Central Venous Catheter Procedures Research Articles

Virtual Reality Training for Central Venous Catheter Placement: An Interventional Feasibility Study Incorporating Virtual Reality Into a Standard Training Curriculum of Novice Trainees

ObjectivesThis study assess the feasibility of integrating virtual reality (VR) simulation into the central venous catheter (CVC) placement training curriculum. DesignThe study consists of three parts: (1) Evaluating current manikin-based training for CVC placement through surveys for senior first-year anesthesia residents and cardiac anesthesia faculty who supervise resident performing the procedure; (2) Interventional study training novice trainees with VR simulator and assessing their reaction satisfaction; and (3) pilot study integrating VR training sessions into CVC training curriculum for first-year anesthesia residents. SettingConducted at a single academic-affiliated medical center from December 2022 to August 2023. ParticipantsJunior first-year anesthesia residents. InterventionsVR training sessions for CVC placements using the Vantari VR system. Measurements and Main ResultsPrimary outcome: novice trainees’ satisfaction with VR training for CVC procedure. Satisfaction of resident and faculty with standard manikin-based training was also collected. Faculty expressed concerns about residents' confidence and perceived knowledge in performing CVC placement independently. Novice trainees showed high satisfaction and perceived usefulness with VR training, particularly in understanding procedural steps and developing spatial awareness. Pilot integration of VR training into the curriculum demonstrated comparable training times and emphasized structured stepwise training modules to ensure completion of vital procedural steps. ConclusionsThe study underscore the potential of VR simulation as a complementary training tool for CVC placement rather than a substitution of standard manikin training. VR is offering immersive experiences and addressing limitations of traditional manikin-based training methods. Integration of VR into training curricula warrants further exploration to optimize procedural proficiency and patient safety in clinical practice.

Central Venous Catheter procedures performed at the outpatient clinics of San Giuliano Hospital of ASL Napoli 2 Nord with a brief overview of pharmacoeconomic evaluations on the procedure

The following work concerns a retrospective, single-center analysis of the data cohort collected between January 2022 and December 2023 regarding outpatient services provided by the Vascular Access Management Service at the Giugliano Hospital in Campania, part of the ASL Napoli 2 Nord. The devices used in these practices are essential for the treatment of both hospitalized and non-hospitalized patients. Their widespread use is justified both due to the particular complexity of the therapeutic regimens to which the patient is subjected, and the frequent need for pharmacological support, hydration, periodic blood draws, nutrient and blood product infusions, and hemodynamic monitoring to safeguard their vascular health. The ASL Napoli 2 Nord area records a significant presence of chronic-degenerative and oncological diseases, therefore, to meet the needs of the population and the numerous requests made by hospital departments and districts, it was decided to activate outpatient clinics for the implantation and management of vascular accesses. It is appropriate that every healthcare operator is adequately trained and involved in the various stages of patient recruitment, device implantation, and management. Therefore, in the ASL Napoli 2 Nord area, it was deemed necessary for these professional figures to be involved in drafting procedures to define the correct use of these devices. The cost of individual outpatient procedures in terms of materials used and specialized personnel involved is an indicator of company expenditure. The amount received by the company for each individual service in terms of patient copayments and reimbursement from the Region represents the revenue of the ASL in relation to the services provided. From the results obtained, there is a slight disproportion regarding regional reimbursement; in particular, the data shows that revenue in terms of dressings is lower than that of irrigations despite the direct costs in the former being much higher than in the latter. These outpatient procedures represent an important source of income in relation to the numbers generated solely at the Giugliano Hospital and still find correspondence and proportionality compared to those recorded in the outpatient clinics of other company facilities.

