Malpositions of peripherally inserted central catheters

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Intravenous literature: Minkovich, L., Djaiani, G., McCluskey, S.A., Mitsakakis, N., Gilbert, R.W. and Beattie, W.S. (2011) Frequent malpositions of peripherally inserted central venous catheters in patients undergoing head and neck surgery. Canadian Journal of Anaesthesia. 58(8), p.709-713.

Abstract:

PURPOSE: Peripherally inserted central venous catheters (PICCs) do not interfere with surgical access during neck dissection and are used in patients undergoing head and neck surgery. However, severe complications associated with malpositioning of PICCs have been reported in these patients. We conducted a retrospective study to determine the incidence of aberrant positioning of PICCs in patients undergoing free flap reconstructive (FFR) surgery for head and neck malignancies.

METHODS: We analyzed a database of 269 patients undergoing FFR surgery. After induction of general anesthesia, a PICC was inserted successfully in 130 patients (48%) at bedside without image guidance. A PICC was not used in 139 patients (52%). A chest x-ray was performed at admission to the postanesthetic care unit, stored digitally, and reviewed retrospectively by two independent observers. Based on the chest x-ray findings, the PICC position was classified as proper, suboptimal, or aberrant and defined according to the position of the PICC tip, i.e., proper, if situated in the ipsilateral innominate vein or in the superior vena cava; suboptimal, if situated in the subclavian vein; and aberrant, if situated in any other location.

RESULTS: Proper, suboptimal, and aberrant PICC positions were found in 68 (52%), 17 (13%), and 45 (35%) patients, respectively. The proper position was confirmed more frequently with a left- than with a right-sided approach: 23/29 (79%) vs 45/101 (44%) patients, respectively (P < 0.001).

CONCLUSIONS: There is a high incidence of aberrant positioning when PICCs are inserted without image guidance. The left-sided approach might be preferable due to a lower incidence of malpositions. The risk-benefit ratio should be estimated carefully before using a PICC in patients undergoing FFR procedures.

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