Direction of the J-tip of the guidewire, in Seldinger technique, is a significant factor in misplacement of Subclavian vein catheter: A randomized, controlled study

Anesth Analg 2005;100:21-24

Introduction

Ipsilateral internal jugular vein misplacement of a central venous catheter after a right infraclavicular subclavian approach is seen in approximately 5%. It may predispose to clotting, thrombophlebitis, erosion of the vascular wall and cerebral effects after the rapid infusion of certain medications. The authors tested the hypothesis that this misplacement may be explained by the direction of the J-tip of the guidewire during its insertion.

Study

The authors performed an adequately powered randomized, controlled, double blind trial in patients scheduled for general anesthesia. Patients with chest or neck deformities were excluded. In group 1 the J-tip was directed caudad and in group 2 the J-tip was directed cephalad. The method by which the subclavian vein was punctured in all patients is clearly described and generally accepted. An independent physician prefixed the direction of the J-tip of the guidewire to either direction in a random fashion using presealed envelopes for the two study groups so that the anesthesiologist was blinded as to the J-tip direction. Position of the catheter was determined using fluoroscopy and repositioned with the help of a reinserted guidewire in case the tip was not at the junction of the SVC/right atrium. In a second study the authors studied the performance of the J-tip of the guidewire in a polyvinyl model of the subclavian, internal jugular and superior cava vein.

A total of 300 patients were included. In 5 patients the subclavian vein puncture failed leaving 147 patients in group 1 and 148 patients in group 2. In group 1 only 3 catheters (2%) were placed in the ipsilateral internal jugular vein compared to 60 (40%) in group 2. The relative risk for canulating the ipsilateral internal jugular vein while using a cephalad direction of the J-tip is 19.9 and the NNT to prevent this by using a caudad J-tip position is only 2.6. Cardiac arrhythmias were significantly more frequent in-group 1 compared to group 2 (33% versus 6% respectively). In the second study using the polyvinyl model, all 30 attempts with the J-tip upward resulted in canulation of the internal jugular vein while all 30 attempts with the J-tip downwards resulted in a proper position in the superior cava vein.

Discussion

This appears to be a convincing study showing that the J-tip should be directed caudad while using the infraclavicular subclavian approach to prevent canulation of the ipsilateral internal jugular vein. There is no reason to doubt the conclusions of the authors. The incidence of ipsilateral internal jugular vein canulation while using a cephalad-directed J-tip appears to be very high compared to the existing literature. Apparently most doctors normally use a caudad-directed J-tip during routine daily practice. The design of this study could have been improved by using the patients as their own controls. Fluoroscopic control of the guidewire could have been done after a second introduction using the other J-tip direction. In this way unexpected differences in patient anatomy between the two groups could have been accounted for. Our final conclusion is simple however: keep the direction of the J-tip caudad.

S. Kurban, Fellow Intensive Care
J.G. van der Hoeven, Intensivist