The Effect of Ultrasound-guided Central Venous Catheterization on Complications and Success Rate in Critically Ill Children: A Multicenter Study

Objective: The aims of this study were to compare the results of ultrasound (US) guidance and the landmark (LM) technique for central venous catheter (CVC) placement in pediatric intensive care units (PICUs) as performed by clinicians. Material and Methods: The patients were divided into two groups according to the technique used: an LM group (459 patients) and a US-guided group (200 patients). We evaluated the success rate, the number of attempts, and the complication rates based on each patient’s age and weight. Results: The time required for the successful placement of the CVC was significantly different between the two groups: 10.9±10.8 min in the LM group and 8.1±7.6 min in the US-guided group (p=0.012). Additionally, the average number of attempts for successful catheterization was 1.8±0.8 in the US-guided group; and 2.5 ± 1.4 in the LM group (p=0.024). A total of 115 (17.3%) complications were noted: 24 (3.6%) in the US-guided group and 91 (13.7%) in the LM group (p=0.014). The frequency of complications decreased as the age and weight of the patients increased. When the inserted catheters used by ultrasound were evaluated, 59.5% of them were placed by clinicians who had ultrasound training while 40.5% were inserted by clinicians who did not have ultrasound training. There was no significant difference in the complication rate, number of punctures, and success rates between the ultrasound-trained and untrained clinicians (p=0.476). Conclusion: This is the largest multicenter study comparing the US-guided vs. LM technique for CVC placement in children. We believe that the US-guided CVC procedure is more safe and takes less time than the LM technique. Also, point-of-care ultrasound is useful, beneficial, and easily available for pediatric intensivists.

Acil Serviste Takılan Santral Venöz Kateterlerin Değerlendirilmesi

Objective 
 In our study, we evaluated central venous catheter procedures performed by Adnan Menderes University, Department of Emergency Medicine in the emergency room and emergency intensive care units. We planned to investigate performing central venous catheter application with ultrasound guidance and the rate of bleeding complications in patients using anticoagulants or antiplatelet.
 Material and Method
 Between 15.11.2018-15.10.2019, central venous catheter application was performed 178 cases over the age of 18 and non-pregnant were included. Research data were evaluated by using SPSS 21.0 statistics program.
 Results
 A Central venous catheter procedure was performed in 78.7% of the patients with ultrasound guidance. 36.5% of the patients had a history of anticoagulant or antiplatelet drug use. The most common complications in our patients were ventricular dysrhythmia and subcutaneous hematoma. 
 Conclusion
 In conclusion, when looking at the relationship between gender, anticoagulant and/or antiplatelet drug use, preferred vein and ultrasound use during the procedure, and complication status, no statistically significant results were found.

Central venous catheterization into the femoral vein

A central venous catheter (CVC) is usually placed to replace the spilled blood volume or inject a vasopressor. Among central catheterizations, the anatomy of the femoral vessel is lesser complex than that of others, and femoral venous catheterization is most easily cannulated percutaneously. However, endovascular training should be considered to complete the deployment of the central catheter and prevent complications systematically. Therefore, this study aimed to share the precise CVC procedure in the femoral vein and to impart endovascular techniques through simulation video clips and pictures.

Central venous catheter access and procedure compliance: A qualitative interview study exploring intensive care nurses’ experiences

ObjectiveTo explore intensive care nurses’ experiences with and perceptions of using a standardised central venous catheter procedure to prevent bacterial contamination when accessing patients’ central venous catheters. Design and methodologyThis study employed an interpretative qualitative design. Data was collected through semi-structured, individual interviews and Qualitative Content Analysis was used in data analysis. SettingSeven Norwegian intensive care nurses were recruited using a purposeful sampling strategy. FindingsThree main themes were identified. 1). Individualised practice revealed varying knowledge of and commitment to following the central line procedure. 2). Risk desensitisation revealed a continuous use of central lines, acute situations and a lack of information on infections, which affect usage. 3). Professional working culture showed nurse-to-nurse interaction, which promoted compliance with the procedure. Their interplay created a team spirit whereby nurses worked together to improve patient safety. ConclusionsThis study shows the diversity and complexity of factors affecting intensive care nurses’ procedure compliance when accessing central lines. The themes of Individualised practice and Risk desensitisation pose a substantial threat to healthcare quality and patient safety in the ICU. Exposure to infection risks could be reduced by applying these themes to inform and strengthen continuing education programs and audit processes. The theme of Professional working culture shows the positive influence nurses can have on each other, promoting compliance when accessing central lines. Intensive care nurses should be aware that their voice matters and that challenging poor practice does not have to be confrontational. Leadership should look for ways to encourage this type of nurse-to-nurse interaction.

