of postprocedural chest radiography. They cite a study by Gladwin and associates [3], who reported a high (14%) incidence of axillary or right atrial vein malposition during jugular vein cannulation even after uncomplicated insertion procedures. Schummer and associates also question the value of electrocardiographic guidance in this situation, and recommend performing chest radiography ‘in case of doubt’. We agree with this and indeed have counselled this in our review [2]. However, we are un- sure of exactly how relevant the study by Gladwin et al. is to the ICU situation. All patients in this study had malignancies, and CVCs were used for administration of chemotherapy. Mechanical ventilation was an exclusion criterion, and thus no ICU patients were included in the study. No in- formation is available regarding previous CVC insertion except the statement that “any individual undergoing more than one CVC placement was considered a separate patient on each occasion”. Both prior CVC insertion at the same site and administra- tion of chemotherapeutic agents are associ- ated with a higher risk for (subclinical) thrombosis, and therefore with increased risk of malposition during subsequent in- sertion procedures. In contrast to the situation in oncology outpatients (in whom postprocedural radi- ography is likely to be the only assessment of correct catheter position for some time), chest radiography in ICU patients is usual- ly performed every day on a routine basis. Thus the catheter position is likely to be checked every day and can be repositioned if this is deemed necessary. In this situation the value of ‘additional’ radiographs made after uncomplicated and easy insertion pro- cedures, solely to assess catheter position, is more doubtful. Moreover, of the nine patients having an ‘unexpected malposition’ in the study by Gladwin et al. [4] the CVC tip was actually located high in the right atrium in six. As explained in our review, in our opinion, this should not be regarded as malposition unless the tip position is per- pendicular to the atrial wall, or located in a small vessel. This then leaves three pa- tients (5%) with malposition in the axillary vein. In our own experience and in a num- ber of studies dealing with the utility of chest radiography after CVC insertion, the incidence of this particular malposition may be significantly lower in ICU patients. Moreover, the risk of adverse events relat- ed to CVC placement in an axillary vein is higher if highly reactive agents (such as chemotherapy) are administered via the line. Therefore we remain unconvinced that additional chest radiographs must al- ways be performed after (clinically uncom- plicated) insertion procedures in the ICU. Naturally this does not apply to situations in which there is some doubt, i.e. after dif- ficult insertion procedures; in these cases radiography should be performed before the catheter is used. References 1. Schummer W, Schummer C (2002) Checking CVC position after insertion: comment on “central venous catheter use. I. Mechanical complications,” by Polderman and Girbes. Intensive Care Med (in press) http://dx.doi.org/ 10.1007/s00134-002-1294-6 2. Polderman KH, Girbes ARJ (2002) Central venous catheter use. I. Mechani- cal complications. Intensive Care Med 28:1–17 3. Polderman KH, Girbes ARJ (2002) Central venous catheter use. II. Infec- tious complications. Intensive Care Med 28:18–28 4. Gladwin MT, Slonim A, Landucci DL, Gutierrez DC, Cunnion RE (1999) Cannulation of the internal jugular vein: is postprocedural chest radiography always necessary? Crit Care Med 27:1819–1823 K.H. Polderman ( ✉ ) · A.R.J. Girbes Surgical ICU, University Hospital Vrije Universiteit, P.O. Box 7057, NL-1007 MB Amsterdam, The Netherlands e-mail: k.polderman@tip.nl Intensive Care Med (2002) 28:807 DOI 10.1007/s00134-002-1295-5 CORRESPONDENCE K. H. Polderman A. R. J. Girbes “Checking CVC position after insertion”: comments on the letter to the editor by Schummer and Schummer Received: 13 February 2002 Accepted: 8 March 2002 Published online: 24 April 2002 © Springer-Verlag 2002 Sir: In their letter Schummer and Schummer [1] raise three relevant points which they feel are important in preventing mechani- cal complications in the use of central ve- nous catheters (CVCs). The first is that (venous) blood should be aspirated easily from the CVC to verify intravenous catheter position. We agree with this addendum in regard to the inser- tion procedure itself; easy return of venous blood immediately following insertion indicates a high probability of correct posi- tion. However, this is not necessarily the case later in the clinical course. As ex- plained in our review [2], aspiration of blood may be prevented by (intermittent) blockage of the catheter lumen by a throm- bus adhering to the catheter. Thus the in- ability to aspirate blood per se does not mean that the position of the catheter is in- correct, and in fact infusion of fluids re- mains possible in this situation. In addi- tion, frequent aspiration of blood to assess catheter position may increase the risk of infection, which is linked to the frequency of catheter manipulations [3]. Therefore we do not recommend this unless the posi- tion of the catheter has been changed. The second and third points raised by Schummer et al. [1] touch upon the issue