European Journal of Pediatrics

, Volume 165, Issue 4, pp 264–266 | Cite as

The carina as a landmark for central venous catheter placement in small children

  • Knut Albrecht
  • Dirk Breitmeier
  • Bernhard Panning
  • Hans Dieter Tröger
  • Heike Nave
Original Paper

Abstract

Central venous devices are frequently used in children to monitor haemodynamic status, to administer fluids, medication, parenteral nutrition and for blood sampling. Life-threatening complications that may occur on insertion if the central venous catheter (CVC) is misplaced, are cardiac tamponade or a hydro-/haemopericardium. There is still controversy over the optimum catheter tip position in paediatric patients, whether to place the CVC tip in the superior vena cava, outside the pericardial boundaries or in the right atrium. However, the exact location of the pericardium cannot be seen on a normal chest x-ray. The carina is a radiographic marker for CVC placement, suggested on the basis of studies with conserved and fresh adult cadavers. In order to confirm this landmark for children, the present study was performed with 31 fresh cadavers of small children (mean age 12.5±3.4 months) that had been selected for autopsy in the Institute of Legal Medicine. Results clearly demonstrate that the carina was 0.5±0.04 cm above the pericardial duplication as it transversed the SVC. In no infant cadaver was the carina inferior to the pericardium. Thus, the results are analogous to those in adults and confirm that the carina is a simple anatomical-radiological landmark, superior to the pericardial reflection, that can be used to identify the placement of CVC even in newborn and small children.

Keywords

Central venous catheter Children Cardiac tamponade Parenteral nutrition Pericardium 

Abbreviations

CVC

Central venous catheter

SVC

Superior vena cava

SIDS

Sudden infant death syndrome

BL

Body length

References

  1. 1.
    Albrecht K, Nave H, Breitmeier D, Panning B, Tröger HD (2004) Applied anatomy of the superior vena cava - the carina as a landmark to guide central venous catheter placement. Brit J Anaesth 92:75-77PubMedCrossRefGoogle Scholar
  2. 2.
    Brown CA, Kent A (1956) Perforation of right ventricle by polyethylene catheter. South Med J 49:466-467PubMedGoogle Scholar
  3. 3.
    Collier PE, Goodman GB (1995) Cardiac tamponade caused by central venous catheter perforation of the heart: a preventable complication. J Am Coll Surg 181:459-463PubMedGoogle Scholar
  4. 4.
    Collier PE, Blocker SH, Graff DM, Doyle P (1998) Cardiac tamponade from central venous catheters. Am J Surg 176:212-214PubMedCrossRefGoogle Scholar
  5. 5.
    Connolly B, Mawson JB, MacDonald CE, Chait P, Mikailian H (2000) Fluoroscopic landmark for SVC-RA junction for central venous catheter placement in children. Pediatr Radiol 30:692-695PubMedCrossRefGoogle Scholar
  6. 6.
    Dollery CM, Sullivan ID, Bauraind O, Bull C, Milla PJ (1994) Thrombosis and embolism in long-term central venous access for parenteral nutrition. Lancet 344:1043–1045PubMedCrossRefGoogle Scholar
  7. 7.
    Flatley ME, Schapira RM (1993) Hydromediastinum and bilateral hydropneumothorax as delayed complications of central venous catheterization. Chest 103:1914–1916PubMedCrossRefGoogle Scholar
  8. 8.
    Fletcher SJ, Bodenham AR (2000) Safe placement of central venous catheters: where should the tip of the catheter lie? Br J Anaesth 85:188–191PubMedCrossRefGoogle Scholar
  9. 9.
    Hayden L, Steward GR, Johnson DC, Fisher MM (1981) Transthoracic right atrial cannulation for total parenteral nutrition-case report. Anaesth Intens Care 9:53–57Google Scholar
  10. 10.
    Hunt R, Hunter TB (1988) Cardiac tamponade and death from perforation of the right atrium by a central venous catheter. Am J Roentgenol 151:1250Google Scholar
  11. 11.
    Leibovitz E, Ashkenazi A, Levin S, Nissim F (1988) Fatal pericardial tamponade complicating total parenteral nutrition via a silastic central vein catheter. J Pediatr Gastroenterol Nutr 7:306–307PubMedCrossRefGoogle Scholar
  12. 12.
    Marcoux C, Fisher S, Wong D (1990) Central venous access devices in children. Pedriatr Nurs 16:123–133Google Scholar
  13. 13.
    Quiney NF (1994) Sudden death after central venous cannulation. Can J Anaesth 41:513–515PubMedCrossRefGoogle Scholar
  14. 14.
    Raad II, Khalil SM, Costerton JW, Lam C, Bodey GP (1994) The relationship between the thrombotic and infectious complications of central venous catheters. JAMA 271:1014–1016PubMedCrossRefGoogle Scholar
  15. 15.
    Rutherford JS, Merry AF, Occleshaw CJ (1994) Depth of central venous catheterization: an audit of practice in a cardiac surgical unit. Anaesth Intens Care 22:267–271Google Scholar
  16. 16.
    Schneider V, Maxeiner H (1983) Herzbeuteltamponade durch zentralen Venenkatheter. In: Barz J, Bösche J, Frohberg H, Joachim H, Käppner R, Mattern R (eds) Fortschritte der Rechtsmedizin – Festschrift für Georg Schmidt. Springer, Berlin, Heidelberg, New York, pp 116–122Google Scholar
  17. 17.
    Schuster M, Nave H, Piepenbrock S, Pabst R, Panning B (2000) The carina as a landmark in central venous catheter placement. Br J Anaesth 85:192–194PubMedCrossRefGoogle Scholar
  18. 18.
    Suarez-Penaranda JM, Rico-Boquete R, Munoz JI, Rodriguez-Nunez A, Martinez Soto MI, Rodriguez-Calvo M, Concheiro-Carro L (2000) Unexpected sudden death from coronary sinus thrombosis. An unusual complication of central venous catheterization. J Forensic Sci 45:920–922PubMedGoogle Scholar
  19. 19.
    Timsit JF, Farkas JC, Boyer JM, Martin JB, Misset B, Renaud B, Carlet J (1998) Central vein catheter-related thrombosis in intensive care patients: incidence, risk factors and relationship with catheter-related sepsis. Chest 114:207–213PubMedCrossRefGoogle Scholar
  20. 20.
    van Ditzhuyzen O, Ronayette D (1996) Cardiac tamponade after central venous catheterization in a newborn infant. Arch Pediatr 3:463–465PubMedCrossRefGoogle Scholar
  21. 21.
    Yoon SZ, Shin JH, Hahn S, Oh AY, Kim HS, Kim SD, Kim CS (2005) Usefulness of the carina as a radiographic landmark for central venous catheter placement in paediatric patients. Br J Anaesth 95:514–517PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  • Knut Albrecht
    • 1
  • Dirk Breitmeier
    • 1
  • Bernhard Panning
    • 2
  • Hans Dieter Tröger
    • 1
  • Heike Nave
    • 3
  1. 1.Institute of Legal MedicineHannover Medical SchoolHannoverGermany
  2. 2.Department of AnaesthesiologyHannover Medical SchoolHannoverGermany
  3. 3.Department of Functional and Applied AnatomyHannover Medical SchoolHannoverGermany

Personalised recommendations