line removal and repositioning (1.1%; 95% IC: -0.45 to 2.6). Bleeds were not correlated with age or sex, although they all occurred in female subjects. The incidence of bleeds was not increased in patients with increased risk of bleeding compared with those without (5.0% vs 1.3%; p = 0.16). The use of anti-thrombotic medications was significantly associated with increased risk of minor bleedings (p = 0.03). In this study we demonstrated that the application of the GAVeCeLT suggested bundle can minimize the number of bleeding complications even in patients hospitalized in Internal Medicine Units. Further data are needed in patients taking antithrombotic drugs who appear to be more prone to minor bleeding, however the benefit of completing the procedure appears to significantly outweigh the risk of mechanical complications.

P 029: Left sided infective endocarditis in end stage kidney disease patient on right temporary internal jugular catheter

P 029: Left sided infective endocarditis in end stage kidney disease patient on right temporary internal jugular catheter

POCUS in the PICU: A Narrative Review of Evidence-Based Bedside Ultrasound Techniques Ready for Prime-Time in Pediatric Critical Care.

Point-of-care ultrasound (POCUS) is an accessible technology that can identify and treat life-threatening pathology in real time without exposing children to ionizing radiation. We aim to review current evidence supporting the use of POCUS by pediatric intensivists with novice-level experience with bedside ultrasound. Current evidence supports the universal adoption of POCUS-guided internal jugular venous catheter placement and arterial line placement by pediatric critical care physicians. Focused cardiac ultrasound performed by PICU physicians who have completed appropriate training with quality assurance measures in place can identify life-threatening cardiac pathology in most children and important physiological changes in children with septic shock. POCUS of the lungs, pleural space, and diaphragm have great potential to provide valuable information at the bedside after validation of these techniques for use in the PICU with additional research. Based on currently available evidence, a generalizable and attainable POCUS educational platform for pediatric intensivists should include training in vascular access techniques and focused cardiac examination. A POCUS educational program should strive to establish credentialing and quality assurance programs that can be expanded when additional research validates the adoption of additional POCUS techniques by pediatric intensive care physicians.

Fatal superior vena cava rupture complicating dialysis catheter exchange.

Central vein stenosis (CVS) is a common and challenging complication in hemodialysis patients with chronic central venous catheters (CVCs). CVS often remains asymptomatic and is discovered incidentally during follow-up imaging. CVS symptoms include arm swelling, venous hypertension, impaired dialysis flow rates, and development of collateral veins. However, these symptoms can be nonspecific and overlap with other conditions, making the diagnosis challenging. Timely recognition and appropriate intervention are crucial to prevent complications and optimize patient outcomes. Diagnostic tools commonly used include duplex ultrasonography and venography to assess the degree and location of stenosis. Management strategies for CVS encompass a multidisciplinary approach involving nephrologists, interventional radiologists, and vascular surgeons. Initial conservative measures may include anticoagulation therapy, along with pharmacological interventions such as antiplatelet agents and thrombolytics. The endovascular approach is the first line for managing CVS by using balloon angioplasty either alone or in combination with stent placement, but CVS typically recurs frequently, requiring repeated interventions with an increased risk of complications. Additionally, alternative vascular access options such as arteriovenous fistulas or grafts may be considered. In this report, we describe a case of a 25-year-old woman who presented with an extensive history of multiple dialysis access failure for left internal jugular vein central venous tunneled catheter exchange. The procedure was complicated by a fatal superior vena cava rupture likely related to the dislodgment of the guidewire causing perforation into the pericardium space with subsequent cardiopulmonary collapse. The post-mortem autopsy showed severe organized stenosis of SVC and transmural defect above the SVC/atrial junction.

