Triple-lumen Central Venous Catheter Research Articles

Misleading tacrolimus concentration value in blood taken from a catheter used for tacrolimus administration

A misleading blood tacrolimus concentration (BTC) value caused by the contamination of a central venous catheter previously used for tacrolimus administration is described. A 59-year-old woman with severe chronic obstructive pulmonary disease successfully underwent double lung transplantation. In the intensive care unit, she received a continuous i.v. infusion of tacrolimus from days 1 to 5 after transplantation through the distal lumen of a polyurethane triple-lumen central venous catheter. The catheter lumen was flushed twice a day with 0.9% sodium chloride injection. The proximal lumen was used for blood sampling after being flushed; the first 10 mL of blood was discarded. BTCs determined in whole blood one, four, and five days after transplantation were within the therapeutic range of 5-15 ng/mL. On day five the patient was transferred to the thoracic surgery ward and was switched to oral tacrolimus 1.5 mg twice daily. The BTC on day 6 was unexpectedly high at 134.5 ng/mL. The patient's clinical status was normal, and no signs of tacrolimus toxicity were observed. On day 7, blood samples were drawn from a peripheral vein and simultaneously through the central venous catheter. Although the central venous catheter had not been exposed to tacrolimus during the preceding two days, it yielded blood with a BTC eight times higher than the BTC in blood from the peripheral vein (41.4 ng/mL versus 5.1 ng/mL). The collection of blood from a central venous catheter lumen that had been used for tacrolimus administration resulted in a BTC about eight times higher than what was measured in peripheral blood.

The Stuck Central Venous Catheter: A Word of Caution

The placement of central venous catheter (CVC) through internal jugular vein is not free from potential hazards. We report two cases of triple lumen central venous catheter, placed into right internal jugular vein, which got entrapped in patients who had undergone mitral valve replacement. The entrapment of catheter went unnoticed until the time of removal. Subsequent investigations, mechanism of entrapment, prevention, and removal is described. To conclude, we encountered an unusual cause of stuck central venous catheter, in the left atrial suture line. Removal of central venous catheter requires utmost care, and should never be done by forceful traction in the postoperative cardiac surgical patients, as it may lead to disruption of suture lines or rupture of vessels.

Use of Catheters With the AgION Antimicrobial System in Kidney Transplant Recipients to Reduce Infection Risk

Microbial blood infection represents a high risk for immuno-suppressed patients. Of all catheter-related infections in the bloodstream, 90% result from the use of central venous catheters, the main cause being microbial colonization at the catheter’s insertion point or the catheter hub. Between January 2003 and December 2004, 102 patients received a renal transplant including 57 who received a triple-lumen central venous catheter (CVC) during the procedure. Two catheters were used: a standard polyurethane catheter placed in the jugular veina or the subclavian veina for group I, and polyurethane catheters with the AgION antimicrobial system always placed in the subclavian veina for group II. Care and maintenance of the CVCs was standardized in both groups. After catheter removal, the tips were analyzed microbiologically. Of 57 (43.9%) CVCs, 25 were found to be contaminated. In the first group 24 out of 41 CVCs (58.5%) showed bacterial growth, whereas in group II only one catheter (6.6%) had a biofilm. The most common contaminant (18 out of 25, 72%) was Staphylococcus epidermidis. In group II, two patients had positive blood cultures yet a microbiologically sterile CVC. None of the catheters with the AgION antimicrobial system had to be removed owing to local infection or intolerance. The continuous release of silver ions increases the protection against bacteria and fungi during the entire time of catheterization. Use of catheters with the AgION antimicrobial system lead to a marked reduction in catheter-associated infections of the bloodstream.

