Central Catheter Tip Position Research Articles

Assessment of Central Catheter Tip Position in Neonates by Ultrasonography Versus X-ray

Assessment of Central Catheter Tip Position in Neonates by Ultrasonography Versus X-ray

A modified method for measuring the length of peripherally inserted central catheters to reduce the risk of malposition during catheter insertion.

Malposition may occur during peripherally inserted central catheter insertion. Accurately measuring the length of a peripherally inserted central catheter is crucial to preventing malposition, including "long peripherally inserted central catheter placement," in which the tip of a peripherally inserted central catheter is deeper than the target position. The traditional method of measuring peripherally inserted central catheter length involves measuring from the insertion site to the parasternal notch and down to the third or fourth intercostal space, which may result in overestimation because of the thickness of the pectoralis major and anterior chest wall. To avoid this overestimation, the authors developed and tested a modified method for reducing long peripherally inserted central catheter placement. This study employed a retrospective design. Chest X-rays were used to examine the peripherally inserted central catheter tip positions in 48 patients in the medical intensive care unit who had undergone peripherally inserted central catheter insertion. The traditional and modified measurement methods were used to measure the peripherally inserted central catheter length in 17 and 31 patients, respectively. Fisher's exact test was used to examine between-group differences in the incidence of different types of peripherally inserted central catheter malposition. The peripherally inserted central catheter tip position was near the target position in five patients (29.41%) in the traditional measurement group and 17 patients (54.84%) in the modified measurement group (p = 0.132), whereas long peripherally inserted central catheter placement occurred in six patients (35.29%) in the traditional measurement group and one patient (3.23%) in the modified measurement group (p = 0.006). However, the incidence of other types of peripherally inserted central catheter malposition did not differ significantly between the groups. The results of this study that the proposed modified measurement method may be able to reduce the incidence of long peripherally inserted central catheter placement among medical intensive care unit patients. The method must be further evaluated in prospective studies and studies with larger sample sizes in the future.

Electrocardiographic localization of peripherally inserted central catheter tip position in critically ill patients with advanced cancer: An application study.

BackgroundWe compared the methods of electrocardiogram (ECG) and X‐ray localization of the peripherally inserted central catheter (PICC) tip position, in order to find a more convenient, practical, and safe method.ObjectiveTo investigate the value of applying electrocardiographic localization of the PICC tip position in critically ill patients with advanced cancer in Hebei Province, China.MethodEnrolled 137 advanced cancers requiring PICC placement. The position of the catheter tip was localized with the bedside electrocardiogram in real time. Then, the localization was performed using a chest X‐ray (the gold standard). The accuracy of electrocardiographic location was checked.ResultsSpecific P waves were observed in 130 patients. No change in the P waves was observed for the remaining seven patients. The age of the latter group of patients was more advanced (87.29 [5.15] years), a significant difference to that of the 130 patients with specific P waves (71.58 [14.84] years) (t = −6.704, p < .001). Specific P waves not only involve ascendance in P waves but also ascendance in QRS waves.ConclusionsThe use of an ECG to localize the PICC tip in critically ill patients with advanced cancer may replace the unnecessary use of chest X‐rays. Specific P waves not only involve an increase in P waves but also an increase in QRS waves. If there is no change in the P wave, a chest X‐ray film must be obtained. In elderly patients, because there is a possibility of catheter tip malposition, a comprehensive evaluation should be performed before surgery.

Machine Learning for Detection of Correct Peripherally Inserted Central Catheter Tip Position from Radiology Reports in Infants.