Using central venous pressure waveform to confirm the placement of an internal jugular central venous catheter in the intensive care unit

BackgroundA mobile chest X-ray is traditionally performed to confirm the position of an internal jugular central venous catheter (CVC) after placement in the intensive care unit (ICU). Using chest radiography to confirm CVC position often results in delays in authorising the use of the CVC, requires the deployment of additional human resources, and is costly. ObjectiveThis study aimed to determine the feasibility and accuracy of using the central venous pressure (CVP) waveform to confirm the placement of internal jugular CVCs. MethodsThis retrospective study was conducted in a single quaternary ICU over a 6-month period. We included adult patients who had internal jugular CVC inserted and CVP transduced as part of their routine care in the ICU. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CVP waveform analysis in confirming the position of internal jugular CVC relative to chest radiography were calculated. ResultsA total of 241 internal jugular CVCs were inserted (in 219 patients, 35.6% female), and the CVP waveform was assessed. In 231 cases, this suggested adequate placement in a central vein, which corresponded with a correct position on subsequent chest X-ray. On six occasions, the CVP waveforms were interpreted as suboptimal; however, on chest X-rays, the CVCs were noted to be in a suitable position (sensitivity: 97.5%). Four suboptimal CVP waveforms were obtained, and they correctly identified CVC malposition on subsequent chest X-ray (specificity: 100%). The average time from CVC insertion to radiological completion was 118 minutes. ConclusionCVP waveform analysis provides a feasible and reliable method for confirming adequate internal jugular CVC position. The use of chest radiography can be limited to cases where suboptimal CVP waveforms are obtained.

Neck Horn Formation After Jugular Vein Catheterization For Haemodialysis: Case Report

Background: Haemodialysis is an essential life-saving procedure for persons suffering from kidney failure. Haemodialysis is usually aceived by central venous catheterization. Neck hornformation is one of the most serious and seldom complications of the procedure.
 Case Report: A haemodialysis catheter was placed in a 43-year-old man's right internal jugular vein after his arteriovenous fistula failed. After having the catheter removed, a neck horn developed at the puncture site. Horn resection and thrombus evacuation were the surgical treatment methods used.
 Conclusion: Neck horn following an internal jugular catheter insertion might be dangerous if left untreated. The horn and thrombus are best removed surgically and treated with antibiotics.

Tunneled femoral dialysis catheters and factors affecting their outcome: a single institution experience.

To assess a single-center experience with tunneled femoral dialysis catheter usage and outcomes and to identify any operator-dependent factors related to risk of premature catheter failure. Retrospective review of the institutional radiology information system for tunneled femoral dialysis catheter placement from 2010 to 2017 was performed. Patients for whom the catheter was placed for an indication other than dialysis or who were less than 18 years of age at the time of catheter placement were excluded. Premature catheter failure rate, cause of premature failure, catheter patency (in days) and infection rate were assessed. Operator/placement characteristics, including laterality, catheter tip placement, and catheter length were also assessed. A total of 101 patients were included in the study. This included n = 116 catheter placements. Thirty-four percent of patients (n = 40) were lost to follow-up, resulting in n = 61 patients and n = 76 catheters analyzed. Premature catheter failure rate was 48% (n = 36), with low flows being the foremost cause of failure (64%, n = 23). Average primary patency of these catheters was 82.4 days (1-328 days). About 8% of catheters (n = 3) were complicated by infection, resulting in an infection rate of 0.4/1000 catheter days. None of the operator-dependent factors analyzed, including catheter laterality, catheter tip placement, and catheter length, demonstrated a significant association with premature catheter failure. Institutional primary access patency rates are comparable to or higher than previously published data, while infection rates are similar to or lower than those reported in the literature. None of the operator-dependent factors related to placement was shown to significantly decrease the risk of premature catheter failure. These findings suggest that while femoral dialysis catheters do not function well in the long term relative to internal jugular vein dialysis catheters, prior literature may undervalue their utility and function, particularly given that these catheters are used as a "last resort" for many patients.

