Central Venous Catheter Placement Research Articles

Using Agitated Saline and Point-of-Care Ultrasound to Confirm Central Venous Catheter Placement: A Quality Improvement Project by Advanced Practice Providers

Central lines placed in the internal jugular or subclavian vein are common among critically ill patients. A chest x-ray serves as the confirmation method in many institutions. However, ultrasound with agitated saline has been proven an effective, faster, and safer alternative. Visualizing microbubbles in the right atrium within 2 seconds can confirm correct placement. This quality improvement project describes the training and competency evaluation of advanced practice providers in using agitated saline with point-of-care ultrasound to confirm central venous catheter placement. Sharing our experience and data may encourage others to implement similar quality improvement efforts.

#2192 Aging dialysis population and late referral: two factors influencing the choice of vascular access

Abstract Background and Aims The decision on the type of vascular access for hemodialysis is based on several factors including the timing of renal replacement therapy initiation and certain patients’ clinical and demographic features. We hypothesized that the increasing age of patients on hemodialysis and the issue of "late referral" can be relevant in this context and favor the use of central venous catheter (CVC) over arteriovenous fistula (AVF), with a surge in catheter-related complications. Method We carried out a retrospective observational study of vascular access procedures (AVF creation and long-term CVCs placement) performed at the Nephrology Unit of the “Fondazione Policlinico Universitario Agostino Gemelli” between January 2020 and December 2023. Results A total of 415 procedures for AVF creation (median age 63.5, IQR 55.5 - 71.5 years), of which 59 (14,2%) in “late referral” patients (median age 61, IQR 47.5 - 72.5 years), were performed. During the same period, 343 CVCs were placed, of which 151 (44%) in patients with planned admission as previously evaluated by a nephrologist (median age 69, IQR 60 - 79 years). The remaining 192 CVC placements (56%) involved patients after an emergency admission (median age 69, IQR 57 - 80 years). In 56 (29%) of these patients an AVF was created concurrently or within 60 days from the emergency procedure. Such patients were significantly younger (median age 66, IQR 57 - 73 years) than those who underwent a CVC placement after a planned admission (p=0.01) or others with emergency admission (p=0.03). In a multivariate analysis (logistic regression) the use of CVC over AVF was significantly and independently correlated with both late referral and age. Conclusion These data suggest that the increasing use of CVCs in hemodialysis may be due to the age of incident patients and remark the importance of early evaluation in order to choose the most appropriate vascular access.

Static Ultrasonographic Assessment for Central Venous Catheterization Reduces Catheter Dysfunction in the Emergency Department

Objective: This study aimed to investigate the effect of a static ultrasonographic (US) examination of the central venous structures before central venous catheterization (CVC) and the success of the procedure. Materials and Methods: In this prospective study, patients who underwent CVC, in an emergency department (ED), were divided into two groups: patients who underwent CVC using the anatomical landmark technique (n = 34) and patients who underwent CVC using a static US examination (n = 33). The procedure times, success rates, and number of catheters used were compared. Results: A total of 67 patients who underwent CVC were included in the study. Compared with the anatomical landmark technique, the static US examination had a higher procedural success rate ( P = .001), fewer total interventions ( P = .001), and fewer postprocedural catheter dysfunctions ( P = .048). While there was no difference in the duration of the CVC between groups ( P = .222), the total time spent was longer using a static US examination ( P = .022). Conclusion: The static US examination was a practical, easy-to-apply method that could be used for CVC placement in an ED. This study demonstrated sonography had a high success rate in CVC procedures and contributed to a reduction in the number of interventions and catheters used.

