Influence of misplaced subclavian vein catheter on transpulmonary thermodilution measurements_Chinese Journal of Respiratory and Critical Care Medicine

Authors：

 LIU Yang ¹ , LI Xiaoshi ¹ , YU Xin ² , LIU Liangliang ² , LI Guofeng ²

1. Department of Critical Care Medicine, Gaochun People's Hospital, Nanjing, Jiangsu 211300, P. R. China;
2. Intensive Care Unit, Characteristic Medical Center of the Chinese People's Armed Police Force, Tianjin 300162, P. R. China;

Corresponding author：

LIU Yang, Email: mdliu2009@163.com

Keywords：

Central venous catheters; Subclavian vein; Misplacement; Thermodilution; Extravascular lung water; Clinical decision-making

DOI：

10.7507/1671-6205.201910069

Video：

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Objective To investigate the influence of misplaced subclavian vein (SCV) catheter into the ipsilateral internal jugular vein (IJV) on transpulmonary thermodilution (TPTD) measurements and explore the possible mechanisms preliminarily.Methods In this prospective study, 408 patients in whom an SCV catheterization was indicated for TPTD monitoring were enrolled. A first set of TPTD measurements was collected at baseline in all patients (group 1, SCV catheters were correctly placed; group 2, SCV catheters were misplaced into the ipsilateral IJV). The parameters included mean transit time (MTt), downslope time (DSt), cardiac index (CI), global end-diastolic volume index (GEDVI) and extra-vascular lung water index (EVLWI). A second set of TPTD measurements was performed only in those with catheter misplacement immediately after the misplaced SCV catheters being corrected (Group 3). The differences in MTt, DSt, GEDVI and EVLWI between group 2 and 3 were recorded as ΔMTt, ΔDSt, ΔGEDVI and ΔEVLWI, respectively.Results GEDVI and EVLWI were significantly higher (all P<0.001) in group 2 than those in group 1, while CI was not significantly different (P>0.05) between these two groups. Multivariate logistic regression identified PaO₂/FiO₂ [adjusted odds ratio (OR) 1.492/10 mm Hg; 95% confidence interval (CI), 1.180 - 1.884; P<0.001], GEDVI (OR=1.307/10 mL/m², 95% CI 1.131 - 1.511; P<0.001) and EVLWI (OR=3.05; 95%CI 1.593 - 5.840; P<0.001) as the 3 independent factors associated with the misplacement of SCV catheter into the ipsilateral IJV. In group 2, GEDVI [(1041±122)mL/m² vs. (790±102)mL/m², P<0.001], EVLWI [(20.3±4.0)mL/kg vs. (10.3±2.3)mL/kg, P<0.001], CI [(3.6±1.2)L·min^–1·m^–2 vs. (2.9±1.0)L·min^–1·m^–2, P<0.001], MTt [(38.2±13.3)s vs. (30.8±9.4)s, P<0.001] and DSt [(18.9±7.2)s vs. (13.2±4.9)s, P<0.001)] were significantly higher than those in Group 3. Multiple regression analysis demonstrated that ΔEVLWI (R²=0.86, P<0.001) was negatively correlated with ΔMTt (coefficient±SE, –0.52±0.12; P<0.001) and positively correlated with ΔDSt (coefficient±SE, 1.45±0.17; P<0.001).Conclusions During TPTD measurements, indicator injection through an SCV catheter misplaced into the ipsilateral IJV results in an overestimation of CI, GEDVI and EVLWI. The increase in DSt might be a key factor in explaining the overestimation of EVLWI in patients with misplaced SCV catheters. Given that the accurate measurements of GEDVI and EVLWI are of utmost importance for guiding resuscitation and decision-making regarding fluids administration, immediate repositioning is required if a misplacement is suspected and confirmed by the chest X-ray.