Impact of Ultrasound Guidance During Placement of Tunnel Dialysis Catheter

Objective: To determine incidence of neck hematoma between with and without ultrasound guided placement of internal jugular vein tunnel dialysis catheter Methodology: A retrospective study was conducted at Heart and Vascular Institution, Kulsum International Hospital, Islamabad. Period: Six months from October 2021 to March 2022. Patients, who presented with End Stage renal failure requiring tunnel dialysis catheter for hemodialysis, were included into this retrospective study. Patient’s statistic profile, indications, signs and symptoms were recorded. Tunnel dialysis catheters were placed through internal jugular vein with or without ultrasound guidance. The study's outcome was measured in terms of the incidence of neck hematoma compared between the two study groups. Results: Overall, out of twenty patients, 13 (65.0%) were male and 7 (35.0%) were female. Age ranged from 16 to 70 with average of 51.0 ± 16.2 years. The incidence of neck hematoma was 3 (30.0%) in internal jugular vein tunnel dialysis catheter placement without ultrasound guidance (group B) compared to none 0 (0.0%) in patients undergoing internal jugular vein tunnel dialysis catheterization with ultrasound guidance (group A). Conclusion: The incidence of neck hematoma was 30% which can be reduced to 0% if ultrasound is used as guidance in cannulation of internal jugular vein during the placement of tunnel dialysis catheter.

Persistent left SVC: Can nephrologist use it for dialysis

Persistent left sided superior vena cava (PLSVC), though rare, is the most common congenital anomaly of thoracic venous circulation. Most of the times, it gets incidentally detected during left internal jugular venous hemodialysis catheter insertion.

Low Posterior Internal Jugular Vein Approach for Tunnelled Haemodialysis Catheter Insertion: A Report on Outcomes at a Single Centre.

The impact of technical differences in cannulation technique for tunnelled haemodialysis catheter insertion is undetermined. We aimed to assess clinical outcomes of the low posterior approach for internal jugular vein tunnelled catheter placement. A retrospective audit was undertaken on consecutive tunnelled catheter procedures performed at a single centre between January 2016 and June 2022. Only catheters specifically placed with a low posterior internal jugular approach were included. The study's primary outcome was 12-month catheter survival, evaluated using the Kaplan-Meier survival curve and log-rank test. Secondary outcomes included catheter performance and procedure-related complications. During the study period, 391 tunnelled internal jugular haemodialysis catheters were inserted in 272 patients using the low posterior technique. The 12-month primary patency rate was 68%. Catheter insertion was successful in 96% of cases. Peri-procedural complications occurred in 4% of cases, most frequently bleeding. The most common reasons for catheter loss were dysfunction (10%) and bacteraemia (6%). The best predictors of catheter failure were advanced age (HR 1.02, 95% CI 1.00-1.04) and in-centre dialysis treatment locality (HR 2.04, 95% CI 1.19-3.45). The low posterior approach for internal jugular vein tunnelled catheter insertion is effective and safe. We demonstrated a 12-month catheter survival rate of 68%. Further research comparing the low posterior approach with other internal jugular vein cannulation techniques is warranted.

Carbon Dioxide Embolism During Laparoscopic Right Hepatectomy: A Case Report

Complications of laparoscopic surgery include carbon dioxide (CO2) embolism, primarily caused by the entry of CO2 gas into blood vessels or solid organs. If significant clinical symptoms occur, timely intervention is crucial as it can be life-threatening. We report a case of CO2 embolism during laparoscopic right hepatectomy. The patient was a 37-year-old male with no history of liver or kidney dysfunction. During the procedure, there were two episodes of oxygen desaturation (SpO2), and the second episode was accompanied by a significant drop in blood pressure and an increase in heart rate. However, there was no sudden decrease in the end-tidal CO2 partial pressure (ETCO2). Simultaneously, a grinding murmur was auscultated in the precordial area, and foamy blood was aspirated from the right internal jugular vein catheter. This article describes a case of CO2 embolism during laparoscopic surgery and provides a summary of its causes, clinical manifestations, diagnosis, and treatment. It is hoped that this article will contribute to the timely recognition and management of such cases, thereby preventing any potential adverse outcomes for patients.