Critical care outcomes in decompensated cirrhosis: a United States national inpatient sample cross-sectional study

BackgroundPrior assessments of critical care outcomes in patients with cirrhosis have shown conflicting results. We aimed to provide nationwide generalizable results of critical care outcomes in patients with decompensated cirrhosis.MethodsThis is a retrospective study using the National Inpatient Sample from 2016 to 2019. Adults with cirrhosis who required respiratory intubation, central venous catheter placement or both (n = 12,945) with principal diagnoses including: esophageal variceal hemorrhage (EVH, 24%), hepatic encephalopathy (58%), hepatorenal syndrome (HRS, 14%) or spontaneous bacterial peritonitis (4%) were included. A comparison cohort of patients without cirrhosis requiring intubation or central line placement for any principal diagnosis was included.ResultsThose with cirrhosis were younger (mean 58 vs. 63 years, p < 0.001) and more likely to be male (62% vs. 54%, p < 0.001). In-hospital mortality was higher in the cirrhosis cohort (33.1% vs. 26.6%, p < 0.001) and ranged from 26.7% in EVH to 50.6% HRS. Mortality when renal replacement therapy was utilized (n = 1580, 12.2%) was 46.5% in the cirrhosis cohort, compared to 32.3% in other hospitalizations (p < 0.001), and was lowest in EVH (25.7%) and highest in HRS (51.5%). Mortality when cardiopulmonary resuscitation was used was increased in the cirrhosis cohort (88.0% vs. 72.1%, p < 0.001) and highest in HRS (95.7%).ConclusionsOne-third of patients with cirrhosis requiring critical care did not survive to discharge in this U.S. nationwide assessment. While outcomes were worse than in patients without cirrhosis, the results do suggest better outcomes compared to previous studies.

Wireless handheld ultrasound for internal jugular vein assessment in pediatric patients.

Rapid evolution of ultrasound technology has allowed widespread use of handheld ultrasound devices (HHUDs) for many possible applications. Along with the adult population, the use of HHUDs for Point of Care Ultrasound (POCUS) in pediatric medicine has been increasing over the last few years. However, pediatric-specific literature is still scarce on mobile vascular ultrasound. To evaluate diagnostic capabilities of Vscan Air™ in comparison with high-end ultrasound for the assessment of the internal jugular vein in children and adolescents. 42 Internal Jugular Veins (IJVs) of 21 pediatric patients were scanned by an experienced examiner using a WLAN-supported handheld ultrasound device (Vscan Air™) and high-end cart-based ultrasound (LOGIQ E9) as reference. B-Mode and Color-coded Doppler (CCDS) were performed and compared. Image quality was assessed using a score of 0 to 5 and statistically analyzed. Results were interpreted independently by two readers in consensus. 21 patients (2-17 years; mean 11,00±4,5 years; female n = 11, male n = 10) were examined. The rating score never dropped below 3 for both devices. The median score evaluation of B-Mode and CCDS for the high-end device was 5.00, of Vscan Air™ 5.00 for B-Mode and 4.00 for CCDS. A significant difference was shown between the two devices in the evaluation of CCDS. Vscan Air™ ultrasound device allows sufficient assessability of the IJV in pediatric patients, opening up new possibilities for fast and mobile POCUS of cervical veins and potential guidance of central venous catheter placement.

Adverse Events from Fluoroscopic versus Portable Placement of Peripherally Inserted Central Catheters and Central Venous Catheters in Pediatric Patients

PurposeTo evaluate the outcomes of fluoroscopic versus portable placement of peripherally inserted central catheters (PICCs) and central venous catheters (CVCs) in pediatric patients. Materials and MethodsThis is a single-center, retrospective review of 346 upper-extremity PICCs (286 fluoroscopic and 60 portable; mean age, 9.83 years [SD ± 5.58]; 49.1% female) and 138 tunneled femoral CVCs (56 fluoroscopic and 82 portable; mean age, 0.23 years [SD ± 0.36]; 57.0% female). Portable placements used mobile plain-film radiography. All lines were placed by board-certified interventional radiologists. ResultsFluoroscopic PICC placements had a lower procedure time (43.9 vs 57.9 minutes; P < .001), radiation dosage (342 vs 590 mGy·cm2; P < .001), incidence of technical failure (0% vs 3.3%; P = .029), and incidence of catheter malfunction (1.7% vs 12.1%; P < .001) compared with portable PICC placements. Fluoroscopic CVC had a lower procedure time (42.6 vs 54.8 minutes; P < .001) and radiation dosage (63.8 vs 405 mGy·cm2; P < .001) compared with portable CVC placements. No technical failures were found in either CVC groups and the difference was nonsignificant for catheter malfunction (0% vs 7.3%; P = .081). Fluoroscopic placements of PICCs and CVCs had a lower incidence rate of central line–associated bloodstream infection compared with portable placements (0.71 vs 2.22 cases per 1,000 line-days; P = .046). Overall, fluoroscopic placements of PICCs and CVCs had fewer adverse events compared with portable placements (3.2% vs 14.8%; P < .001). Portable procedure was the only significant factor associated with adverse events (odds ratio, 33.77; 95% CI, 4.56–757.01). ConclusionsFluoroscopic placements of PICCs and CVCs are associated with lower procedure time, radiation dose, and risk of adverse events compared with portable placements in pediatric patients.