Anesthetic management of bronchopleurocutaneous fistula - an alternate approach

To the Editor: A 48-yr-old man with a persistent left bronchopleurocutaneous fistula (BPCF) and empyema thoracis following pneumonectomy presented for bronchial stump closure and left thoracoplasty. The patient refused any attempts at awake intubation. He was placed in semi-recumbent position with the left side down after topicalization and mask induction. Right-sided double-lumen tube (DLT) placement was attempted while the patient was breathing spontaneously, but was unsuccessful in the absence of adequate muscle relaxation. Attempts to position a left bronchial blocker under fibreoptic guidance resulted in the balloon either slipping into the fistulous opening or backing up into the trachea. Advancing a single-lumen tube into the right main stem bronchus resulted in right upper lobe obstruction and attempted DLT insertion over a tube exchanger was also unsuccessful. When rescheduled, he was positioned and induced in the same manner as before and intubated with an 8.5 size endotracheal tube. Anesthesia was maintained with air, oxygen and sevoflurane using a Bain circuit, the patient breathing spontaneously. A triple-lumen central line and a transesopheal echocardiograph (TEE) were added to standard monitoring. The patient was positioned in the sitting position and stabilized in the appropriate frame, with his hands abducted and flexed forwards. The surgeon approached the BPCF through a left thoracotomy by transaxillary approach. Transtracheal jet-ventilation was delivered through the tip of a catheter placed above the level of fistula, to lessen the possibility of barotrauma. Anesthesia was maintained with an infusion of ketamine. During jet-ventilation PaO2 values were 80 to 90 mmHg while PaCO2 increased to 60 mmHg. The fistula was repaired and leak tested while purulent material from the left chest cavity was suctioned clean. Controlled ventilation restored blood gas levels towards normal. Left thoracoplasty was completed and the patient was extubated in the operating room. Postoperative pain control was achieved by a thoracic epidural catheter with continuous infusion of bupivacaine and fentanyl. While anesthetizing the patient with BPCF in the sitting position, oxygenation can be assured with jetventilation, and gravity aids in draining away purulent secretions from the trachea.1 CO2 accumulation can be managed by limiting the surgical time and establishing controlled ventilation at the earliest opportunity. Hypotension can be corrected with crystalloid infusion. The hazard of air embolism can be monitored with TEE and treated with a triple lumen central venous catheter.2 When conventional methods of pulmonary isolation fail, anesthesia and surgery pose unusual challenges during the operative management of BPCF.3,4 Careful planning and meticulous anesthetic management can transform a difficult case into a manageable one.

Reduced colonization and infection with miconazole–rifampicin modified central venous catheters: a randomized controlled clinical trial

Central venous catheters (CVC) are a major cause of nosocomial bloodstream infections. Catheters modified with miconazole and rifampicin that constantly and slowly release antimicrobial substances are assumed to be beneficial in reducing rates of colonization and catheter-related infections. Prospective controlled non-blinded randomized clinical trial in two German university hospitals. 223 adult inpatients with CVC between October 2000 and February 2002. Baseline characteristics, APACHE II score and therapeutic interventions were comparable. Randomization to receive either a miconazole and rifampicin modified catheter (n=118) or a standard triple-lumen CVC (n=105). MEASUREMENTS, DEFINITIONS: Microbiological evaluation was done after CVC removal. A catheter was considered colonized if growth of > or =15 cfu was found by semi-quantitative roll-plate technique from a proximal or distal catheter segment. A catheter-related infection (CRI) was defined as a colonized catheter with local signs of inflammation. A catheter-related bloodstream infection (CR-BSI) was defined as a colonized catheter with isolation of the same organism from the patient's blood with accompanying clinical signs of infection. A colonization of CVC was observed in six patients (5.1%) with a modified catheter and 38 patients (36.2%) with a standard catheter (P < 0.001). Five patients in the modified group (4.2%) and 18 in the standard group (17.1%) developed CRI (P=0.002). One assumed CR-BSI was detected in the standard group, with none in the modified group. No adverse effects related to the modified catheters and no antimicrobial resistance were observed. CVC supersaturated with miconazole and rifampicin were associated with a significantly lower risk for catheter colonization and catheter-related infections compared to standard catheters.

Reduction of catheter-related infections in neutropenic patients: a prospective controlled randomized trial using a chlorhexidine and silver sulfadiazine-impregnated central venous catheter