Association between preoperative C-reactive protein to albumin ratio and late arteriovenous fistula dysfunction in hemodialysis patients: a cohort study

Arteriovenous fistula (AVF) dysfunction is a critical complication in hemodialysis (HD) patients, with inflammation potentially contributing to its development. This retrospective cohort study aimed to investigate the association between preoperative C-reactive protein to albumin ratio (CAR) and AVF dysfunction in Chinese HD patients. A total of 726 adults with end-stage renal disease who underwent new AVF placement between 2011 and 2019 were included. Multivariable Cox regression and Fine and Gray competing risk models were employed to assess the relationship between CAR and AVF dysfunction, considering death and renal transplantation as competing risks. Among 726 HD patients, 29.2% experienced AVF dysfunction during a median follow-up of 36 months. Adjusted analyses revealed that higher CAR levels were associated with an increased risk of AVF dysfunction, with a 27% higher risk per one-unit increase in CAR. Furthermore, patients with CAR values ≥ 0.153 exhibited a 75% elevated risk compared to those with CAR values < 0.035 (P = 0.004). The relationship between CAR and AVF dysfunction varied by the site of internal jugular vein catheter placement (P for trend = 0.011). Notably, the Fine and Gray analysis confirmed the association between CAR and AVF dysfunction, with a 31% increased risk per one-unit increase in CAR. The highest CAR tertile remained an independent predictor of AVF dysfunction (HR = 1.77, 95% CI 1.21–2.58, P = 0.003). These findings highlight the potential of CAR as a prognostic marker for AVF dysfunction in Chinese HD patients. Clinicians should consider CAR levels and catheter placement site when assessing the risk of AVF dysfunction in this population.

#4047 ULTRASOUND-GUIDED RIGHT INTERNAL JUGULAR TUNNELED CATHETER INSERTION FOR HAEMODIALYSIS: PRACTICES AND OUTCOMES FROM A SINGLE CENTRE

Abstract Background and Aims Internal jugular vein tunneled catheters are important vascular access for haemodialysis (HD). In our practice, Left-sided internal jugular (LIJ) catheter insertion is performed in radiology under direct X-ray screening. Most right-side internal jugular (RIJ) catheters are inserted under ultrasound guidance in dedicated renal procedure rooms. Vascular access can become challenging with the potential for venous stenosis and thrombosis with catheter use. The aims of this study are to evaluate our practices and outcomes of non-radiologically inserted RIJ tunneled HD catheters and to investigate the predictors of procedure failure. Method 200 successive RIJ tunnel HD catheters inserted from June 2016 under ultrasound guidance at our centre were included in this analysis. Data including demographics, co-morbidities, first or higher order insertion, outcome (success or failed attempt), and immediate complications were collated from electronic patient records. Binary logistic regression analysis was conducted to investigate the predictor for failure in catheter insertion. Results Of the 200 patients, 152 (76%) were first-time insertions and 48 (24%) were second or higher-order insertions. The median age of our cohort was 58 years, with a predominance of males (68%) and white ethnicity (82%). 36.5% were diabetic, with 37.5% having a history of cardiovascular disease. Nearly 30% of patients were on an antiplatelet agent, and 8% were on anticoagulants, which were appropriately managed before line insertion. Pre-operative median haemoglobin was 93 g/dl, with clotting screen and platelet counts in the target range. There was a statistically significant difference in the success of insertion, depending on the insertion being first or subsequent (96.1% vs 81.2%; p = 0.001). The reason for failure in insertion included on-table observation of a small calibre vein on ultrasound or failure to thread wire/dilator due to possible stenosis or thromboses. All line rewire (12/48) procedures were performed successfully. Immediate complication (&amp;lt;1 week) was recorded in 9% of patients, predominantly tunnel bleeding (n = 7) and malposition (deep or high; n = 7) (Table 1). Second or higher-order RIJ catheter insertion showed a higher risk for failure in a multivariable binary logistic regression analysis. (OR: 6.4; CI: 2.1-20.5; P = 0.002) (Figure 1). Of the higher-order insertions, the longer duration between the first and subsequent catheters showed a higher risk for failure (OR:1.19; CI-1.04-1.4; p = 0.010). Conclusion Second or higher-order catheter insertions with a longer duration between the first and the subsequent insertion carry a significant risk of failure due to vein stenosis and thrombosis. Therefore, a careful case-to-case triaging of patients based on previous access history is warranted before listing patients for routine ultrasound-guided insertion.

