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 Table of Contents    
LETTER TO THE EDITOR
Year : 2011  |  Volume : 15  |  Issue : 1  |  Page : 61-62

Right subclavian artery cannulation: Is chest roentgenogram sufficient to diagnose the complication?


Department of Anaesthesia & Intensive Care, Alchemist Hospitals Ltd., Panchkula, Haryana, India

Date of Web Publication22-Mar-2011

Correspondence Address:
Amit Jain
Department of Anaesthesia & Intensive Care, Alchemist Hospitals Ltd., Panchkula
India
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DOI: 10.4103/0972-5229.78234

PMID: 21633554

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How to cite this article:
Jain A. Right subclavian artery cannulation: Is chest roentgenogram sufficient to diagnose the complication?. Indian J Crit Care Med 2011;15:61-2

How to cite this URL:
Jain A. Right subclavian artery cannulation: Is chest roentgenogram sufficient to diagnose the complication?. Indian J Crit Care Med [serial online] 2011 [cited 2014 Jul 31];15:61-2. Available from: http://www.ijccm.org/text.asp?2011/15/1/61/78234


Dear Editor,

I read with interest the letter to the editor, "Finding on a chest radiograph: A dangerous complication of subclavian vein cannulation" by Srinivasan and Kumar.[1] The inference of the authors seems to be simple, and is based on the prior, yet limited, reports of the radiographic findings of inadvertent subclavian artery cannulation and interpretation of the anatomy of the great vessels of body. [2],[3] However, a closer look reveals the omission of many simple and easily available methods that should have been used to further confirm the diagnosis before abruptly removing the catheter in the hemodynamically unstable patient.

Ultrasound-guided insertion of central venous cannulation and trans-thoracic or trans-esophageal Doppler, when available, are the most reliable techniques to diagnose subclavian artery cannulation. However, these may not be readily available and need expertise. Pressure tracings using pressure transducer can also differentiate between venous or arterial cannulation. [3] However, when not available, various alternate bedside techniques should be used in addition to chest roentgenogram for confirming the subclavian artery malpositioning of central venous catheter.

Absence of free flow of intravenous fluid may be possible even if the catheter tip is in the lumen of subclavian vein with the tip abutting walls of the vein. Further, pulsatile movements of the fluid column (at a rate similar to the patient's heart rate) should appear if the catheter is in artery, at least when the pulse pressure is 40 mmHg, i.e. ≈55 cm of water (as the patient's blood pressure was 80/40 mmHg). Blood gas analysis of the samples aspirated from the central venous catheter lumen and from the peripheral artery (e.g. radial artery) can be compared in such confusing situations. This method could be a safe, easy and reliable method to diagnose an inadvertent arterial cannulation, especially in intensive care unit settings.

Nonetheless, the post procedural chest radiographic findings of subclavian artery cannulation are important to understand. The usefulness of the post procedural chest radiograph is increased by the fact that even with the electrocardiogram monitoring of the tip, using either electrolyte solution or wire stylet, all catheters-arterial and venous-could reveal an increase in size of the P wave as well as the QRS complex, once the catheter tip extends beyond the pericardial reflection. [4]

 
 » References Top

1.Srinivasan NM, Kumar A. Finding on a chest radiograph: A dangerous complication of subclavian vein cannulation. Indian J Crit Care Med 2010;14:95-6.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Dedhia HV, Schiebel F. What is wrong with this chest roentgenogram? Right subclavian artery cannulation. Chest 1987;92;921-2.  Back to cited text no. 2
    
3.Jansen HJ, Spaargaren GJ, de Jager CP. Right subclavian vein cannulation? Insertion of a central venous catheter with inadvertent cannulation of the subclavian artery. Neth J Med 2006;64:429-30.  Back to cited text no. 3
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4.Schummer W, Schummer C, Schelenz C, Brandes H, Stock U, Muller T, et al. Central venous catheters-the inability of 'intra-atrial ECG' to prove adequate positioning. Br J Anaesth 2004;93:193-8.  Back to cited text no. 4
    



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Srinivasan, N.M., Kumar, A.
Indian Journal of Critical Care Medicine. 2011; 15(1): 62
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