Take a short stroll through the IVTEAM pages and you will discover a number of articles that describe ideal tip location with respect to patient safety. York (2012) reminds us that the lower third of the superior vena cava is the ideal location for a central venous catheter tip. It is also suggested by York (2012) that upper extremity DVT is linked to tip location. I would suggest that this phenomena is accepted by the majority of the global vascular access community. Being part of that community I have to say that I believe tip location is important. However, I would like to briefly discuss the variation in tip location that our patients experience on a daily basis.
It is important that we do not view a central venous catheter tip as a fixed object! 2.5L/min of the patients blood flooding the superior vena cava provides somewhat of a turbulent environment for a central venous catheter tip to reside. Also, the position of the patient (sitting, lying or standing) and arm position will also add a variance to tip location. Confirmation of tip location is really ‘tip location at a single point in time’.
Also, central venous catheters with staggered lumen exits do not appear to fulfil our desire for a fixed tip location! The variance between proximal and distal exit points could be 4cm or more with multi-lumen catheters.
Finally, should we be concerned about catheter migration at dressing change? Of course the answer is yes! However, I feel that tip location is not the only important consideration when placing central venous catheters. An equal question for consideration is one of acceptable tip (or more accurately – lumen exit) variance that can be tolerated before we will worry about an increased risk of upper extremity DVT.
Following this brief discussion can we view tip location in a different way? My advice would be to view the risk of upper extremity DVT as problem that extends beyond tip location. Other considerations include ‘multiple central venous catheters’ (Altassan et al 2014), ‘obesity’ (Maneval and Clemence 2014) and ‘catheter gauge and diagnosis of cancer’ (Chopra et al 2014) – not an exhaustive list.
Closing remarks… when you next place a central venous catheter consider the variance in ‘lumen exit’ and start a) counting the incidence of upper extremity DVT, b) list the confounding factors that may have contributed towards the formation of the upper extremity DVT and c) describe the anatomical location of the DVT and suggest its anatomical/catheter position origin if possible!
Altassan, R., Al Alem, H. and Al Harbi, T. (2014) Temporary central line related thrombosis in a pediatric intensive care unit in central Saudi Arabia. Two-year incidence and risk factors. Saudi Medical Journal. 35(4), p.371-6.
Chopra, V., Ratz, D., Kuhn, L., Lopus, T., Lee, A. and Krein, S. (2014) Peripherally Inserted Central Catheter-Related Deep Vein Thrombosis: Contemporary Patterns and Predictors. Journal of Thrombosis and Haemostasis. March 10th. [epub ahead of print].
Maneval, R.E. and Clemence, B.J. (2014) Risk Factors Associated With Catheter-Related Upper Extremity Deep Vein Thrombosis in Patients With Peripherally Inserted Central Venous Catheters: A Prospective Observational Cohort Study: Part 2. Journal of Infusion Nursing. 37(4), p.260-268.
York, N. (2012) The importance of ideal central venous access device tip position. British Journal of Nursing. 21(21), p.19-24.