a catheter malpositioned patient with pain and paresthesia

We report a 54-year-old woman with the history of end-stage renal disease (esrd) who was admitted to our hospital because of volume overload. due to long-term use of peripheral veins and arteriovenous fistula (avf) failure, central venous catheterization was the only choice for hemodialysis. she developed right upper extremiti’s pain and paresis during hemodialysis. a posteroanterior chest x-ray showed the catheter tip was accidently pushed from right internal jugular vein into right subclavian vein during hemodialysis by the dialysis center nurse. therefore, we believe that the physician should be aware of any changes in the catheter size after insertion. and a chest x-ray should ensure the catheter’s correct position in any patient who develops complications.