In critically ill infants, the position of a peripherally inserted central catheter (PICC) must be confirmed frequently, as the tip may move from its original position and run the risk of hyperosmolar vascular damage or extravasation into surrounding spaces. Automated detection of PICC tip position holds great promise for alerting bedside clinicians to noncentral PICCs. This research seeks to use natural language processing (NLP) and supervised machine learning (ML) techniques to predict PICC tip position based primarily on text analysis of radiograph reports from infants with an upper extremity PICC. Radiographs, containing a PICC line in infants under 6 months of age, were manually classified into 12 anatomical locations based on the radiologist's textual report of the PICC line's tip. After categorization, we performed a 70/30 train/test split and benchmarked the performance of seven different (neural network, support vector machine, the naïve Bayes, decision tree, random forest, AdaBoost, and K-nearest neighbors) supervised ML algorithms. After optimization, we calculated accuracy, precision, and recall of each algorithm's ability to correctly categorize the stated location of the PICC tip. A total of 17,337 radiographs met criteria for inclusion and were labeled manually. Interrater agreement was 99.1%. Support vector machines and neural networks yielded accuracies as high as 98% in identifying PICC tips in central versus noncentral position (binary outcome) and accuracies as high as 95% when attempting to categorize the individual anatomical location (12-category outcome). Our study shows that ML classifiers can automatically extract the anatomical location of PICC tips from radiology reports. Two ML classifiers, support vector machine (SVM) and a neural network, obtained top accuracies in both binary and multiple category predictions. Implementing these algorithms in a neonatal intensive care unit as a clinical decision support system may help clinicians address PICC line position.

The accuracy and safety of using the electrocardiogram positioning technique in localizing the peripherally inserted central catheter tip position: A systematic review and meta-analysis.

AimWe performed a systematic review and meta‐analysis to examine the accuracy and safety of using the electrocardiogram (ECG) positioning technique to localize the peripherally inserted central catheter (PICC) tip position to provide objective evidence for its clinical application.MethodsWe searched the literature for randomized controlled trials evaluating the diagnostic analysis of using electrocardiograms to localize PICC tip positions in the MEDLINE, EMBASE, PubMed, Cochrane Central Register of Controlled Trials (CENTRAL) and PsycINFO databases. We used a risk ratio with accompanying 95% confidence interval (CI) to express estimates. Reviewer Manager (RevMan) 5.1.0 was used to complete all statistical analyses.ResultsThis systematic review identified 9 studies (N = 3,194 patients). Overall, the results of the meta‐analysis revealed that, for patients in whom the ECG positioning method was used compared with patients in whom the landmark positioning method was used, the RR for accurate catheter tip positioning was RR = 1.17, and the difference was statistically significant. The RR for the incidence of complications was RR = 0.28, and the difference was statistically significant.ConclusionsThe application of ECGs in PICC tip positioning can improve the accuracy of catheter tip positioning and reduce the incidence of related complications.

Occurrence and Risk Factors for Unplanned Catheter Removal in a PICU: Central Venous Catheters Versus Peripherally Inserted Central Venous Catheters.

We aimed to identify the occurrence and risk factors for unplanned catheter removal due to catheter-associated complications and the effects on catheter survival probability in a PICU. Retrospective, single-center, observational study of cases involving conventional central venous catheters or peripherally inserted central venous catheters. The PICU of a tertiary children's hospital. Consecutive PICU patients with central venous catheters between April 2016 and February 2019. None. We identified unplanned catheter removals that were related to central line-associated bloodstream infection, thrombosis, and mechanical complications. During the study period, 582 central venous catheters and 474 peripherally inserted central venous catheters were identified. The median durations of catheter placement were 4.0 days for central venous catheters and 13.0 days for peripherally inserted central venous catheters (p < 0.001), and unplanned catheter removals due to catheter-associated complications were in 52 (8.9%) central venous catheter cases and 132 (27.8%) peripherally inserted central venous catheter cases (p < 0.001) (15.0 and 16.0 per 1,000 catheter-days, respectively [p = 0.75]). Unplanned catheter removal was associated with a peripheral catheter tip position among both central venous catheters and peripherally inserted central venous catheters (p < 0.001 and p = 0.001), and it was associated with surgical patient status among peripherally inserted central venous catheters (p = 0.009). In contrast, the use of ultrasound-guided insertion was associated with a lower occurrence of unplanned catheter removal among peripherally inserted central venous catheters (p = 0.01). With regard to catheter survival probability, there was no significant difference between central venous catheters and peripherally inserted central venous catheters (p = 0.23). However, peripherally inserted central venous catheters had a lower occurrence of central line-associated bloodstream infection than central venous catheters (p = 0.03), whereas there was no significant difference in the rates of thrombosis (p = 0.29) and mechanical complications (p = 0.84) between central venous catheters and peripherally inserted central venous catheters. In a PICU, peripherally inserted central venous catheters had lower occurrence of central line-associated bloodstream infection than central venous catheters; however, similar catheter survival probabilities were observed between both catheters. A central catheter tip position for both catheters and ultrasound-guided insertion for peripherally inserted central venous catheters may help limit unplanned catheter removal due to catheter-associated complications.

