Malposition

Extravascular

Central venous catheters (or their guidewires) can dissect through the vein wall, pleura, pericardium, heart, or mediastinum, leaving the tip of the catheter resting in a potentially lethal position. This should be suspected if a catheter or guidewire advancement is difficult or if blood cannot be freely aspirated.

Intravascular

Accidental arterial placement of central venous catheters can easily occur in hypotensive patients, but this is usually quickly recognized. Rarely, severe arterial trauma requiring rapid intervention can occur.

It is best to position catheters in the superior vena cava and avoid kinks, loops, or retrograde placement into the internal jugular vein. Should the latter event occur, a conscious patient may complain of the 'ear gurgling' sign as the infusion is commenced. Rarely, the retrograde infusion of lidocaine (lignocaine) has led to coma and hyperosmolar solutions have caused cerebral venous thrombosis. Catheters can work themselves into an abnormal aberrant position after a period of time and cause thrombosis. It is wise to avoid over advancement of long-term catheters into the right atrium since endocardial injury and the serious sequelae of arrhythmias, mural thrombosis, perforation, advancement into the coronary sinus, or catheter knotting have been reported.

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Sleep Apnea

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