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Canadian Journal of Anesthesia 53:422-423 (2006)
© Canadian Anesthesiologists' Society, 2006

Correspondence

Radiographic confirmation following pediatric femoral venous cannulation

Jean-Christophe Bouchut, MD and Daniel Floret, MD

Hôpital Edouard Herriot, Lyon, France, E-mail: jean-christophe.bouchut{at}chu-lyon.fr

To the Editor:

In adult patients, radiographic confirmation of catheter position is usually considered unnecessary following uncomplicated femoral venous cannulation. However, for anatomical reasons, the potential for catheter malposition may be greater in pediatric patients, with morbidity and potential mortality implications. Especially in young children, it has been recommended that radiography be used to confirm correct catheter position.1 We recently experienced a case of unintended placement of a left femoral venous catheter into the ascending lumbar vein.

A six-week-old 5 kg male infant presented to our pediatric intensive care unit in coma related to acute bacterial meningitis. Due to difficulties in obtaining peripheral venous access, a central iv catheter was required. The left femoral vein was cannulated by an experienced staff physician, using the Seldinger technique. During the first attempt, an 8-cm 19-G, single-lumen catheter was inserted easily, and blood specimens were collected via the catheter. A radiograph of the abdomen (systematically indicated in our unit), showed opacification of the ascending lumbar vein (Figure 1Go). Under sterile conditions, the catheter was withdrawn until the catheter tip was in the common iliac vein. A longer guidewire was then passed through the catheter. The guide met no resistance, and the catheter was removed and a new catheter was inserted over the wire. An abdominal x-ray confirmed correct catheter position (Figure 2Go). The catheter was removed electively eight days after insertion, without complication.


Figure 1
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  		FIGURE 1 Abdominal radiography shows opacification of the ascending lumbar vein and the vertebral venous plexus. The tip of the catheter is to the left of the L5 vertebral body.

 

Figure 2
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  		FIGURE 2 Abdominal radiography confirms correct positioning of the catheter within the inferior vena cava.

 
This experience demonstrates the importance of radiographic confirmation of femoral venous catheter position in the pediatric population, even in the absence of clinical signs of misplacement. The ascending lumbar vein drains the vertebral venous plexus into the common iliac vein. Due to angulation of the left femoral vein, the left ascending lumbar vein is easier to cannulate. However, incorrect positioning using the right femoral venous approach has been reported.2 Several signs of femoral catheter misplacement have been reported. These include: difficulty in advancing the guidewire, difficulty or inability to aspirate blood through the catheter, lateral deviation of the catheter at the L4 and L5 levels on abdominal plain films, a catheter path directly overlying the vertebral column, signs of unexplained acute respiratory distress or seizure, and neurological deficits in children receiving parental nutrition via the catheter.2–4

Despite the absence of warning signs during the described procedure, the catheter was clearly misplaced. Only the abdominal x-ray demonstrated the incorrect ascending lumbar venous cannulation. This experience highlights the importance of routine radiographic confirmation of femoral venous catheter position in the pediatric population.

Footnotes

Accepted for publication December 9, 2005.

References

1 Carrion E, Hertzog JH, Gunter AW, Lu T, Ruff C, Hauser GJ. Misplacement of a femoral venous catheter into the ascending lumbar vein: repositioning using ultrasonographic guidance. Intensive Care Med 2001; 27: 240–2.[Medline]

2 Lavandosky G, Gomez R, Montes J. Potentially lethal misplacement of femoral central venous catheters. Crit Care Med 1996; 24: 893–6.[Medline]

3 de Jonge RC, Polderman KH, Gemke RJ. Central venous catheter use in the pediatric patient: mechanical and infectious complications. Pediatr Crit Care Med 2005; 6: 329–39.[Medline]

4 Chen CC, Tsao PN, Yau KI. Paraplegia: complication of percutaneous central venous line malposition. Pediatr Neurol 2001; 24: 65–8.[Medline]





This Article
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