Positioning of Central Venous Catheters* - Chest

Evaluation of Formulas for Optimal
Positioning of Central Venous Catheters*
Christine A. Czepizak, MS, PA-C; James M. O'Callaghan, PA-C; and
Bahman Venus, MD, FCCP
Objective: To evaluate the accuracy of formulas designed
to estimate the optimum intravenous length of
central venous catheters.
Design: A prospective study of catheter insertion sites
to evaluate the accuracy of predetermined formulas that
predict the intravascular insertion length required to
avoid intracardiac catheter tip placement.
Setting: A 320-bed tertiary hospital.
Patients: Critically ill patients requiring central venous
access for therapy or monitoring.
Main results: The formulas accurately predicted required
intravascular length of the central venous catheter
in 217 of 228 (95%) cases. The formula for predicting
catheter length was most accurate when the subclavian
vein was used. It was least accurate when the right
Obtaining central venous access is one of the most
common procedures performed in critically ill
patients.' Cardiac tamponade,2'6 atrial'7 and ven
tricular dysrhythmias,18 hemothorax,12 hydrothorax
5,7,15,19,20 and mediastinal fluid collection 5,15,21
are among the serious complications of central venous
catheterization. These complications result from
placement in and erosion through vessels and atrial
or ventricular chambers by the catheter tip.3,4'13'15'19
Recently, McGee et a122 observed that, utilizing
30-cm catheters, 47% of their catheter tips were located
in the heart chambers. A reliable formula to
predict the necessary intravascular catheter length to
achieve the desired superior vena cava (SVC) placement
would likely reduce complications and save
time and expense. It would also provide a simple alternative
to electrocardiographic techniques for
placement guidance.
In a study, Peres23 utilized patients' height to develop
formulas to predict the optimum length of the
catheter to be inserted for right internal (RIJ) or external
jugular (REJ) catheters, right infraclavicular
subclavian (RSC) catheters, and left external jugular
(LEJ) catheters.
In this study, successful placement using the
formulas suggested by Peres23 was prospectively
*From the Department of Critical Care Medicine, Colombia
Memorial Hospital, Jacksonville, Fla.
Manuscript received July 19, 1994; revision accepted October 7.
Reprint requests: Dr. Venus, Dept. of CCM, Colombia Memorial
Hospital, P.O. Box 16325, 3625 University Blvd, Jacksonville,
FL 32216
1 662
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internal jugular vein was selected.
Conclusions: The formulas can accurately predict the
required length of catheters and thereby reduce the
possibility of complications and save time and expense.
(CHEST 1995; 107:1662-64)
IJ=internal jugular; LEJ=left external jugular; LIJ=left
internal jugular; LSC=left subclavian; REJ=right external
jugular; RIJ=right internal jugular; RSC=right subelavian;
SC=subelavian; SVC=superior vena cava
Key words: catheter; central venous access; tamponade;
vascular erosion
tested, and formulas for left infraclavicular subclavian
(LSC) and left internal jugular (LIJ) vein
approaches were determined and evaluated.
MATERIALS AND METHODS
Patients admitted to Colombia Memorial Hospital who were
scheduled for central venous catheter placement by the Critical
Care Team were entered into the study. The protocol was
approved by the Memorial Hospital Institutional Review Board.
Central venous cannulation was performed by a critical care
specialist, two physician assistants, and seven residents. All catheters
were obtained from the same company (Arrow-Howes
Multi-Lumen Central Venous Catheterization Kits, Product No.
AK15703 [20 cm] and AK14703 [30 cm], Reading, Pa). Site
selection was done per operator preference taking into account
previous sites and patient comfort as long as no contraindications
for the selected site existed. Positioning, preparation of the
patient, and techniques of insertion used in the study have been
published elsewhere.24'25 Details recorded during the study
included the patient's name, age, height in centimeters, weight in
kilograms, body habitus, and catheter length inserted. After
placement, position of the tip and whether adjustment was
required were noted and recorded. Catheter tip position was
confirmed in all patients by anteroposterior chest radiograph that
was read by a radiologist who was unaware of the study protocol.
Position was considered optimum if the catheter tip was above or
in the distal SVC.
The catheter length to be inserted was calculated using
formulas recommended by Peres23 (Table 1) for RIJ, right external
jugular (REJ) and RSC veins, as well as left external jugular
(LEJ) vein. For internal jugular (IJ) sites, distances were approximated
from the level of the cricoid. For subelavian (SC) sites,
distances were approximated from the medial curve of the clavicle.
To complete the study for all jugular and infraclavicular sites,
a review of the anatomy was used to prospectively develop formulas
for the LIJ and LSC veins. Using the known anatomic relationship
that the subclavian vein has with the SVC-right atrial
Clinical Investigations in Critical Care