Practices to prevent central line-associated bloodstream infection: A 2021 survey of infection preventionists in US hospitals.

To determine prevalence of technical and behavioral interventions aimed at preventing central line-associated bloodstream infection (CLABSI) following the COVID19 pandemic. Cross-sectional survey. US acute care hospitals. Infection preventionists at participating hospitals. Surveys were sent to infection preventionists from a national random sample of 881 US acute care hospitals. Questions covered use of technical interventions to prevent CLABSI (eg, alcohol-containing chlorhexidine gluconate [CHG] for skin antisepsis, use of coated catheters), socio-adaptive interventions (eg, feedback of CLABSI rates, use of appropriateness criteria), and leadership support for CLABSI prevention. Survey response rate was 47% (415/881). Technical interventions such as maximal sterile barriers (99%) or CHG-impregnated dressings (92%) were highly prevalent, but routine use of CHG bathing was less common (68% indicated regular use in intensive care unit [ICU] vs 18% in non-ICU settings). Although 97% of respondents indicated use of systems to monitor CLABSI, feedback to providers on CLABSI events was reported by 89%. Only 53% of respondents indicated regular use of tools to determine appropriateness of central venous catheters (CVC). Three-quarters of respondents indicated their hospital assessed CVC necessity daily, but only 23% reported strategies to reduce routine blood cultures. CLABSI prevention was extremely important to hospital leadership at 82% of responding hospitals. Most US hospitals continue to use evidence-based methods to prevent CLABSI as recommended by leading organizations. Opportunities to focus on socio-adaptive interventions such as feedback of infection rates, use of appropriateness criteria for CVC placement, and improving the "culture of pan-culturing" remain.

Most procedures performed in the intensive care unit are invasive: tracheal intubation, tracheostomy, central catheterization, chest tubes and others. However, they are not without complications that can be life-threatening. The aim of this prospective epidemiological study is to assess the incidence of complications arising from invasive procedures performed in the ICU, and to analyze certain risk factors that expose patients

Most procedures performed in the intensive care unit are invasive: tracheal intubation, tracheostomy, central catheterization, chest tubes and others. However, they are not without complications that can be life-threatening. The aim of this prospective epidemiological study is to assess the incidence of complications arising from invasive procedures performed in the ICU, and to analyze certain risk factors that expose patients to these complications. This was a prospective study of 453 invasive procedures performed in the various intensive care units of Casablanca University Hospital, over a period of 18 months, using 4 data sheets. In our series, central venous catheters accounted for 66% of invasive procedures. The average age of our patients was 40 years, and 67% were male. The main complications associated with the placement of central venous catheters are: Hematoma (16%); pneumothorax (3%), aberrant trajectory (4%) and thrombosis (3%). The incidence of hematoma is 20% when the procedure is performed on-call, and 38.3% when the operator has more than 2 years’ experience. The second most frequently performed invasive procedure is tracheostomy, with a percentage of 16%, which most frequently cited complications are as follows: bleeding (12%), pneumothorax (8%), and subcutaneous emphysema (9%). Statistical analysis showed that there was no correlation between the occurrence of complications and the risk factors studied. Other complications accounted for less than 10%. The outcome of intensive care patients has improved considerably, thanks to the protocols proposed by the various hospitals. Reducing complications is an important objective, in which the importance of learning the procedure and the experience of the operator should figure prominently.

Central venous catheters do not increase the hemorrhagic risk in acute promyelocytic leukemia patients during induction therapy.

