Tracking the tip: Preventing the malposition of central venous catheters

Central venous catheterisation (CVC) is a commonly performed procedure in anaesthesiology, perioperative medicine, and critical care practice. It is undertaken at high frequency in operating rooms, intensive care units, and emergency resuscitation areas by anaesthesiologists and perioperative physicians. The routine nature of the procedure may contribute to operator complacency, particularly when correct catheter position is inferred solely from the ability to aspirate dark venous blood from a functioning lumen.

The assumption that successful venous cannulation equates to correct catheter placement is therefore misleading.

The two systematic reviews published in this issue of the Indian Journal of Anaesthesia (IJA) underscore that establishment of central venous access is only the first step in ensuring patient safety.[1,2] The insightful review of malpositioned catheters in this issue meticulously analyses data from 66 reports of 75 cases across 20 countries (with a large proportion of data reported after 2014).[1] The review emphasises that presumably due to greater awareness and better use of imaging, the true clinical burden of catheter tip malposition has become increasingly apparent. Interestingly, malposition was documented in various veins—including the left and right internal jugular, subclavian, femoral, and some unusual anatomical variants such as the persistent left superior vena cava and internal mammary, accessory, and hemiazygos veins. Even rare sites like vertebral and pericardiophrenic veins were reported to be involved. The review highlights the multifactorial nature of catheter malposition. Technical reasons which are often implicated include handling of the wire and catheter, pushing the guidewire too far, choosing a straight tipped instead of a J-tip wire, failing to follow the wire with ultrasound once it has entered the vein, excessive head rotation, and using soft silicone catheters that tend to drift into side branches. Patient-related factors associated with malposition included emergency insertions, coughing, sudden patient movement, and periods of increased intrathoracic pressure.[1]

Ultrasound guidance has undoubtedly increased the success rate of CVC in all age groups;[3] however, various techniques are still evolving. Common approaches for ultrasound-guided internal jugular vein cannulation described in the literature are short-axis out-of-plane. Notably, as reported in the review, catheter malposition continued to occur despite ultrasound guidance, particularly when sonographic assessment was discontinued after venous puncture. Nevertheless, the authors of the review advocate that the patient’s bedside course should be observed with utmost caution: Difficulty aspirating blood, resistance to infusion, pain, new arrhythmias, or unexplained respiratory or neurological change should all prompt us to question the placement of the central venous catheter.[1] The authors also stress how additional tools—transoesophageal echocardiography, saline flush tests, arterial blood gas sampling, and waveform analysis—can help to clear the picture. Chest radiography was the default confirmatory modality used in the majority of the cases but had its own share of limitations. Thus, a computed tomography scan was needed to define complex or extravascular malpositions. The unintended consequences ranged from mild (catheter dysfunction, misleading central venous pressure readings), intermediate (pleural effusions, hydrothorax), and severe (vascular perforation with haemothorax or haemomediastinum, cardiac tamponade, neurological injury, and inadvertent arterial cannulation).

The case reports included in the reviews are subject to publication biases like inclusion of unusual or severe cases or incomplete cases, which is an inherent limitation of case-based evidence.[1,2] The review on malposition of central venous catheters also indicates that a central venous catheter that appears correctly positioned initially may subsequently migrate with time due to factors such as patient movement, mechanical ventilation, or high-pressure infusions.[1] To summarise, the review underscores the persistent risk of central venous catheter placement and its associated morbidity, despite advances in insertion techniques and imaging guidance.[1] Nonetheless, central venous catheter malposition is a severe complication of a commonly performed procedure, driven by several interacting factors, and can lead to catastrophic consequences. Several reports suggest that left-sided catheterisation may be associated with a higher risk of malposition owing to its anatomical course.[4] Ultrasound has undoubtedly eased venous access and made it safer; however, it should not be regarded as a definitive safeguard against catheter malposition. Early confirmation using complementary techniques and maintaining a low threshold for reassessing catheter position are essential for patient safety as delayed recognition of catheter malposition can lead to serious complications.