Citation： LIU Yang, LI Xiaoshi, YU Xin, LIU Liangliang, LI Guofeng. Influence of misplaced subclavian vein catheter on transpulmonary thermodilution measurements. Chinese Journal of Respiratory and Critical Care Medicine, 2021, 20(1): 42-48. doi: 10.7507/1671-6205.201910069 Copy

1.	Cecconi M, De Backer D, Antonelli M, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med, 2014, 40(12): 1795-1815.
2.	Sakka SG, Reinhart K, Meier-Hellmann A. Comparison of pulmonary artery and arterial thermodilution cardiac output in critically ill patients. Intensive Care Med, 1999, 25(8): 843-846.
3.	Beurton A, Teboul JL, Monnet X. Transpulmonary thermodilution techniques in the haemodynamically unstable patient. Curr Opin Crit Care, 2019, 25(3): 273-279.
4.	Monnet X, Teboul JL. Transpulmonary thermodilution: advantages and limits. Crit Care, 2017, 21(1): 147.
5.	李红. PICCO 在 ICU 危重患者的临床应用及护理进展. 医学信息, 2015, 28(19): 346-347.
6.	Reuter DA, Huang C, Edrich T, et al. Cardiac output monitoring using indicator-dilution techniques: basics, limits, and perspectives. Anesth Analg, 2010, 110(3): 799-811.
7.	Rath GP, Bithal PK, Toshniwal GR, et al. Saline flush test for bedside detection of misplaced subclavian vein catheter into ipsilateral internal jugular vein. Br J Anaesth, 2009, 102(4): 499-502.
8.	Liu Y, Wei LQ, Li GQ, et al. Pulse pressure variation adjusted by respiratory changes in pleural pressure, rather than by tidal volume, reliably predicts fluid responsiveness in patients with acute respiratory distress syndrome. Crit Care Med, 2016, 44(2): 342-351.
9.	Malbrain M, Van Regenmortel N, Saugel B, et al. Principles of fluid management and stewardship in septic shock: it is time to consider the four D's and the four phases of fluid therapy. Ann Intensive Care, 2018, 8(1): 66.
10.	Tagami T, Ong MEH. Extravascular lung water measurements in acute respiratory distress syndrome: why, how, and when?. Curr Opin Crit Care, 2018, 24(3): 209-215.
11.	Jozwiak M, Teboul JL, Monnet X. Extravascular lung water in critical care: recent advances and clinical applications. Ann Intensive Care, 2015, 5(1): 38.
12.	Hofkens PJ, Verrijcken A, Merveille K, et al. Common pitfalls and tips and tricks to get the most out of your transpulmonary thermodilution device: results of a survey and state-of-the-art review. Anaesthesiol Intensive Ther, 2015, 47(2): 89-116.
13.	Sakka SG, Ruhl CC, Pfeiffer UJ, et al. Assessment of cardiac preload and extravascular lung water by single transpulmonary thermodilution. Intensive Care Med, 2000, 26(2): 180-187.
14.	Smit JM, Raadsen R, Blans MJ, et al. Bedside ultrasound to detect central venous catheter misplacement and associated iatrogenic complications: a systematic review and meta-analysis. Crit Care, 2018, 22(1): 65.
