Anesthesiology and ICU, ASST Sette Laghi, Varese, Lombardia, Italy.
J Vasc Access. 2024 Jan;25(1):336-339. doi: 10.1177/11297298221113695. Epub 2022 Jul 26.
Venous access in small infants is difficult and central venous catheter placed into the brachiocephalic vein is often the preferred approach. Ultrasound guided vein cannulation is standard practice and endocavitary electrocardiography is a reliable catheter tip location method. We report a not immediately recognised 2 month old case of inadvertent intra-arterial catheterisation with a 3 Fr - 8 cm catheter during right innominate vein cannulation under ultrasound guidance. Endocavitary electrocardiography showed an increased amplitude P wave with a low P/R wave ratio but further insertion of the catheter resulted in a reduction of the P wave amplitude. At ultrasound re-evaluation of the innominate vein, the catheter seemed to be inside the vessel into the proximal part of the vein, but distally appeared to surpass the vein to get into the brachiocephalic artery at the level of the bifurcation of the right common carotid artery and the right subclavian artery. Cardiac ultrasound from the suprasternal notch view identified the catheter into the aortic arch. Contrast-enhanced CT scan with 3D reconstruction confirmed the intra-arterial catheterisation and showed that the innominate vein was shifted and partially compressed but not transfixed by the catheter. The catheter was non-surgically removed uneventfully. During innominate vein cannulation the catheter cannot always be visualised into the distal tract of the vein and the maximal P wave may have a low P/R ratio; a chest X-ray can identify intra-arterial but false negative results are possible. We recommend always using a real time ultrasound tip navigation and location protocol, like the Neo-ECHOTIP protocol, to confirm the correct position of the guidewire and the catheter. If the catheter cannot be identified inside the venous system, we suggest systematically visualising the aortic arch from the suprasternal notch view and the aortic root from the parasternal view to identify arterial malposition.
在小婴儿中进行静脉通路建立较为困难，通常首选将中心静脉导管置入头臂静脉。超声引导下静脉置管是标准操作，心腔内电图是一种可靠的导管尖端定位方法。我们报告了一例在超声引导下进行右无名静脉置管时，使用 3Fr-8cm 导管意外误穿入动脉的 2 个月大婴儿病例，未立即被识别。心腔内电图显示 P 波振幅增加，P/R 波比值较低，但进一步插入导管导致 P 波振幅降低。再次进行超声检查评估无名静脉时，导管似乎在血管内，进入静脉的近端部分，但远端似乎超出静脉，在右颈总动脉和右锁骨下动脉分叉处进入头臂动脉。胸骨上窝切面的心脏超声识别出导管进入主动脉弓。增强 CT 扫描并进行 3D 重建证实了动脉内导管插入，并显示无名静脉移位并部分受压，但未被导管贯穿。导管非手术顺利取出。在进行无名静脉置管时，导管不能始终被可视化到静脉的远端，最大 P 波可能具有较低的 P/R 比值；X 射线胸片可以识别动脉内，但可能出现假阴性结果。我们建议始终使用实时超声尖端导航和定位方案，如 Neo-ECHOTIP 方案，以确认导丝和导管的正确位置。如果导管不能在静脉系统内被识别，我们建议从胸骨上窝切面系统地观察主动脉弓，并从胸骨旁切面观察主动脉根部，以识别动脉错位。