Further, the persistence of catheter malposition despite ultrasound-guided insertion highlights the distinction between successful venous access and accurate catheter placement, emphasising the need for dedicated tip-confirmation strategies, and highlights the limitations of conventional ultrasound in confirming final catheter tip position. Although ultrasound facilitates accurate vessel localisation and guides consistent needle placement, it is not sufficient as a sole modality to reliably confirm guidewire, catheter, or tip position. Unusual anatomy, like a persistent left superior vena cava or other rare venous pathways, can still misdirect the catheter in the wrong direction.

The second review article by Maurya et al.[2] in this issue proposes a practical approach towards addressing this challenge. It focusses on the ultrasound view through the right supraclavicular fossa to locate the catheter tip in real time. This method could detect malposition during the procedure and allow for quick correction in most cases. In a pooled cohort of 252 adult patients, correct tip placement was radiographically confirmed in 99.16% of cases (247 of 252). Real-time right supraclavicular fossa ultrasound detected 27 cases of intraprocedural malposition (a pooled rate of 7.89%). Among these, 23 of the 27 malpositioned catheters were successfully corrected under direct sonographic guidance, with no reported procedural complications.[5]

At each stage of a clinical procedure, steps that are omitted and inadequately performed and verified are invariably associated with an increased risk of adverse events. This is especially relevant in unstable patients, during emergency insertions, and when the line is placed on the left side, where venous angulation and branching anatomy can increase the risk of deviation.[6] Together, these reviews reinforce a simple safety principle: enter the vein, track the guidewire, and confirm the catheter tip before use.

Chest radiography remains the most widely used modality for post-procedural tip confirmation; however, it may not reliably detect all catheter malpositions and does not provide immediate feedback during insertion. The right supraclavicular fossa ultrasound view, on the other hand, allows one to check the catheter’s direction at the bedside, before initiating infusions through the catheter.

The practical implications for anaesthesiologists and intensivists are evident. Pre-procedural ultrasound should not stop at vein identification; it should also be used to look for unusual anatomy whenever feasible. Guidewire advancement should be deliberate, not routine. Tip confirmation should precede the administration of vasoactive drugs, parenteral nutrition, and other high-risk infusions. If the catheter behaves unexpectedly, the procedure should be paused and the catheter’s position should be reassessed and confirmed rather than used in the hope that “it will probably be fine”.

These reviews highlight the need to incorporate catheter tip confirmation, recognition of malposition, and troubleshooting strategies into routine training programmes. Embedding routine catheter tip verification into clinical culture will prevent more harm than just focusing on speed and success. The mere assumption that the catheter is safe just because it was inserted smoothly is flawed; it is only safe once its path and tip position have been accurately verified. In closing, these two reviews do not discourage the use of central venous catheters; rather, they emphasise the importance of approaching this commonly performed procedure with appropriate vigilance and adherence to best practices and established guidelines.

Although CVC is a routine procedure, these reviews remind us that every insertion carries the potential for clinically significant complications if catheter position is not adequately verified. If we can slow down just enough to track the wire, question the odd tracing, repeat the scan, or order the extra image when something does not fit, we can convert a “routine” act into a safer one. Additionally, we can drive our collective efforts towards establishing robust evidence-based guidelines for safer and more reliable venous access and universally incorporate them in our teaching and training programmes.[7] A practical, multimodal approach can help translate these findings into routine clinical care. This includes a brief pre-procedural ultrasound scan prior to sterilisation to rule out anatomical variations or thrombosis, continued use of ultrasound to track the guidewire during insertion, and use of additional acoustic windows when required to better visualise the guidewire and catheter tip. Catheter position should be confirmed before administering vasoactive agents or other high-risk infusions, and any concern regarding function should prompt immediate imaging.[8,9,10] Ultimately, meticulous technique, systematic tip confirmation, and continued vigilance remain the cornerstones of safe central venous catheter insertion. The mindset of curiosity instead of complacency may be the most important clinical tool that we can bring to the patient’s bedside.

Study data availability

None.

Disclosure of use of artificial intelligence (AI)-assistive or generative tools

No artificial intelligence (AI) assistive or generative tools used.

Author contributions

BN: Concept, design, literature search, data acquisition, manuscript preparation, manuscript editing. RH: Concept, definition of intellectual content, data acquisition, manuscript preparation and editing, guarantor. SSN: Concept, definition of intellectual content, manuscript preparation and editing.