Antiseptic coating of intravascular catheters may be an effective means of decreasing catheter-related colonization and subsequent infection. The purpose of this study was to assess the efficacy of chlorhexidine and silver sulfadiazine (CH-SS)-impregnated central venous catheters (CVCs) to prevent catheter-related colonization and infection in patients with hematological malignancies who were subjected to intensive chemotherapy and suffered from severe and sustained neutropenia. Proven CVC-related bloodstream infection (BSI) was defined as the isolation of the same species from peripheral blood culture and CVC tip (Maki technique). This randomized, prospective clinical trial was carried out in 106 patients and compared catheter-related colonization and BSI using a CH-SS-impregnated CVC (n=51) to a control arm using a standard uncoated triple-lumen CVC (n=55). Patients were treated for acute leukemia (n=89), non-Hodgkin's lymphoma (n=10), and multiple myeloma (n=7). Study groups were balanced regarding to age, sex, underlying diseases, insertion site, and duration of neutropenia. The CVCs were in situ a mean of 14.3+/-8.2 days (mean+/-SD) in the study group versus 16.6+/-9.7 days in the control arm. Catheter-related colonization was observed less frequently in the study group (five vs nine patients; p=0.035). CVC-related BSI were significantly less frequent in the study group (one vs eight patients; p=0.02). In summary, in patients with severe neutropenia, CH-SS-impregnated CVCs yield a significant antibacterial effect resulting in a significantly lower rate of catheter-related colonization as well as CVC-related BSI.

Central venous catheters—the inability of ‘intra-atrial ECG’ to prove adequate positioning

The classic increase in P wave size, known as 'P-atriale', is a widely accepted criterion for determination of proper positioning of central venous catheter tips. Recent transoesophageal echocardiography (TOE) studies did not confirm intra-atrial position despite advancing the central venous catheter further than indicated by ECG guidance. We postulate that the pericardial reflection rather than the entry into the right atrium corresponds to the ECG changes. In order to test our hypothesis we sought to determine the anatomical substrate for the electrical changes in an animal study. Subsequently, a modified version of the study was undertaken in man and is also reported. In six juvenile pigs the left external jugular vein and right carotid artery were cannulated. A triple-lumen central venous catheter was positioned by ECG guidance using a Seldinger wire as an exploring electrode. The venous and arterial catheters were suture fixed 2 cm beyond the onset of an increase in P wave size. The corresponding anatomical catheter tip position was determined by open exploration of the vessels and the heart. Subsequently the catheter tip position (during advancement) of a pulmonary artery catheter and the corresponding electrical ECG changes were examined in 10 patients during open chest cardiac surgery. All catheters-arterial and venous, in animals and humans-revealed an increase in size of the P wave as well as the QRS complex. All venous catheters were positioned in the superior vena cava, beyond the pericardial reflection but outside the right atrium. All arterial catheters were positioned in the ascending aorta thus also beyond the pericardial reflection. The start of an increase in P wave size does not correspond with the entrance of the right atrium. The anatomic equivalent for the electrophysiological changes of the ECG is the pericardial reflection. ECG guidance is unable to distinguish between venous and arterial catheter position.

A prospective, randomized study in critically ill patients using the Oligon Vantex ® catheter

Microbial colonization and the incidence of catheter-related bloodstream infections (CR-BSI) associated with Oligon Vantex ® silver central venous catheters (CVC) in critically ill patients were determined. A prospective, randomized, controlled 17-month trial was carried out in an intensive care unit (ICU). All patients requiring a triple-lumen CVC for four days or longer were enrolled. Patients were randomized to receive a standard polyurethane CVC or an Oligon Vantex silver CVC. Before removal of the catheter either due to discharge from the ICU or suspected infection, blood for cultures was taken via the CVC and a peripheral site. Skin and hub swabs and catheter-tips were also cultured. Two hundred and six catheters, 103 in both groups, were evaluated. In the control group (CG) 45/103 (44%) and in the silver group (SG) 30/103 (29%) were colonized or had a CR-BSI ( P=0.04). The SG was less likely to be colonized than the CG when the catheter remained in situ for eight days or less ( P=0.03) or over 15 days ( P=0.01); a second or subsequent catheter was present in the same patient ( P=0.002), or if the CVC was placed in the internal jugular vein ( P=0.05). Multivariate logistic-regression showed predisposing factors for catheter colonization were jugular and femoral sites, second or subsequent catheter, and being a member of the CG. CR-BSI occurred in five cases (four in CG). Rates of CR-BSI per 1000 catheter-days in the CG were 2.8 and in the SG, 0.8 ( P<0.001). The Oligon Vantex silver catheter reduced the incidence of catheter-colonization and may decrease the risk of CR-BSI.