A 1-Year Study on Association between Peripherally Inserted Central Catheter Tip Position and Complications in Neonates.

Aims:A peripherally inserted central catheter (PICC) is required in preterm neonates, especially those with low birth weight. However, PICC is associated with various complications resulting in increased morbidity and mortality. The objective of the study was to evaluate the association between PICC tip position and complications in neonates.Materials and Methods:One hundred neonates were recruited in a 1-year hospital-based, longitudinal, observational study. Radiographs were obtained to confirm the position of the catheter tip as central or noncentral in relation to vertebral level (T9–L5). The variables studied included site of insertion, duration of stay of PICC, time of removal, reason for removal, and associated complications. These were compared between the groups using SPSS version 20. Fisher's exact test was used to find the associations.Results:Most of the neonates were preterm (78%) and 81% were low birth weight. Catheter was placed in the right lower limb in most of the neonates (85%), and the catheter tip was central in position in 84% of neonates. The incidence of complications was observed in 29%. Noninfectious complications were common (26%) compared to infectious (3%). The most frequent PICC-induced complication was phlebitis (11%). Incidence of complications (P = 0.020), especially occlusion (P = 0.008), was significantly higher in neonates with noncentral catheter tip compared to the central tip.Conclusion:We observed a high incidence of PICC-induced complications in neonates, with phlebitis being most common. Further, the incidence of complications is influenced by noncentral tip position.

Ultrasound to Localize the Peripherally Inserted Central Catheter Tip Position in Newborn Infants.

This study aimed to evaluate the application of ultrasound for the localization of the tip position of peripherally inserted central catheters (PICCs) in newborn infants. This study was a retrospective analysis on ultrasonic localization for PICC placement conducted in our department over the past 2 years. Ultrasonic localization was performed immediately after PICC placement in all neonatal patients. Successful PICC placement was confirmed if the PICC tip position was located at the inferior/superior cavoatrial junction. Chest X-ray localization was performed on 32 infants immediately after ultrasound examination to compare the accuracy of ultrasound localization. Of the 186 patients, 174 (93.5%) had successful PICC placement on the first attempt. In 11 (5.9%) patients, the catheter tip was placed beyond the ideal location as follows: too deep (in the right atrium) in 4 patients, too shallow in 4 patients, and malpositioned in 3 patients. Both the sensitivity and the specificity of ultrasound for identifying PICC tip localization were 100%. Complications occurred in 2.7% of this group of patients. Ultrasonic localization of the PICC tip position is a timely, accurate, and reliable method and can identify the catheter tip with high accuracy. This method could be widely applied in neonatal wards.

Improved visualization of peripherally inserted central catheters on chest radiographs of neonates using fractional multiscale image processing

BackgroundPeripherally inserted central catheters (PICCs) provide secure intravenous access for the delivery of life-sustaining medications and nutrition. They are commonly used in pediatrics. Confirmation of correct central catheter tip position is crucial. Verification is usually done by a radiograph. The aim of this study is to evaluate the ability of Fractional Multiscale image Processing (FMP) to detect PICC tips on the digital chest radiographs of neonates.MethodsA total of 94 radiographs of 47 patients were included in the study. 29 patients were male, 18 were female. The mean age of all examined children was 9.2 days (range 0–99 days). In total, six readers (two radiologists, two residents in radiology, one last year medical student, one neonatologist) evaluated 94 unprocessed and catheter-enhanced radiographs using a 5-point Likert scale (1 = poor catheter tip visualization, 5 = excellent catheter tip visualization). Additionally, the two radiologists evaluated the diagnostic confidence for chest pathologies using a 5-point Likert scale (1 = poor diagnostic confidence, 5 = excellent diagnostic confidence). Radiographs were evaluated on a dedicated workstation.ResultsIn all cases, the catheter-enhanced radiograph rated higher than (n = 471), or equal (n = 93) to, the unprocessed radiograph when visualizing catheter tips. 87% of the catheter-enhanced radiographs obtained a rating of 4 or higher, while only 42% of unprocessed radiographs received 4 or more points. Regarding diagnostic confidence for chest pathologies one radiologist rated two catheter-enhanced radiographs higher than the unprocessed radiographs, while all other 186 evaluations rated the catheter-enhanced radiographs equal to (n = 78) or lower than (n = 108) the unprocessed radiographs. Only 60% of the catheter-enhanced radiographs yielded a diagnostic confidence of 4 or higher, while 90% of the unprocessed images received 4 or more points.ConclusionCatheter-enhanced digital chest radiographs demonstrate improved visualization of low contrast PICC tips in neonates compared to unprocessed radiographs. Furthermore, they enable detection of accompanying chest pathologies. However, definitive diagnosis of chest pathologies should be made on unprocessed radiographs.