In acute promyelocytic leukemia (APL), hemorrhage, particularly intracranial hemorrhage, is the most common cause of early death. A central venous catheter (CVC) may provide a greater guarantee of safety and comfort to APL patients. However, CVCs have seldom been attempted in APL patients during induction therapy because of concerns about increasing the risk of hemorrhagic complications after this invasive procedure. To evaluate the hemorrhagic risk after CVC placement in APL patients during induction therapy, we retrospectively analyzed 95 newly diagnosed patients with APL from January 2010 to December 2022. Among these patients, 39 patients in the CVC group and 56 patients in the non-CVC group were included. Laboratory and clinical parameters of the two groups were collected and compared. There were no significant differences in median platelet, fibrinogen (Fbg), D-dimer, prothrombin time (PT), white blood count (WBC) and hemoglobin (Hb) between the CVC and non-CVC groups on the first day of the visit (day 0) and the following days (day 4, day 7, day 11, day 14, day 18 and day 21) (p = 0.382, p = 0.805, p = 0.456, p = 0.902, p = 0.901 and p = 0.097, respectively). The consumption of transfused platelets and Fbg was not significantly different between the CVC group and non-CVC group (5.0 vs. 4.5 units, p = 0.34, and 6.8 vs. 6.0, p = 0.36, respectively). The last day of platelet and Fbg transfusion was also not significantly different (21 vs. 19, p = 0.238 and 7.5 vs. 8.5, p = 0.684, respectively). The incidences of total hemorrhagic events and hemorrhagic death were lower in the CVC group than in the non-CVC group (17.9% vs. 37.5%, p = 0.04 and 0% vs. 16.1%, p = 0.01, respectively). The 30-day survival rate was not significantly different (92.3% vs. 82.1%, respectively, p = 0.145) for the CVC group compared with the non-CVC group. Our study suggested that CVCs did not increase the hemorrhagic risk in APL patients during induction therapy and that a CVC should be considered in this type of clinical situation.

Validating the anatomical landmark technique for bedside tunneled central venous catheter placement in the medical intensive care unit.

A non-tunneled dialysis catheter (nTDC) is often the vascular access of choice to initiate dialysis in an intensive care unit (ICU). In the absence of contraindications, if a patient remains dialysis dependent beyond 2-weeks, the options are either to replace the nTDC with another nTDC or convert to a tunneled dialysis catheter (TDC). As a standard of care, TDCs are placed under fluoroscopic guidance. To determine if TDCs and other tunneled central venous catheters (tCVC) can be placed safely using anatomical landmark techniques without the use of fluoroscopy. Subjects that met a predetermined selection criteria underwent placement of tunneled catheters with the use of the anatomical landmark technique. We looked at various outcomes to determine the safety and effectiveness of this technique. One hundred eleven TDCs and other tCVCs were placed using the anatomical landmark technique in the intensive care unit. All but one (110/111) of the catheters placed had recommended tip placement confirmed by at least one blinded physician. Major complications encountered were bleeding (two cases), pneumothorax (one case), and line associated blood stream infection (one case). We did find a higher-than-expected rate of "unnecessary procedures" with 18/111 lines placed in patients who did not survive beyond 7 days after placement of the catheter. Using the anatomical landmark technique for bedside tunneled catheter placement can be an effective approach in the right population.