15.	Bekele NA, Abebe WA, Shifa JZ. Misplaced subclavian central venous catheter. Pan Afr Med J, 2017, 27: 59.
16.	Yu WQ, Zhang Y, Zhang SY, et al. Impact of misplaced subclavian vein catheter into jugular vein on transpulmonary thermodilution measurement variables. J Zhejiang Univ Sci B, 2016, 17(1): 60-66.
17.	Verhoeff K, Mitchell JR. Cardiopulmonary physiology: why the heart and lungs are inextricably linked. Adv Physiol Educ, 2017, 41(3): 348-353.
18.	Vieillard-Baron A, Matthay M, Teboul JL, et al. Experts’ opinion on management of hemodynamics in ARDS patients: focus on the effects of mechanical ventilation. Intensive Care Med, 2016, 42(5): 739-749.
19.	Chen SL, Chen LF, Du ZS, et al. Influence of injection rates of calibrating standard solution on monitoring pulse indicator continuous cardiac output. Biomed Eng Online, 2018, 17(1): 34.
20.	Wang H, Cui N, Su LX, et al. Prognostic value of extravascular lung water and its potential role in guiding fluid therapy in septic shock after initial resuscitation. J Crit Care, 2016, 33: 106-113.
21.	张灯亮, 何先弟, 刘杰, 等. PiCCO 监测下的目标导向集束化治疗脓毒性休克的疗效及相关血流动力学指标对预后的诊断价值. 中国急救医学, 2020, 40(6): 536-541.
22.	Soussi S, Deniau B, Ferry A, et al. Low cardiac index and stroke volume on admission are associated with poor outcome in critically ill burn patients: a retrospective cohort study. Ann Intensive Care, 2016, 6(1): 87.
23.	Stephan F, Mazeraud A, Laverdure F, et al. Evaluation of reperfusion pulmonary edema by extravascular lung water measurements after pulmonary endarterectomy. Crit Care Med, 2017, 45(4): e409-e417.
24.	Pottecher J, Roche AC, Degot T, et al. Increased extravascular lung water and plasma biomarkers of acute lung injury precede oxygenation impairment in primary graft dysfunction after lung transplantation. Transplantation, 2017, 101(1): 112-121.
25.	Tran-Dinh A, Augustin P, Dufour G, et al. Evaluation of cardiac index and extravascular lung water after single-lung transplantation using the transpulmonary thermodilution technique by the PiCCO2 device. J Cardiothorac Vasc Anesth, 2018, 32(4): 1731-1735.
26.	Bhattacharjee A, Pradhan D, Bhattacharyya P, et al. How useful is extravascular lung water measurement in managing lung injury in intensive care unit?. Indian J Crit Care Med, 2017, 21(8): 494-499.
27.	Nolan ME, Yadav H, Cawcutt KA, et al. Complication rates among peripherally inserted central venous catheters and centrally inserted central catheters in the medical intensive care unit. J Crit Care, 2016, 31(1): 238-242.
28.	Nusmeier A, van der Hoeven JG, Lemson J. Interpretation of the transpulmonary thermodilution curve in the presence of a left-to-right shunt. Intensive Care Med, 2011, 37(3): 550-551.