Rates of infection for single-lumen versus multilumen central venous catheters: A meta-analysis

Since the introduction of multilumen central venous catheters two decades ago, there has been controversy whether the additional lumens place patients with these catheters at higher risk for infection. Our objective was to determine the risk of catheter-related bloodstream infection (CRBSI) and catheter colonization in multilumen catheters compared with single-lumen catheters. Studies were identified by a computerized search of MEDLINE, EMBASE, CINAHL, Current Contents, and PREMEDLINE databases and by review of bibliographies and expert consultation. Studies comparing the prevalence of CRBSI or catheter colonization among single-, double-, and triple-lumen central venous catheters were included. We excluded studies if they included central venous catheters that were long-term, cuffed, tunneled, or coated with antibiotic or antiseptic agents. Two independent reviewers abstracted data on: 1) risk factors for CRBSI and colonization, 2) outcome definitions used, 3) the absolute prevalence of CRBSI and catheter colonization, and 4) study design and quality. A total of 15 studies met inclusion criteria. Summary odds ratios were calculated using a random-effects model. Although CRBSI was more common in multilumen catheters (summary odds ratios, 2.15; 95% confidence interval, 1.00-4.66), catheter colonization was not (summary odds ratios, 1.78; 95% confidence interval, 0.92-3.47). Tests for heterogeneity, however, suggested substantial variation by study. When only studies of higher quality were included, multilumen catheters were found not to be associated with a significant increase in CRBSI prevalence (summary odds ratios, 1.30; 95% confidence interval, 0.50-3.41). Multilumen central venous catheters may be associated with a slightly higher risk of infection when compared with single-lumen catheters; however, this relationship diminishes when only high-quality studies that control for patient differences are considered. The slight increase in infectious risk when using multilumen catheters is likely offset by their improved convenience, thereby justifying the continued use of multilumen vascular catheters.

Each lumen is a potential source of central venous catheter-related bloodstream infection.

To determine the relative rates of microbial colonization of individual lumens in triple-lumen central venous catheters (CVCs) and calculate the chance of detecting catheter-related blood stream infection (CRBSI) if only one lumen is sampled. Prospective evaluation of CVCs from suspected and nonsuspected CRBSI cases. University teaching hospital. Triple-lumen CVCs from 50 cases of suspected CRBSI (a raised peripheral white blood cell count, temperature >37 degrees C, and/or local signs of infection at the catheter skin entry site) were evaluated. For comparison, 50 triple-lumen CVCs routinely removed at the end of use were evaluated. In both groups, peripheral blood cultures were taken before CVC removal. After CVC removal, each lumen was sampled in vitro using the endoluminal brush, and the tip was then cultured using the Maki roll technique. CVCs causing CRBSI had significant microbial colonization in one, two, or three lumens in ten (40%), ten (40%), or five (20%) cases, respectively. Overall, random sampling of only one lumen in CVCs causing CRBSI had a 60% chance of detecting significant colonization. If only one CVC lumen is sampled, a negative result does not reliably rule out infection. Each lumen of multiple-lumen CVCs should be considered as a potential source of CRBSI.

A prospective clinical audit of central venous catheter use and complications in 1000 consecutive patients.

We conducted a prospective audit of central venous catheter (CVC) use in 1000 consecutive patients to better define the rates of postoperative complications (particularly vascular perforation) and the pattern of CVC and pulmonary artery catheter (PAC) usage (particularly the number of lumens inserted and utilized). Details of CVCs, complications, and the number of lumens in place and used, were recorded daily until all CVCs were removed. A total of 1546 CVCs and 223 PACs were placed in study patients. Two non-fatal perforations occurred: a perforated right atrium in a patient who received an Arrow triple-lumen CVC (previously reported), and a perforated pulmonary artery in a patient upon withdrawal of a Baxter PAC. The risk per patient of any CVC-related perforation was 0.2% (95% confidence interval (CI): 0.02% to 0.7%). The rates of CVC-related sepsis and local infection were 3% (95% CI: 2% to 4%) and 2% (95% CI: 1% to 3%) respectively. At the peak of CVC use (day 1 in the ICU) the overall number of lumens placed was significantly correlated with lumens used (r = 0.53), endorsing clinical judgement in the anticipation of the needs of the patient. The modal number of lumen uses in adults and children was four. However, in children, fewer catheters were inserted per patient than in adults (1.28 vs 1.63, P = 0.01), and placed lumens were used more intensively (P < 0.001). Data appear to justify the routine selection of a triple-lumen CVC in adult patients, but not of a quad-lumen CVC.

