Exact placement is an essential prerequisite for long-term use of a central venous catheter. Reported data show an extremely wide range of catheteral misplacements: from less than 1% to more than 60%. Some approaches appear to be less advantageous than others, but the highest rates of misplacement occur in the cubital, external jugular and saphenous veins. A series is presented of 378 radiographically controlled central venous catheters analysed for aberrant placement and loop formation. The total occurrence of faulty positioning and coiling reached 5.3%, while the respective incidences were 30% for the external jugular vein, 5.7% for the internal jugular vein, 5.5% for the infraclavicular technique of subclavian venepuncture, 5.3% for the innominate vein and 1.4% for the supraclavicular approach of subclavian venepuncture. The total frequency for pure loop formation was 2.9%. The authors discuss numerous reported data on catheter malpositioning, according to the specific techniques used, and compare them with thier own results. The relatively low incidence in the present series is possibly due to the high proportion of cases where the supraclavicular subclavian approach was used, the omission of the sphrenous/femoral and cubital techniques, and to pre-determining the length of the inserted catheteral segments.
An aberrant placement of a central venous catheter into the upper part of the thoracic duct with loop formation in the left innominate vein was observed on catheterizing via the left internal jugular vein. The misplacement, which did not have any deleterious effects, was caused by the atypical insertion site of the thoracic duct at the dorsocaudal wall of the left innominate vein and, possibly, by its incompetent closing valve. The stiffness of the nylon catheter used may also have been a contributory factor. The possible causes of this complication of central venous catheterization are discussed. The preferential use of the right internal jugular vein is stressed.
Recurrent acute respiratory failure in an epileptic subject is described. The first episode of respiratory failure occurred while the patient was having frequent epileptic fits and was probably secondary to cerebral oedema with temporal herniation. The second occurred suddenly after 27 days during which the patient had been free from seizures. It is suggested that this episode of acute respiratory failure was the result of an epileptic seizure without any motor symptoms.
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