450 Inflammatory Brachial Plexitis Mimics Postoperative Iatrogenic Neurological Deficits

INTRODUCTION: A common cause of neurosurgical malpractice cases is the misrepresentation of idiopathic brachial neuritis (incidence: 1/1000) as an iatrogenic neurological insult caused by a surgeon. METHODS: Confirmed postprocedural brachial neuritis patients from a single quaternary care institution were identified and analyzed. RESULTS: We identified 6 (3 female) postprocedural brachial neuritis patients with mean age 63.7 (range 50-75) years. Procedures included 5 cervical spine surgeries (3 multilevel ACDFs, 2 multilevel posterior fusions with laminectomies, 1 multilevel disc arthroplasty) and 1 intrajugular central venous catheter placement. Average time to symptom onset was 1 week post-procedure (range 1 day-2.5 weeks). Initial symptom was moderate-to-severe shoulder (5), arm (4), and/or neck (1) pain. Subsequently, all developed axillary/shoulder weakness; 3 distal arm/hand weakness, 2 winged scapula, and 2 dyspnea/orthopnea. For diagnosis, two patients had confirmatory EMG, 1 had MR neurography confirming plexus inflammation, and 3 had both (positive EMG findings and inflammation on MR Neurography). Average time to accurate diagnosis was 3.1 (range 1.5-5) months. Average number of clinicians seen prior to accurate diagnosis: 5. Treatments included opioids (5), steroids (1), and/or physical therapy (6). All experienced partial pain relief by 1-8 weeks; 2 had persistent pain requiring gabapentin past 6 months. All patients continued to experience motor deficits past 6 months: (4 patients had atrophy and 2-4/5 motor strength in proximal the proximal arm, 1 had distal arm 3/5 motor strength, and 1 had scapular winging). CONCLUSIONS: Postoperative idiopathic brachial plexitis mimics iatrogenic nerve damage following neurosurgical procedures. Recognition of this entity is difficult, and 6 patients at our institution saw on average 5 providers over 3 months prior to accurate diagnosis. Brachial plexitis has a prolonged course with typically only partial recovery at 6 months.

Percutaneous interventional thrombectomy of an endovascular AV-fistula, a case report.

Dialysis access thrombosis is a common complication in the process of care. With the introduction of endovascular AV-fistulas [AVF]s the situation gained complexity with new potential thrombosis localizations. Several thrombectomy methods are available for recanalization of thrombosed AVFs ranging from invasive surgical methods to minimal invasive endovascular approaches. Early assessment, diagnosis and treatment is crucial for prolonging the life span of an AVF and preventing the need for placement of central venous catheters. To our best knowledge, we present the first case in which an obstructed antecubital communicating vein (aka perforating vein) of an endovascular created AVF was re-opened via interventional thrombectomy with the Rotarex® System (BD Interventional). The procedure was performed primarily under ultrasound guidance with fluoroscopic support. Our case report shows that this method, if done correctly and successfully, may prevent loss of the dialysis access. Additionally, we point towards the central role of ultrasound in this method.

Simulation-based learning in nephrology.

Simulation is a technique to replace and amplify real experiences with guided ones that evoke or replicate substantial aspects of the real world in a fully interactive fashion. In nephrology (a particularly complex specialty), simulation can be used by patients, nurses, residents, and attending physicians alike. It allows one to learn techniques outside the stressful environment of care such as central venous catheter placement, arteriovenous fistula management, learning about peritoneal dialysis, or performing a kidney biopsy. Serious games and virtual reality are emerging methods that show promise. Simulation could also be important in relational aspects of working in a team or with the patient. The development of simulation as a teaching tool in nephrology allows for maintaining high-quality training for residents, tailored to their future practice, and minimizing risks for patients. Additionally, this education helps nephrologists maintain mastery of technical procedures, making the specialty attractive to younger generations. Unfortunately, the inclusion of simulation training programmes faces occasional logistical or funding limitations that universities must overcome with the assistance and innovation of teaching nephrologists. The impact of simulation-based teaching on clinical outcomes needs to be investigated in clinical studies.

Surgical outcomes of very-early-onset ulcerative colitis: retrospective comparative study with older pediatric patients

PurposeThe study compares the surgical outcomes of very-early-onset ulcerative colitis (VEO-UC), which is a rare disease diagnosed in pediatric patients < 6 years, with those of older pediatric patients with ulcerative colitis (UC).MethodsA retrospective observational study of 57 pediatric patients with UC was conducted at a single center. The study compared surgical complications and postoperative growth between the two groups.ResultsOut of the 57 patients, 6 had VEO-UC, and 5 of them underwent total colectomy. Compared with the surgical cases of older patients with UC (n = 6), the rate of postoperative complications in patients with VEO-UC (n = 5) was not significantly different, except for high-output ileostomy (80% vs. 0% at 3 weeks postoperatively, p = 0.02). The rate of postoperative central venous catheter (CVC) placement at > 90 days was higher in patients with VEO-UC (100% vs. 17%, p = 0.02). The median change in the Z-score of height before and 2 years after colectomy was not significantly different between VEO-UC and older patients (1.1 vs. 0.3, p = 0.13).ConclusionWith regard to complications and outcomes, total colectomy for VEO-UC patients and that for older pediatric UC patients is comparable. However, high-output ileostomy and the long duration of CVC placement may pose management challenges.

