Correct Depth of Insertion of Right Internal Jugular Central Venous Catheters Based on External Landmarks: Avoiding the Right Atrium

Objective: Radiographically, a central venous catheter (CVC) tip should lie at the level of the right tracheobronchial angle. Precalculation of length of CVC insertion may avoid unnecessary catheter malposition. The purpose of this study was to assess the accuracy of a method of CVC positioning, based on external topographic landmarks.

Design: A prospective, randomized study.:

Setting: University-affiliated hospital, single institution.

Participants: Patients scheduled for surgery.

Interventions: Patients were allocated for insertion of the catheter through the right internal jugular vein to either a fixed, predetermined, 15-cm length (n = 50) or to a depth calculated topographically (n = 50) by drawing a line from the level of the thyroid notch to the sternal manubrium. The catheter was repositioned if its tip was situated >5 cm above the carina or >1 cm below it. The distance from the catheter tip to the carina was measured. The main study endpoint was the need for catheter repositioning.

Measurements and Main Results: Two percent of patients required repositioning in the topographic group compared with 78% in the 15-cm length group (p < 0.001). No patient in the topographic group and 10 patients (20%) in the 15-cm group had the catheter placed in the right atrium (p < 0.05). The mean distance from the CVC tip to the carina was 2.9 ± 1.4 cm above the carina in the topographic group and 1.9 ± 1.1 cm below the carina in the 15-cm length group (p < 0.001). No patient had a too proximally placed catheter. Insertion lengths in the topographic group ranged between 9 and 12.5 cm.

Conclusions: It is recommended to use the topographic approach in deciding CVC depth with right internal jugular CVC placement.

Key Words: central venous catheterization, central venous catheters, internal jugular vein, methods of positioning, topographic, complications, cardiac tamponade