The value of real-time ultrasound-guidance for definite placement of a right supraclavicular subclavian central venous catheter

Central venous catheters (CVC) are widely used in critically ill patients and in those undergoing major surgery. Significant adverse events, such as pneumothorax and hemothorax, can be caused by needle insertion during CVC insertion. CVC misplacement is less often described, yet equally important, as it can lead to deleterious complications. Here, we describe a case in which misplacement of a guidewire following infraclavicular puncture of the right axillary vein was detected by continuous ultrasound employing the right supraclavicular fossa view. Utilizing this ultrasound view, the insertion approach to the vessel was changed and correct CVC placement could be achieved. While ultrasound guidance is widely accepted for vessel puncture, this case demonstrates the value of continuous ultrasound guidance for the entire process of CVC insertion: vessel puncture, correct guidewire advancement, catheter placement, and exclusion of complications such as pneumothorax. It also shows that there should be a high index of suspicion for guidewire misplacement, even after successful venipuncture. In conclusion, ultrasound protocols covering the complete CVC insertion process should be implemented into current clinical practice.