Cephalad malposition after central venous catheterization through right internal jugular vein

provided the original work is properly cited. CC Central venous catheterization is performed in the operating room, intensive care unit and emergency room for various reasons. Internal jugular vein is preferred in the operating room due to little chance of pneumothorax and straight route for catheterization to the right atrium. We experienced a case of central venous catheter malposition to cephalad in the right internal jugular vein. A 60-year-old man, 176 cm in height and 82 kg in weight, was presented for Whipple’s operation due to the bile duct cancer. After completion of anesthesia induction and intubation, patient’s head was turned left in Trendelenburg position. After skin disinfection, 18 guage, 2 inch thin-walled needle was inserted at the point of sternocleidomastoid (SCM) muscle apex along with medial border of lateral head of SCM muscle about angle of 45 degree to skin without using the finder needle. At the same time, anesthesiologist’s left 2, 3, and 4 fingers palpated the patient’s right carotid artery for avoiding arterial puncture. However, blood was not aspirated, needle was reinserted more medial direction about angle of 70 degree to skin. After aspiration of venous blood from needle, the J shape guide wire was introduced via the guiding needle using Seldinger technique. Introduction of 20 cm of J-shaped wire was done without any problem, except some resistance at 5 cm depth of the internal jugural vein. Seven Fr double lumen catheter (Prime-S, Sungwon medical, Cheongju, Korea) was advanced to the following J-shaped wire. Blood aspiration was done to remove the air in catheter without any resistance. Catheter was sutured at the proper site and surgery was done as planned. After the operation, the patient was transferred to an intensive care unit. Head and neck antero-posterior view X-ray was checked because the central venous catheter was not seen on chest X-ray. Antero-posterior view of the head and neck showed that central venous catheter was bent sharply to the cephalad in the right internal jugular vein (Fig. 1). We removed malpositioned catheter and reinserted central venous catheter via the same side subclavian vein. The proper position of subcalvian catheter was confirmed by a chest X-ray and the patient discharged at postoperative day 13.