Is ultrasound guidance sufficient?

Central venous catheter malpositioning despite ultrasound-guided placement

Abstract

Introduction: real-time ultrasound guidance has reduced the complications of central venous catheterization; however, catheter tip malpositioning persists and may be associated with device malfunction and thromboembolic events.

Case presentation: we present two cases of “U-shaped” malpositioning of central venous catheters placed under ultrasound guidance, one through the right subclavian and the other through the left internal jugular, which required immediate relocation after x-ray confirmation. Both patients recovered without complications.

Conclusion: recent literature shows residual malpositioning despite the use of ultrasound, indicating that immediate verification improves with the addition of a second bedside method, such as intracavitary electrocardiography, an agitated saline contrast study, or central venous pressure measurement. These cases illustrate the limitations of only using ultrasound and support the implementation of combined algorithms to reduce adverse events.