title: Malposition of subclavian vein catheter inserted through indirect technique in a pediatric liver transplantation: a case report.
abstract: BACKGROUND
  Clinicians use either direct or indirect (Seldinger) techniques for internal juguler or subclavian vein catheterization. This report aims to point out that the success rate of the direct technique where the catheter is inserted directly through the cannula may be higher particularly in catheterization of pediatric cases.
  
  
  METHODS
  A 7.5-month-old female infant weighing 7200 gm was operated on for liver transplantation. The patient suffered jaundice at one month of age and was diagnosed with neonatal colestatic hepatitis. After routine monitoring, via indirect technique, central catheterization was attempted through internal jugular vein. However, the attempt failed. Therefore, again via indirect technique, catheterization was achieved through the right subclavian vein and fixed at 8 cm. After the operation started, fluid replacement and central venous pressure monitoring were performed with this catheter. Immediately after the operation, a control postero-anterior chest radiograph of the patient was obtained. This graph revealed that the tip of the catheter was fixed in the right internal jugular vein. Since the vital symptoms of the patient were not stable, the catheter was not removed and fluid replacement was performed via this technique. The catheter was removed on the postoperative 2(nd) day.
  
  
  CONCLUSIONS
  The J wire advanced via the indirect technique advances anatomically following the upper wall of subclavian vein. Because of the smaller vessel dimensions and sharper, more angulated routes the subclavian and internal jugular veins make in infants, the rigid J wire may advance in the cephalic direction. However, in the technique where the catheter (Cavafix ((R)) catheter) is inserted directly through the cannula, this probability is less since J wire is not used and the catheter employed is flexible. We concluded that especially in pediatric cases, employment of the technique where the catheter is inserted directly through the cannula would be more convenient in order to decrease the catheter malpositioning probability.
authors.affiliation: Department of Anesthesia and Reanimation, Gazi University Medical Faculty, Ankara, Turkey. dcoskun@gazi.edu.tr
authors.forename: Demet
authors.initials: D
authors.lastname: Coskun
authors.forename: Ahmet
authors.initials: A
authors.lastname: Mahli
authors.forename: Sema
authors.initials: S
authors.lastname: Oncul
authors.forename: Gizem
authors.initials: G
authors.lastname: Ilvan
authors.forename: Aydin
authors.initials: A
authors.lastname: Dalgic