Peripherally Inserted Central Catheter Tip Position: A Novel Empirical-Ultrasonographical Index in a Modern Surgical Oncology Department

The correct positioning of ultrasound-guided, peripherally inserted central catheters (UGPICCs) is essential to avoid multiple complications. We describe for the first time a retrospective study to evaluate a novel and easy transabdominal ultrasound-guided approach, so-called "Marano index," to place the UGPICCs tip correctly, making oncological surgeons able to obtain a high successful initial placement rate without postinsertion chest radiography. We examined the placement of UGPICCs applying, in 53 patients, the "Marano index." The tip catheter location was controlled by postprocedural chest radiography. Sensitivity, positive predictive value, and accuracy of index application also were calculated and compared with radiographic findings. The ultrasonographic-guided insertion was successful in all patients (100%). The identification of catheter inside the inferior vena cava was registered in 50 patients (94.3%), and in all cases it was clear the precise catheter placement, after Marano index application, with the real tip position and the concordance between postprocedural radiography in 100% of cases. The overall accuracy of this novel empirical-ultrasonographical index was 94%, with positive predictive value of 94% and sensitivity of 100%. This technique, once validated in a larger cohort, would allow the insertion of UGPICC without radiologic confirmation in selected patients with an adequate ultrasound body habitus. This would avoid unneeded radiation exposure from chest X-rays and would potentially save cost and time. This strategy provides only minimal deviation from the current practice and it is hence technically easy to learn and perform accurately with basic training by digestive oncological surgeons.

Impact of phase of respiration on central venous catheter tip position.

To determine the impact of the phase of respiration on CVC tip position using cross-sectional imaging. We retrospectively analyzed the CT scans of 24 consecutive patients (eight men and 16 women, mean age 56.3 years, range 18-79) who underwent a CT scan protocol that includes both imaging of the thorax in inspiration and expiration. Only patients with a central venous catheter and absence of any substantial pulmonary pathology that might affect lung volumes were included. Measurements of the catheter tip location and central venous structures were obtained from inspiratory and expiratory phase images in each patient and compared using the paired t test. The length of the SVC and superior mediastinum were significantly longer during inspiration compared to expiration (9 mm and 7 mm respectively, P<0.001 for both). The distance between the superior and inferior cavo-atrial junction did not change significantly with respiration. The catheter tip location moved on average 9 mm (range 0-25 mm) cephalad during inspiration compared to expiration (P=0.001) in relation to the superior cavoatrial junction. The amount of catheter tip movement correlated significantly with the degree of diaphragmatic excursion with respiration (R=0.58). During inspiration, the cavo-atrial junction was on average 11 mm inferior to the right cardiomediastinal angle observed on radiography, but was nearly identical during expiration (R=0.78, P<0.001). The central catheter tip position varied significantly with respiratory motion, with a mean excursion of 9 mm. The right cardiomediastinal border demonstrated a strong correlation with the actual location of the superior cavo-atrial junction in expiration, but not in inspiration.

Defining peripherally inserted central catheter tip position and an evaluation of insertions in one unit

Peripherally inserted central catheters are increasingly used to provide access to the central venous circulation. They are commonly positioned 'blind' using a variety of anthropometric techniques and operator experience to direct insertion length. Malposition rates are poorly defined because of differing insertion techniques, difficulties defining anatomical tip position on chest radiographs, controversy over what constitutes an adequate catheter position and possible differences between patient groups. We have developed a reproducible method to define catheter positions on chest radiograph and have applied this in a retrospective analysis of 256 ICU and 243 non-ICU catheter insertions over a 6-month period. Two different definitions were used for adequate position. 'Blind' positioning of peripherally inserted central catheters was associated with a definition-dependent malposition rate of 42-76%. Malposition rates were significantly higher in ICU patients. Emerging technologies may assist in reducing these high rates.