Complication Rates of Central Venous Catheters

Central venous catheters (CVCs) are commonly used but are associated with complications. Quantifying complication rates is essential for guiding CVC utilization decisions. To summarize current rates of CVC-associated complications. MEDLINE, Embase, CINAHL, and CENTRAL databases were searched for observational studies and randomized clinical trials published between 2015 to 2023. This study included English-language observational studies and randomized clinical trials of adult patients that reported complication rates of short-term centrally inserted CVCs and data for 1 or more outcomes of interest. Studies that evaluated long-term intravascular devices, focused on dialysis catheters not typically used for medication administration, or studied catheters placed by radiologists were excluded. Two reviewers independently extracted data and assessed risk of bias. Bayesian random-effects meta-analysis was applied to summarize event rates. Rates of placement complications (events/1000 catheters with 95% credible interval [CrI]) and use complications (events/1000 catheter-days with 95% CrI) were estimated. Ten prespecified complications associated with CVC placement (placement failure, arterial puncture, arterial cannulation, pneumothorax, bleeding events requiring action, nerve injury, arteriovenous fistula, cardiac tamponade, arrhythmia, and delay of ≥1 hour in vasopressor administration) and 5 prespecified complications associated with CVC use (malfunction, infection, deep vein thrombosis [DVT], thrombophlebitis, and venous stenosis) were assessed. The composite of 4 serious complications (arterial cannulation, pneumothorax, infection, or DVT) after CVC exposure for 3 days was also assessed. Of 11 722 screened studies, 130 were included in the analyses. Seven of 15 prespecified complications were meta-analyzed. Placement failure occurred at 20.4 (95% CrI, 10.9-34.4) events per 1000 catheters placed. Other rates of CVC placement complications (per 1000 catheters) were arterial canulation (2.8; 95% CrI, 0.1-10), arterial puncture (16.2; 95% CrI, 11.5-22), and pneumothorax (4.4; 95% CrI, 2.7-6.5). Rates of CVC use complications (per 1000 catheter-days) were malfunction (5.5; 95% CrI, 0.6-38), infection (4.8; 95% CrI, 3.4-6.6), and DVT (2.7; 95% CrI, 1.0-6.2). It was estimated that 30.2 (95% CrI, 21.8-43.0) in 1000 patients with a CVC for 3 days would develop 1 or more serious complication (arterial cannulation, pneumothorax, infection, or DVT). Use of ultrasonography was associated with lower rates of arterial puncture (risk ratio [RR], 0.20; 95% CrI, 0.09-0.44; 13.5 events vs 68.8 events/1000 catheters) and pneumothorax (RR, 0.25; 95% CrI, 0.08-0.80; 2.4 events vs 9.9 events/1000 catheters). Approximately 3% of CVC placements were associated with major complications. Use of ultrasonography guidance may reduce specific risks including arterial puncture and pneumothorax.

Risk factors for medical adhesive-related skin injury at the site of peripherally inserted central venous catheter placement in patients with cancer: a single-centre prospective study from China

ObjectivesThis study aims to explore the incidence of, and risk factors for medical adhesive-related skin injury (MARSI) at peripherally inserted central venous catheter (PICC) sites in patients with cancer.DesignA prospective...