1. Cecconi M, De Backer D, Antonelli M, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med, 2014, 40(12): 1795-1815.
2. Sakka SG, Reinhart K, Meier-Hellmann A. Comparison of pulmonary artery and arterial thermodilution cardiac output in critically ill patients. Intensive Care Med, 1999, 25(8): 843-846.
3. Beurton A, Teboul JL, Monnet X. Transpulmonary thermodilution techniques in the haemodynamically unstable patient. Curr Opin Crit Care, 2019, 25(3): 273-279.
4. Monnet X, Teboul JL. Transpulmonary thermodilution: advantages and limits. Crit Care, 2017, 21(1): 147.
5. 李红. PICCO 在 ICU 危重患者的临床应用及护理进展. 医学信息, 2015, 28(19): 346-347.
6. Reuter DA, Huang C, Edrich T, et al. Cardiac output monitoring using indicator-dilution techniques: basics, limits, and perspectives. Anesth Analg, 2010, 110(3): 799-811.
7. Rath GP, Bithal PK, Toshniwal GR, et al. Saline flush test for bedside detection of misplaced subclavian vein catheter into ipsilateral internal jugular vein. Br J Anaesth, 2009, 102(4): 499-502.
8. Liu Y, Wei LQ, Li GQ, et al. Pulse pressure variation adjusted by respiratory changes in pleural pressure, rather than by tidal volume, reliably predicts fluid responsiveness in patients with acute respiratory distress syndrome. Crit Care Med, 2016, 44(2): 342-351.
9. Malbrain M, Van Regenmortel N, Saugel B, et al. Principles of fluid management and stewardship in septic shock: it is time to consider the four D's and the four phases of fluid therapy. Ann Intensive Care, 2018, 8(1): 66.
10. Tagami T, Ong MEH. Extravascular lung water measurements in acute respiratory distress syndrome: why, how, and when?. Curr Opin Crit Care, 2018, 24(3): 209-215.
11. Jozwiak M, Teboul JL, Monnet X. Extravascular lung water in critical care: recent advances and clinical applications. Ann Intensive Care, 2015, 5(1): 38.
12. Hofkens PJ, Verrijcken A, Merveille K, et al. Common pitfalls and tips and tricks to get the most out of your transpulmonary thermodilution device: results of a survey and state-of-the-art review. Anaesthesiol Intensive Ther, 2015, 47(2): 89-116.
13. Sakka SG, Ruhl CC, Pfeiffer UJ, et al. Assessment of cardiac preload and extravascular lung water by single transpulmonary thermodilution. Intensive Care Med, 2000, 26(2): 180-187.
14. Smit JM, Raadsen R, Blans MJ, et al. Bedside ultrasound to detect central venous catheter misplacement and associated iatrogenic complications: a systematic review and meta-analysis. Crit Care, 2018, 22(1): 65.
15. Bekele NA, Abebe WA, Shifa JZ. Misplaced subclavian central venous catheter. Pan Afr Med J, 2017, 27: 59.
16. Yu WQ, Zhang Y, Zhang SY, et al. Impact of misplaced subclavian vein catheter into jugular vein on transpulmonary thermodilution measurement variables. J Zhejiang Univ Sci B, 2016, 17(1): 60-66.
17. Verhoeff K, Mitchell JR. Cardiopulmonary physiology: why the heart and lungs are inextricably linked. Adv Physiol Educ, 2017, 41(3): 348-353.
18. Vieillard-Baron A, Matthay M, Teboul JL, et al. Experts’ opinion on management of hemodynamics in ARDS patients: focus on the effects of mechanical ventilation. Intensive Care Med, 2016, 42(5): 739-749.
19. Chen SL, Chen LF, Du ZS, et al. Influence of injection rates of calibrating standard solution on monitoring pulse indicator continuous cardiac output. Biomed Eng Online, 2018, 17(1): 34.
20. Wang H, Cui N, Su LX, et al. Prognostic value of extravascular lung water and its potential role in guiding fluid therapy in septic shock after initial resuscitation. J Crit Care, 2016, 33: 106-113.
21. 张灯亮, 何先弟, 刘杰, 等. PiCCO 监测下的目标导向集束化治疗脓毒性休克的疗效及相关血流动力学指标对预后的诊断价值. 中国急救医学, 2020, 40(6): 536-541.
22. Soussi S, Deniau B, Ferry A, et al. Low cardiac index and stroke volume on admission are associated with poor outcome in critically ill burn patients: a retrospective cohort study. Ann Intensive Care, 2016, 6(1): 87.
23. Stephan F, Mazeraud A, Laverdure F, et al. Evaluation of reperfusion pulmonary edema by extravascular lung water measurements after pulmonary endarterectomy. Crit Care Med, 2017, 45(4): e409-e417.
24. Pottecher J, Roche AC, Degot T, et al. Increased extravascular lung water and plasma biomarkers of acute lung injury precede oxygenation impairment in primary graft dysfunction after lung transplantation. Transplantation, 2017, 101(1): 112-121.
25. Tran-Dinh A, Augustin P, Dufour G, et al. Evaluation of cardiac index and extravascular lung water after single-lung transplantation using the transpulmonary thermodilution technique by the PiCCO2 device. J Cardiothorac Vasc Anesth, 2018, 32(4): 1731-1735.
26. Bhattacharjee A, Pradhan D, Bhattacharyya P, et al. How useful is extravascular lung water measurement in managing lung injury in intensive care unit?. Indian J Crit Care Med, 2017, 21(8): 494-499.
27. Nolan ME, Yadav H, Cawcutt KA, et al. Complication rates among peripherally inserted central venous catheters and centrally inserted central catheters in the medical intensive care unit. J Crit Care, 2016, 31(1): 238-242.
28. Nusmeier A, van der Hoeven JG, Lemson J. Interpretation of the transpulmonary thermodilution curve in the presence of a left-to-right shunt. Intensive Care Med, 2011, 37(3): 550-551.

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