Peripherally inserted central catheter tip position and risk of associated complications in neonates

To characterize the relationship between peripherally inserted central catheters (PICC) tip positions and associated complications in neonates. Catheter tip position for 319 infants was classified into superior vena cava (SVC, n=131), inferior vena cava (IVC, n=72), brachiocephalic (BC, n=59), midclavicular (MC, n=49) or iliac. Duration of catheter stay and complication profile was compared between central (SVC/IVC) vs non-central PICC, and between SVC vs IVC, SVC vs BC and SVC vs MC. Kaplan-Meier survival analysis and regression models were used. Overall length of catheter stay was similar between central and non-central group. Non-central catheters (n=116) had higher complication rates (47 vs 29%; P=0.001), non-elective removals (45 vs 27%; P=0.002) and shorter time to complication (6.2 vs 11.4 days; P=0.043). This difference was primarily due to the complications encountered in MC group, which had the highest rate of infiltration (P<0.001) and mechanical complications while outcomes were similar among other subgroups. Interestingly, catheter survival probability was similar in all groups for first 4 days. Rate and types of blood stream infections were not related to catheter tip position. Non-central PICCs are associated with higher rates of infiltration and mechanical complications when the tip is in MC region. BC catheters may have comparable outcomes to SVC in neonates. A careful risk-benefit analysis is warranted when MC catheters are used in neonates.

Ultrasound-guided umbilical catheter insertion in neonates

Umbilical catheter placement is a routine neonatal emergency procedure that has large variability in technical methods. Commonly used methods are unable to accurately estimate insertion lengths, and X-rays cannot always identify malpositioned catheters. In clinical practice, the placement of umbilical lines takes time away from nursing during a critical transition period. Ultrasound is a safe and commonly used tool in the nursery for clinical management of sick neonates and has been shown to readily identify central catheter tip position. In this study, we sought to determine a more time-efficient and accurate means of umbilical catheter placement using bedside ultrasound. This is a prospective, randomized, pilot trial of infants of any age or weight admitted to the neonatal intensive care unit who required umbilical catheter placement. Infants were excluded if they had congenital heart disease, abdominal wall defects or had a single umbilical artery. Catheters were placed using either the conventional method, with blinded evaluation of the catheters using ultrasound, or with ultrasound guidance, with input pertaining to catheter tip location. The number of X-rays required to confirm proper positioning, completion time points throughout the procedure and manipulations of the lines were recorded for both groups. Ultrasound use decreased the time of line placement with an average saving of 64 min, as well as decreased the number of manipulations required and X-rays taken to place the catheters. The average X-ray time from request to viewing per X-ray was 40 min for all subjects. Ultrasound-guided umbilical catheter placement is a faster method to place catheters requiring fewer manipulations and X-rays when compared with conventional catheter placement.

The carina as a landmark for evaluation of adequate central catheter tip position with computerized tomography

The carina as a landmark for evaluation of adequate central catheter tip position with computerized tomography

Change in Peripherally Inserted Central Catheter Tip Position with Abduction and Adduction of the Upper Extremity

This study examines whether the tip of peripherally inserted central catheters (PICCs) moves significantly with changes in arm position from abduction to adduction. The catheters were inserted in the brachial or basilic veins under ultrasonographic guidance with the upper extremity in a 90 degrees abducted position. A flexible, radiopaque ruler was then placed on the anterior chest and digital images were obtained with the arm abducted and adducted in a similar phase of quiet respiration. Catheter tip movement was measured with use of the radiopaque ruler and fixed, bony anatomic landmarks. Sixty-one consecutive PICCs were placed and evaluated during the study period (eight patients were excluded). Thirty-three catheters were placed from the right arm and 20 from the left. Overall, 43 moved caudally, seven moved cephalad, and three did not move with movement of the arm from abduction to adduction. Of those that moved caudal, the mean distance of movement was 21 mm (range, 2-53 mm). Right arm PICCs tended to move more than left arm PICCs, but this did not attain significance (P = .29). There is a tendency for the PICC tip to move in a caudal direction with the change in arm position from abduction to adduction; 58% of PICCs moved 20 mm or more. This change in position should be considered during final catheter tip positioning.