Development of an Anatomically Accurate Three-Dimensional Simulation Model for Pediatric Central Line Placement

Abstract Intensive care unit patients can require a central venous catheter (CVC) which medical trainees often place. The purpose of this study was to create a novel three-dimensional (3D) printed model, based on actual patient anatomy from a de-identified computed tomography (CT) scan, with improved anatomy, tactile properties, and realism beyond current task trainers for pediatric CVC placement simulation. Bakken Center researchers converted CT DICOM slices into a 3D model using multiple computer programs and multiple 3D printers. Faculty of various subspecialties at our institution attempted to place a CVC line into the model and then evaluated the model in 5 categories using an anonymous REDCap survey. Fifteen faculty participated and fourteen completed their survey. Feedback, based on a 0–10 scale with 10 being highest, was as follows: the model's size scored an average of 8.4, the model's tactile properties scored a 6.1, the model's anatomy received a 7.1, the model's perceived usefulness for practicing central line placement received a 7.6, and the model received a 7.6 in regard to whether it should be utilized in procedural training curriculums. Additional comments were collected in the survey and participants requested that the model's blood vessels be fully visible on ultrasound and that the model be firmer. In conclusion, creating a 3D simulation model for pediatric CVC placement is possible.

Numerical Study on the Impact of Central Venous Catheter Placement on Blood Flow in the Cavo-Atrial Junction.

An in silico study is performed to investigate fluid dynamic effects of central venous catheter (CVC) placement within patient-specific cavo-atrial junctions. Prior studies show the CVC infusing a liquid, but this study focuses on the placement without any liquid emerging from the CVC. A 7 or 15-French double-lumen CVC is placed virtually in two patient-specific models; the CVC tip location is altered to understand its effect on the venous flow field. Results show that the CVC impact is trivial on flow in the superior vena cava when the catheter-to-vein ratio ranges from 0.15 to 0.33. Results further demonstrate that when the CVC tip is directly in the right atrium, flow vortices in the right atrium result in elevated wall shear stress near the tip hole. A recirculation region characterizes a spatially variable flow field inside the CVC side hole. Furthermore, flow stagnation is present near the internal side hole corners but an elevated wall shear stress near the curvature of the side hole's exit. These results suggest that optimal CVC tip location is within the superior vena cava, so as to lower the potential for platelet activation due to elevated shear stresses and that CVC geometry and location depth in the central vein significantly influences the local CVC fluid dynamics. A thrombosis model also shows thrombus formation at the side hole and tip hole. After modifying the catheter design, the hemodynamics change, which alter thrombus formation. Future studies are warranted to study CVC design and placement location in an effort to minimize CVC-induced thrombosis incidence.

Central venous catheter tip positioning using ultrasound in pediatric patients-A prospective observational study.

In children, central venous catheter (CVC) placement is usually performed under ultrasound guidance for optimal visualization of vessels and reduction of puncture-related complications. Nevertheless, in many cases, additional radiographic examinations are performed to check the position of the catheter tip. The primary objective of this observational feasibility study was to determine the number of ultrasound-guided central venous catheter tips that can be identified in a subsequent position check using ultrasonography. Furthermore, we investigated the optimal ultrasound window, time expenditure, and success rate concerning puncture attempts and side effects. In addition, we compared the calculated and real insertion depths and analyzed the position of the catheter tip on postoperative radiographs with the tracheal bifurcation as a traditional landmark. Ninety children with congenital heart defects who required a central venous line for cardiac surgery were included in this single-center study. After the insertion of the catheter, the optimal position of its tip was controlled using one of four predefined ultrasound windows. A chest radiograph was obtained postoperatively in accordance with hospital standards to check the catheter tip position determined by ultrasonography. The children had a median (IQR) age of 11.5 (4.0, 58.8) months and a mean (SD) BMI of 15.3 (2.91) kg/m2 Ultrasound visualization of the catheter tip was successful in 86/90 (95.6%) children (95% confidence interval [CI]: 91.3%, 99.8%). Postoperative radiographic examination showed that the catheter tip was in the desired position in 94.4% (95% CI: 89.7%, 99.2%) of the cases. None of the children needed the catheter tip position being corrected based on chest radiography. Additional radiation exposure after the placement of central venous catheters can be avoided with the correct interpretation of standardized ultrasound windows, especially in vulnerable children with cardiac disease.

Abstract No. 294 Analysis of Non-Tunneled Central Venous Catheter Placement Trends Among Medicare Patients (2010-2022): Procedural Volume, Specialty Involvement, and Reimbursement Patterns

Abstract No. 294 Analysis of Non-Tunneled Central Venous Catheter Placement Trends Among Medicare Patients (2010-2022): Procedural Volume, Specialty Involvement, and Reimbursement Patterns