Central venous catheter tip position right atrium
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Many publications, including the instructions accompanying central venous catheters, state that it is negligent to site the catheter tip in the right atrium. If the catheter tip is above the carina on a post-procedure radiograph then it is generally accepted that the catheter lies outside the right atrium. It is also recommended that the catheter tip should lie in the long axis of the superior vena cava without acute abutment to the vein wall. We performed a retrospective audit of the position of central venous catheter tips on routine post-procedure chest radiographs in intensive care unit patients, to see if these potentially conflicting requirements had been met. Show MethodsWe identified 213 central venous catheters suitable for analysis, within a study population of 200 consecutive cases. We measured the distance of the central venous catheter tip above or below the carina and the angle of the central venous catheter tip to the vertical (a surrogate marker for the angle of abutment of the tip to the approximately vertical superior vena cava wall). ResultsFor right-sided catheters there was a high (74/163) number placed with their tips below the carina, but a very low number (4/163) with their tips at a steep (>40°) angle to the vertical. For left-sided catheters very few (7/50) were placed with their tips below the carina, but for those 43 sited above the carina most could be considered to be in suboptimal positions. This was because they were either too high and had not even crossed the midline (9), or had an acute angle (>40°) between the tip and the vertical (27). ConclusionsWe suggest that for left-sided catheters placement of the tip below the carina is more likely to result in a satisfactory placement. Percutaneous central venous catheterization. Three years' experience in a neonatal intensive care unit. American Journal of Diseases in Children 144:1246–1250.OpenUrlCrossRefPubMed
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Darling JC, Newell SJ, Mohamdee O, et al. Central venous catheter tip in the right atrium: a risk factor for neonatal cardiac tamponade. J Perinatol 2001;in press.
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Positioning the tip of a central venous catheter (CVC) within the superior vena cava (SVC) at or just above the level of the carina is generally considered acceptable for most short-term uses, such as fluid administration or monitoring of central venous pressure. Ideally the distal end of a CVC should be orientated vertically within the SVC. CVCs placed for the purpose of long term chemotherapy may be placed more inferiorly at the cavo-atrial junction - the junction of the SVC and right atrium (RA). Catheters used for haemodialysis may be placed at the cavo-atrial junction or even in the RA itself. Positioning the catheter tip too proximally, for example in the right or left brachiocephalic veins, is associated with increased risk of line infection and thrombosis. AnatomyThe lower part of the SVC is surrounded by the pericardial reflection; this is where the upper pericardium folds back on itself to form a sac. Positioning a CVC tip within the SVC and below the level of the pericardial reflection is associated with a small risk of pericardial tamponade. Neither the SVC nor the pericardial reflection are visible on a chest X-ray. As the carina is a visible structure, which is located above the level of the pericardial reflection, it can be used as an anatomical landmark to help determine the level of a CVC tip within the SVC and above the pericardial reflection. What is the ideal location for a CVC tip?The correct position of the tip of CVC is considered to be in the superior vena cava (SVC) above the level of pericardial reflection. Blood flow conditions are then optimal to keep the catheter away from the intima and to dilute the infused drugs immediately.
Is it OK for central line to be in right atrium?It is generally agreed that the tip of an inserted central venous catheter (CVC) should not lie within the right atrium. However, the tip of a CVC not inserted to an adequate depth could lie outside the superior vena cava, predisposing to thrombus formation and infection.
Where is a central venous catheter CVC tip placed?CVCs are most commonly inserted via the right internal jugular vein. Right internal jugular catheters are positioned on the right side of the neck, and pass vertically from a position above the clavicle.
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