Real Time Ultrasound Guided Practice in Passing Central Venous Pressure Line in Pediatric Population

Objective: To assess the success of ultrasound guided central venous catheter (CVC) placement, its associated factors, and complications among patients admitted to pediatric intensive care unit (PICU). Methods: A retrospective cross-sectional study was conducted at Department of Pediatrics, Pak Emirates Military Hospital from October 2018 to November 2019. All patients admitted in PICU who underwent ultrasound guided CVC placement were consecutively enrolled. The number of previous ultrasound lines placed, comfort with the ultrasound device, and opinion of the utility of the ultrasound device were recorded. Moreover, type of procedure, preferred side attempts, single attempt to success, CVC size used, sedation required, and complications were noted.Results: Of total 108 children, the mean age was 5.15 ± 3.4 years. There were 69 (63.9%) males and 39 (36.1%) females. There were 12 (11.1%) children found with complications of passing central venous pressure (CVP)line. Of these 12 children, arterial puncture was found in 9 (75%) children, pneumothorax in 2 (17%) children, and hematoma in 1 (8%) child. The complications of passing CVP line was found significantly higher among children with organ failure diseases 9 (17.6%) as compared to other diseases 3 (5.3%) (p-value 0.041).Conclusion: The use of ultrasound in CVC procedures is an asset to all trained personnel who conduct this procedure as it reduces the time required to complete the procedure and substantially minimizes potential complications

Catheter-Related Bloodstream Infection for End Stage Renal Disease Patients -Evaluation in the Era of Low Budget National Health Insurance Coverage in Indonesia-

Introduction: The use of central venous catheter (CVC) plays an essential role in patient care. The catheter-related bloodstream infection (CRBSI) is one of complications and associated with morbidity and mortality. In Indonesia, the national health coverage for single CVC procedure claim is only US$ 197-286. The aim of this study is to evaluate CRBSI number after subclavian and femoral non-tunnelled catheter insertion for urgent haemodialysis access. Method: A retrospective study with the simple consecutive sampling was conducted. The inclusion criteria were adult and end stage renal disease (ESRD) patients required urgent haemodialysis access with infection on the site of insertion on the subclavian or femoral access. Exclusion criteria were artery catheter placement, pacing catheter, and another sources of previously infection was defined. Patients were divided into subclavian and femoral access group then we evaluate them retrospectively based on medical record data. Results: Forty patients with 20 patients were subclavian inserted, and rest were femoral inserted. Infections rate was 7.84%. Demographic showed 55% was male (22/40) & age 51.8±14.3 years. Catheter duration in subclavian and femoral group were 47.7±34.2 and 36.7±18.4 days, respectively. Hospital stays in subclavian and femoral group were 9.9±6.4 and 9.3±7.2 days, respectively. From SIRS criteria, in subclavian group showed the heart rate, respiratory rate, body temperature and white blood cell (WBC) count were 90.1±7.8 x/min, 21.1±2.6 x/min, 37.4±0.8 °C, 15.5.0±7.0 *103/μL, respectively. For femoral group were 86.8±10.5 x/min, 21.6±4.0 x/min, 36.9±0.6 °C, 14.9±8.4 *103/μL, respectively. The p- values of them were 0.273, 0.612, 0.041, and 0.793 respectively. Eighty percent in subclavian group was first insertion, and for femoral group was 50% (p=0.047). In subclavian group was 10% (2/20) patients had more than three times insertion and femoral group was 25% (5/20) (p=0.225). Creatinine and ureum level in subclavian group were 9.4±5.8 and 155.5±83.6 mg/dL and for femoral group were 11.4±6.2 and 133.6±50.3 mg/dL (p=0.298 and 0.322, respectively). A 62.5% of all patients (25/40) was treated with third generation cephalosporin. The p-value for amount of intravenous antibiotic (single, double, triple) between subclavian and femoral group was 0.352. There was no blood culture taken for all patients. Sepsis and death as complication was 10% and 5% from all patients, respectively. Conclusion: Prolonged use of central venous catheter more than 2 weeks and recurrent procedure were the cause of increasing incidence of CRBSI. Ultrasound guiding is needed to decrease complication. In a low budget system for national health insurance in Indonesia, a good strategy (pre-ESRD arteriovenous fistula, internal jugular vein access, nosocomial infection prevention, and rational antibiotic usage with a rational blood culture) need to be developed to prevent the infection of CRBSI. Keywords: catheter, infection, prevention, health insurance, Indonesia.

