ACCURATE PLACEMENT OF CENTRAL VENOUS CATHETERS - A PROSPECTIVE, RANDOMIZED, MULTICENTER TRIAL

Objectives: a) To define the frequency of dangerous (intracardiac) cen tral venous catheter placement in a multicenter study of large communi ty hospital intensive care units (ICUs) and to evaluate physician resp onses to this finding. b) To validate right atrial electrocardiography as a technique to assure adherence with recent Food and Drug Administ ration (FDA) guidelines regarding the location of central venous cathe ter tips. c) To conduct a literature review of vascular cannulation an d its associated potentially lethal complications. Design: Prospective , randomized, blinded, multicenter study. Setting: Multidisciplinary I CUs in five large community teaching hospitals. Patients: Consecutive patients (n = 112) who required a central venous catheter by either in ternal jugular vein or subclavian vein at four separate hospitals were assessed using 30-cm catheters. Consecutive patients (n = 50) in a fi fth hospital who subsequently required a central venous catheter via t he internal jugular vein or subclavian vein route were prospectively r andomized to receive a 20-cm central venous catheter with either conve ntional surface-landmark guidance, or with the right atrial electrocar diography-guided technique. Main Outcome Measures: a) Occurrence rate of malpositioned central venous catheters. b) Ability of right atrial electrocardiography to aid in the accurate placement of central venous catheters. Results: a) Using conventional placement techniques with a 30-cm catheter, 53 (47%) of 112 initial central venous catheter place ments resulted in location of the catheter tip within the heart. Cathe ter tips were not repositioned to locations outside the right atrium a fter this finding was identified on initial postprocedure films. b) Us ing the right atrial electrocardiography technique to place 20-cm cent ral venous catheters resulted in no catheter tip locations within the heart (0/25) vs. 14 (56%) of 25 (p < .0001) intracardiac placements us ing conventional techniques. c) The literature suggests that serious m echanical complications of central venous catheterization, although un common, are associated with a high mortality rate. Deaths are associat ed with intracardiac placement. Conclusions: a) The FDA guidelines reg arding catheter tip location (catheter tip should not be in the right atrium) have not been widely publicized. b) The average safe insertion depth for a central venous catheter from the left or right internal j ugular vein or subclavian vein is 16.5 cm for the majority of adult pa tients; a central venous catheter should not be routinely inserted to a depth of >20 cm. Catheters longer than this size are rarely needed, and potentially dangerous. Catheter tip location is important to docum ent following central venous catheter insertion. Thirty-centimeter cen tral venous catheters should not be used when accessing the central ci rculation via internal jugular or subclavian veins. c) Right atrial el ectrocardiography is a technique that assures initial tip position out side the heart in accordance with FDA guidelines. This technique would virtually eliminate the major risk of death (i.e., cardiac perforatio n) associated with this procedure. d) Recently available, 15- and 16-c m central venous catheters have significant potential to minimize intr acardiac placement of central venous catheters by either the internal jugular or subclavian vein route and may become the standard of care.