Central venous stenosis after subclavian versus internal jugular dialysis catheter insertion (CITES) in adults in need of a temporary central dialysis catheter: study protocol for a two-arm, parallel-group, non-inferiority randomised controlled trial

BackgroundThe right internal jugular vein is currently recommended for temporary central dialysis catheters (tCDC) based on results from previous studies showing a lower incidence of central vein stenosis compared to the subclavian vein. Data is however conflicting, and there are several advantages when the subclavian route is used for tCDCs. This prospective, controlled, randomised, non-inferiority study aims to compare the incidence of post-catheterisation central vein stenosis between the right subclavian and the right internal jugular routes.MethodsAdult patients needing a tCDC will be included from several hospitals and randomised to either subclavian or internal jugular vein catheterisation with a silicone tCDC. Inclusion continues until 50 patients in each group have undergone a follow-up CT venography. The primary outcome is the incidence of post-catheterisation central vein stenosis detected by a CT venography performed 1.5 to 3 months after removal of the tCDC. Secondary outcomes include between-group comparisons of (I) the patients’ experience of discomfort and pain, (II) any dysfunction of the tCDC during use, (III) catheterisation success rate and (IV) the number of mechanical complications. Furthermore, the ability to detect central vein stenosis by a focused ultrasound examination will be evaluated using the CT venography as golden standard.DiscussionThe use of the subclavian route for tCDC placement has largely been abandoned due to older studies with various methodological issues. However, the subclavian route offers several advantages for the patient. This trial is designed to provide robust data on the incidence of central vein stenosis after silicone tCDC insertion in the era of ultrasound-guided catheterisations.Trial registrationClinicaltrials.gov; NCT04871568. Prospectively registered on May 4, 2021.

Massive hemothorax secondary to internal jugular vein central venous catheter placement in a patient undergoing spinal surgery complicated by chest trauma: a case report

BackgroundPlacement of a central venous catheter (CVC) is a common procedure for spinal surgery and is relatively safe under ultrasound guidance.Case presentationWe report the case of a 56-year-old female who underwent ultrasound-guided placement of an internal jugular vein CVC for fluid replacement during spinal surgery for thoracic vertebral burst compression fracture and multiple rib fractures as a result of a high-altitude fall injury. Hemothorax developed intraoperatively. During a thoracotomy, the tip of the CVC was found within the chest cavity. The presence of chest trauma may impact on clinician’s appreciation of the potential complications of internal jugular vein CVC placement.ConclusionThe present case demonstrates the need for clinical awareness of the potential complications of CVC placement in patients with chest trauma and the need for adequate training in this technique.

Guided, motor, and mental imagery adjuncts to teaching central venous access.

Mental, motor, and guided imagery techniques are commonly used in sports psychology, but less often in medical education. Utilization of imagery-based techniques (IBTs) in combination with traditional teaching methods may provide a low-cost, innovative approach to improving outcomes in graduate medical education. The objective was to assess whether medical students demonstrate greater proficiency in the ability to obtain central venous access in simulation trainers following exposure to guided, mental, and motor imagery teaching methods in comparison to traditional methods. Volunteer fourth-year medical students during their emergency medicine rotation were randomly assigned to two groups, traditional plus imagery teaching or traditional teaching alone. The control group watched a video tutorial on central line placement methods. The study group watched the same video with the addition of imagery components. Participants filled out survey questions before and after the video and again after line placement. Proctors blinded to student group assignments then observed student placement of an internal jugular triple-lumen catheter on a simulation trainer and completed a standardized performance rubric. Sixty medical students participated. Two were excluded for having performed five or more lines either clinically or in a previous simulation. There was no difference in self-perceived competence in line placement prior to watching the video or in the number of lines previously performed between groups. The imagery group (n = 25) averaged 1.3 errors/need for intervention compared to 2.2 errors/need for intervention in the control group (n = 33; p = 0.045, 95% confidence interval [CI] 0.02 to 1.61). Time to place the line was similar-8.9 min for the control group versus 8.6 min for the imagery group (p = 0.74, 95% CI -1.39 to 1.95). The use of IBTs may be a promising adjunct to traditional medical teaching of procedures in emergency medicine.

Outcome of Ultrasound-guided Insertion of Internal Jugular Vein Permanent Hemodialysis Catheters

Outcome of Ultrasound-guided Insertion of Internal Jugular Vein Permanent Hemodialysis Catheters