The optimal position of the central venous catheter

Correct positioning of the central venous catheter in close proximity to the heart is a prerequisite for therapeutic success with a CVC. For most applications, placement of the catheter tip in the superior vena cava approximately 2 cm before the opening into the right atrium is seen as ideal.

Injuries to the venous wall cannot be ruled out with central venous catheters, particularly when the catheter is not correctly positioned in the vena cava. Therefore correct positioning of the catheter is of extreme importance.

• The catheter tip is not in the superior or inferior vena cava. This criterion does not apply to central venous catheters functioning as midline catheters (advanced into the subclavian vein).
• The catheter forms a loop in a vessel in close proximity to the heart (for example in the vena cava or in the atrium).
• The catheter tip is advanced too far into the heart so that the distal end of the catheter is positioned in the atrium, which may cause arrhythmia, damage to the right heart valve or cardiac tamponade.
• The catheter tip is badly positioned along the venous wall so that infusion and aspiration are not possible.

As this listing illustrates, correct positioning of the catheter is of critical importance for the success of any clinical therapy using a CVC. Incorrect placement can even have life threatening consequences for the patient.

(Fletcher / Bodenham,

However, there is general agreement that for a therapy over several days the catheter tip must be positioned outside of the right atrium in order to avoid damaging the heart (Fletcher / Bodenham, Food and Drug Administration).

If the access occurs via the superior vena cava, the catheter tip should be positioned approximately 2 cm before the opening into the right atrium. (Table below, Position A and Fletcher / Bodenham, Andropoulos, et al.).

If the catheter is advanced via the inferior vena cava (an approach frequently used in pediatric practice), the catheter tip should be positioned in the inferior vena cava at the height of the diaphragm or above (illustration below, Position B and Lynch, et al.).