Subcutaneous emphysema at the site of central line placement due to the haematogenous spread of Clostridium septicum

Subcutaneous emphysema at the site of central line placement due to the haematogenous spread of Clostridium septicum

CASE 6—2001 exsanguinating endotracheal hemorrhage during cardiopulmonary bypass

A 42-year-old, hypertensive man weighing 55 kg with triple-vessel coronary artery disease and a left ventricular ejection fraction of 0.5 was scheduled to undergo elective coronary artery bypass graft surgery. Preoperative evaluation was unremarkable except for a 5-year history of essential hypertension controlled with oral diltiazem, 60 mg twice daily. There were no respiratory complaints. The patient was premedicated with oral lorazepam, 2 mg. Anesthesia was induced with morphine, thiopental, and vecuronium to facilitate uneventful tracheal intubation, with a 9-mm cuffed endotracheal tube. A triple-lumen central venous catheter was introduced through the right internal jugular vein. After saphenous vein, left radial artery, and left internal mammary artery harvest, aortic and right atrial cannulation with a 2-stage cannula were performed with systemic heparinization. When the patient was on cardiopulmonary bypass (CPB), a cardiotomy sucker was introduced through a stab incision in the pulmonary artery (PA) to act as a PA vent. Surgery was uneventful, with 2 saphenous vein grafts to the right coronary artery and marginal, radial artery to the first marginal, and internal mammary to left anterior descending artery.

No effect of nadroparin prophylaxis in the prevention of central venous catheter (CVC)-associated thrombosis in bone marrow transplant recipients.

Complications of CVCs in 382 consecutive patients receiving a stem cell transplantation (SCT) were analysed. Early complications were pneumothorax (3.6%), haematothorax (0.5%), dislocation (3%) and dysfunction (3.6%). Eighty-seven-associated infections (22%) were observed, leading to removal of the CVC in 26 patients. More bacteraemias were associated with double- or triple-lumen CVCs, 19% vs 5% in single lumen CVCs (P < 0.0001). Coagulase-negative staphylococci were the predominant microorganisms in 72%. A special point of investigation was CVC-associated thrombosis and the prophylactic value of nadroparin. Two consecutive regimens with nadroparin were used and compared; 7 days 2850 IE nadroparin and 10 days 5700 IE nadroparin. The incidence of CVC-associated thrombosis was 6.9% in 382 patients with 390 catheters. The incidence was 8% in patients receiving one of the prophylactic nadroparin regimens compared to 6% in a comparable control group without prophylaxis. A short course of nadroparin was unable to prevent thrombotic complications after discontinuation.

A central venous catheter coated with benzalkonium chloride for the prevention of catheter-related microbial colonization

In an attempt to overcome infections associated with central venous catheters, a new antiseptic central venous catheter coated with benzalkonium chloride on the internal and external surfaces has been developed and evaluated in a clinical trial. Patients (235) randomly received either a triple-lumen central venous catheter coated with benzalkonium chloride (117) or a polyurethane non-antiseptic catheter (118). The incidence of microbial colonization of both catheters and retained antiseptic activity of the benzalkonium chloride device following removal were determined. The benzalkonium chloride resulted in a significant reduction of the incidence of microbial colonization on both the internal and external catheter surfaces. The reduction in colonization was detected at both the intradermal (21 benzalkonium chloride catheters vs. 38 controls, P=0.0016) and distal segments of the antiseptic-coated catheters. Following catheter removal retained activity was demonstrated in benzalkonium chloride catheters which had been in place for up to 12 days. No patients developed adverse reactions to the benzalkonium chloride catheters. The findings demonstrate that the benzalkonium chloride catheter significantly reduced the incidence of catheter-associated colonization.

High incidence of intravenous thrombi after short-term central venous catheterization of the internal jugular vein

