title: A better landmark for positioning a central venous catheter.
abstract: BACKGROUND
  Improper positioning of central venous catheters (CVCs) can lead to erosion through the superior vena cava (SVC) or right atrium (RA) and pericardial tamponade. It is widely recommended that the tip of CVCs be placed above the heart or the pericardial reflection. The purpose of this study was to identify an easily recognized landmark to allow identification of the proximal extent of the pericardial reflection on a routine chest radiograph (CXR).
  
  
  METHODS
  We analyzed the computerized tomograms of the chest from 97 adults to evaluate the relationship between the pericardial reflection, SVC, carina, and right mainstem bronchus. Correlations between demographic data and length of SVC or pericardial reflection were sought.
  
  
  RESULTS
  The mean length of the SVC was 6.5 cm. The pericardial reflection covered an average of 3.6 cm of the distal SVC. The carina was a mean of 1.3 cm below the mid-point of the SVC and 0.7 cm below the pericardial reflection. There was no significant correlation between SVC or pericardial length and either age, height, or weight.
  
  
  CONCLUSIONS
  The distal half of the SVC lies within the pericardial reflection, and the upper limit of the pericardial reflection is slightly above the level of the carina. These landmarks are useful for determining proper position of the tip of a CVC on CXR.
authors.affiliation: Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida 32610-0254, USA. caruso@anestl.anest.ufl.edu
authors.forename: Lawrence J
authors.initials: LJ
authors.lastname: Caruso
authors.forename: Nikolaus
authors.initials: N
authors.lastname: Gravenstein
authors.forename: A Joseph
authors.initials: AJ
authors.lastname: Layon
authors.forename: Keith
authors.initials: K
authors.lastname: Peters
authors.forename: Andrea
authors.initials: A
authors.lastname: Gabrielli
mesh_terms: D000328:Adult; D000367:Age Factors; D001835:Body Weight; D002305:Cardiac Tamponade / Q000209:etiology / Q000517:prevention & control; D002405:Catheterization, Central Venous / Q000009:adverse effects* / Q000379:methods*; D005260:Female; D006325:Heart Atria / Q000473:pathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D010496:Pericardium / Q000033:anatomy & histology* / Q000000981:diagnostic imaging; D013902:Radiography, Thoracic; D012016:Reference Values; D012737:Sex Factors; D014057:Tomography, X-Ray Computed; D014683:Vena Cava, Superior / Q000473:pathology