Table 1-Position of the Catheter Tip
Using Derived Formulas*
No. of In SVC, In RA,
Site Formula Cath Tips No. (%) No. (%)
RSC (Hgt/10)-2 cm 76 73 (96) 3 (4)
LSC (Hgt/10)+2 cm 61t 59 (97) 1(2)
RIJ Hgt/10 49 44(90) 5 (10)
LIJ (Hgt/10)+4 cm 44f 41 (94) 2 (5)
*Cath=catheter; RA=right atrium; Hgt=height.
tlncludes catheter tip in contralateral innominate vein.
junction, formulas were derived for both the LIJ and LSC veins.
All catheter lengths were measured from the puncture site perpendicular
to the skin to the distal tip of the triple-lumen catheter.
RESULTS
Two hundred twenty eight patients (113 men, 115
women) were entered into the study. The results of
the central venous catheterization using the above
formulas for determining catheter length are summarized
in Table 1. Average height for male and female
patients and corresponding catheter lengths
inserted for each site can be found in Table 2. The
overall prediction accuracy for these formulas was
217 of 228 (95%). The formula for predicting catheter
length was most accurate for the LSC site (97%)
and least accurate for the RIJ site (90%). One LSC and
one LIJ catheter were placed in the innominate vein
but did not require repositioning.
DISCUSSION
Catheter migration has been shown to occur even
when central approaches are used for venous cannulation
resulting in vessel or cardiac perforation and
cardiac tamponade.2,6,11,12,14-16,20,26 Immediate perforation
can occur from tissue puncture by guidewire,
dilator, or overinsertion of a hard-tip catheter.4
Catheter pressure on the vessel or cardiac wall can
result in perforation within 24 h.7'26 In cases of late
perforation, it is postulated that vessel or heart wall
puncture occurs secondary to catheter advancement
with head, arm, or trunk movement.3'4'14'20'26'27 A
second mechanism for late perforation postulates that
the catheter tip abutting against the vessel or heart
wall causes tissue erosion that is potentiated by cardiac
contraction.2'7'19'26 This is supported by results of
an in vitro study in which perforation rates by catheters
pulsating against a simulated membrane were
measured.28
In a 2-year study by Ellis et al,7 vessel erosion was
diagnosed in ten patients who had undergone surgery.
Mean interval from time of catheter insertion
to onset of symptoms was 60.2 h, making it unlikely
that puncture occurred during central line placement.
Nine patients recovered from complications of
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Table 2-Catheter Length Inserted in Male and
Female Patients to Achieve Superior Vena Cava
Catheter Tip Placement
Male (n=113) Female (n=115)
Average height, cm 175.2 ± 8.6* 157.7±16.5
Range, cm 140-190 122-180
RSC, cm 15.6±0.83 14.1±1.1
LSC, cm 19.5 ±0.89 17.9±1.3
RIJ, cm 17.1±1.3 15.7±0.79
LIJ, cm 21.1±0.85 19.2±1.6
*Mean ± standard deviation.
vascular erosion. One patient died despite pericardiocentesis
for cardiac tamponade.
Hydrothorax has been reported in eight patients
who presented with dyspnea, chest pain, pleural effusions,
or mediastinal widening after central venous
catheter insertion. In these cases, left-sided catheter
placement was associated with a higher risk for vascular
erosion.19
Catheter-induced arrhythmias can present as atrial
or ventricular premature beats or ventricular tachycardia
or fibrillation.17"18 Catheter-induced rhythm
disturbances are usually resistant to drug suppression;
however, withdrawal of the catheter from the right
atrial or ventricular chamber usually stops the arrhythmias.18
McGee et a122 found that when a blind insertion
technique was used for insertion of 20- or 30-cm
catheters, 53 (47%) of 112 catheter tips were located
in the atrium. Surprisingly, although the position of
the catheter tip was noted in the postprocedure chest
radiograph in 36 patients, no attempts were made to
reposition the catheters in 32 of the patients. They
suggested that the operators may not be sufficiently
concerned with potential complications of right atrial
tip placement or may not be aware of Food and Drug
Administration guidelines regarding proper catheter
tip placement.
Several recommendations to decrease the risk of
vessel or myocardial wall perforation by central
venous catheter tips, including omission of beveled or
hard tips,3,9,15,21 avoidance of left-sided approaches,15'20'21
and immobilization of the catheter3'21 have
been made. The most effective method has been to
place the catheter tip in an extracardiac position
within the SVC and confirming placement by chest
radiograph 3,5,7,11,15,20,21,23 If repositioning is required,
another chest radiograph is recommended to
confirm optimum placement.21 The use of right atrial
electrocardiography ensures placement of the catheter
tip above the right atrium,22 but it requires a
special adaptor and ECG monitor or machine and
may not be readily available when catheters are
placed in nonmonitored or emergency situations.
From results of their study, McGee et a122 con-
CHEST / 107/6/ JUNE, 1995 1663

cluded that by using a 15- or 16-cm central venous
catheter, cardiac cannulation may be reduced. Our
study shows, however, that the site of insertion and
patient height are significant factors that influence
the appropriate catheter insertion length to avoid
intracardiac catheter tip position. Body habitus, eg,
obesity, also may affect catheter insertion length although
this was not tested in this study. When RSC
or RIJ sites are used in patients that are less than 150
cm in height, even a 14-cm catheter insertion length
may cause atrial cannulation. Neither the formulas
derived by Peres23 nor those determined in this study
take into account the probable differences in catheter
insertion length due to variations in same site approaches,
ie, high vs cricoid IJ approaches or medial
vs lateral SC approaches. Low IJ or medial SC sites
are more likely to result in atrial placement.
In our study, different formulas based on patient
height and insertion site were prospectively derived
to predict optimum central venous catheter insertion
length. They were found to be 90 to 97% accurate and
simple to use. It is likely that accuracy for RIJ sites
could be improved by modifying the formula to
height/10-1 cm. We recommend using the formulas
to guide catheter placement to increase the likelihood
of desired tip location within the SVC on the
first attempt and eliminating the need for readjustment
and confirmation chest radiograph. If time or
circumstances do not permit rough measurement of
patient height, the average catheter insertion lengths
calculated for each site may be used as guidelines for
catheter placement. Follow up chest radiograph is
still required to verify proper placement.
ACKNOWLEDGMENTS: We thank Dr. Nikaulaus Gravenstein
for his critical review of the manuscript.
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Clinical Investigations in Critical Care