Study Objective: To assess incidence and characteristics of intravenous (IV) thrombi associated with short-term central venous catheterization through the internal jugular vein. Design: Prospective clinical study. Setting: University hospital. Patients: 81 patients undergoing cardiac surgery. Interventions: A triple-lumen central venous catheter was inserted into the right internal jugular vein immediately before surgery and removed 3 to 4 days later. Heparin at an IV dose of 15,000 IU/24 hours was started 6 hours after surgery and continued until the first postoperative morning, followed by subcutaneous low molecular weight heparin 5,000 IU/day in combination with oral aspirin 100 mg/day. Measurements and Main Results: Anatomy of the internal jugular vein and IV blood flow were studied using two-dimensional and color Doppler ultrasonography before insertion of the catheter and after its removal. Thrombi were found in 45 patients (56%). Twenty-five of these thrombi (56%) had the shape of a sleeve, and 20 thrombi (44%) were compact. Length of the thrombi was 1.4 ± 0.8 cm (mean ± SD). Half of the thrombi floated with venous blood flow and half were stable. Neither impaired venous blood flow nor clinical signs of embolism or sepsis was found. Follow-up studies in eight patients revealed that the thrombi had not disappeared 5 days after removal of the catheter but had become smaller. Conclusion: The incidence of IV thrombi associated with short-term catheterization of the internal jugular vein was high despite prophylactic anticoagulation. This finding reaffirms the importance of removing central venous catheters as soon as clinically possible. Additional studies using specific outcome tests are needed to thoroughly assess the clinical importance of this finding.

Use of pulsed field gel electrophoresis to determine the source of microbial contamination of central venous catheters.

Microorganisms detected in situ on the distal tip of central venous catheters (CVC) within 90 min of insertion were investigated using pulsed-field gel electrophoresis to analyse genomic fragments obtained with the SmaI restriction enzyme. Thirty patients received a triple lumen CVC, which was inserted directly through the skin using the Seldinger technique. In a further 30 patients a triple lumen CVC was inserted through a Swan sheath, thereby avoiding direct contact of the CVC with the skin. Staphylococci were isolated from the distal tips of the catheters in 6 patients (5 who had the CVC inserted directly through the skin and 1 who had the CVC inserted via a Swan sheath.) Twenty-three staphylococcal isolates were also isolated from the insertion equipment and the skin swabs surrounding the insertion site of these six patients. All the isolates were genotyped. In one of the patients the organisms isolated from the skin were identical to those on the CVC tip. In two further patients similar organisms were isolated from the insertion equipment and the patients' skin. These results, in addition to the reduced colonisation rates observed when catheters were introduced through a Swan sheath, support the hypothesis that microorganisms from the skin are impacted onto the CVC tip and the CVC insertion equipment at catheter insertion.

PREVENTION OF CATHETER-RELATED BLOODSTREAM INFECTION.

One approach to preventing catheter-related bloodstream infections is to coat the catheter with antibiotic or antiseptic agents. Two randomized trials examined that approach in hospitalized patients who required triple-lumen polyurethane central venous catheters. The first study included 403 catheters and 158 patients in the University of …

Physical and biological effects of a surface coating procedure on polyurethane catheters

Central venous catheters are widely used in clinical practice; however, complications such as venous thrombosis or infection are frequent. The physical and biological effects of a coating procedure designed to improve the blood-contacting properties of polyurethane central venous catheters (CVCs) were studied. The surface atomic composition of poly(vinyl pyrrolidone) (PVP)-coated or uncoated Pellethane ® single lumen CVCs was characterized by electron spectroscopy for chemical analysis (ESCA), which confirmed the presence of an oxygen-rich PVP layer on the former material. Topological analysis of both single and triple lumen CVCs by scanning force microscopy (SFM) revealed a very smooth surface in PVP-coated catheters compared to the more frequent surface irregularities found either in uncoated Pellethane ® or in four additional randomly selected, commercially available triple lumen polyurethane CVCs. The PVP-coated Pellethane ® showed a strong reduction in either fibrinogen or fibronectin adsorption compared to all other PVP-free polyurethane CVCs. This decreased protein adsorption led to a proportional reduction in protein-mediated adhesion of either Staphylococcus aureus or Staphylococcus epidermidis and in the binding of a monoclonal antibody directed against the cell-binding domain of fibronectin. Increased surface smoothness and hydrophilic properties of polyurethane CVCs might decrease the risk of bacterial colonization and infection.

Erroneous Arterial Placement of a Central Venous Catheter

In a 63-year-old man with unresectable gastric adenocarcinoma, intractable vomiting and worsening abdominal pain prompted hospitalization. Radiographic and endoscopic evaluation disclosed complete obstruction of the gastric outlet due to a large gastric tumor. Because of his malnourished condition and inability to tolerate food orally, he underwent placement of a triple-lumen central venous catheter for parenteral hyperalimentation. Catheterization through the right internal jugular vein was accomplished uneventfully by using a standard Seldinger technique.