Local diagnostic reference levels for paediatric non-cardiac interventional radiology procedures

PurposeTo establish local diagnostic reference levels (DRLs) for non-cardiac interventional procedures in paediatrics. MethodsThe type of procedure, the patient’s weight and age and dose-related data from 279 interventions was recorded in a database completed by interventional radiologists, radiographers and technicians of the Medical Physics department. These procedures were classified into 14 categories and 6 weight ranges. Local DRLs were proposed for those ranges in which a sample of at least 15 patients could be gathered and were calculated as the third quartile (Q3) of the air kerma-area product (PKA) values. The Q3 of the fluoroscopy time (FT) and number of digital subtraction angiography (DSA) images were also obtained. Finally, the correlation between PKA and weight was analysed. ResultsLocal DRLs are proposed for three types of procedures: hepatic/biliary interventions (5–15 kg, 1304 cGy·cm2; 15–30 kg, 2121 cGy·cm2), sclerotherapy procedures (15–30 kg, 704 cGy·cm2; 30–50 kg, 4049 cGy·cm2; 50–80 kg, 3734 cGy·cm2) and central venous catheter (CVC) procedures (5–15 kg, 84 cGy·cm2). Hepatic/biliary interventions showed a moderate correlation (r = 0.61), while sclerotherapy procedures presented a poor correlation (r = 0.34) between PKA and weight, possibly due to the PKA dependence on the complexity level. Regarding CVC procedures, a clearly higher correlation was found when the fluoroscopy PKA value was normalised to the FT (r = 0.85 vs r = 0.35). ConclusionsThe results support the feasibility of establishing DRLs for the most common procedures (sclerotherapy, hepatic/biliary and CVC interventions) despite the small number of paediatric interventions.

Ultrasound Guided Central Line Placement: Is a Gelatine Phantom a Good and Affordable Alternative?

Introduction - Central Venous Catheter (CVC) insertion is a common procedure. However, CVC insertion has a complication rate up to 15 percent. Ultrasound guided central venous catheter (USG-CVC) is advocated to reduce these complications, as it allows actual visualization of intravenous needle and catheter insertion. US guided punctures require good hand–eye–coordination. It is important to train these skills in vitro before starting performing these procedures on patients. Simulation-based instead of patients-based technical skill training have generated much enthusiasm. US guided puncture training requires an adequate training phantom that mimics the (US-) characteristics and haptic feedback of real tissue and veins. The aim of this proof of concept study was to produce a low cost, realistic phantom to train eye-hand coordination needed US guided punctures. In addition, the quality and utility of the phantom were reviewed by several participants experienced in US guided punctures. Methods - This is a proof of concept study took place in one peripheral teaching hospital (Maxima Medical Centre, Veldhoven, Netherlands) and one academic centre (Maastricht Medical Centre, Maastricht, Netherlands). Participants: The selection procedure of participants was random. All available participants (N=20) with experience in UG-CVC insertion were asked to perform an US guided puncture in this phantom. In addition, they were asked to assess the quality and possible utility of the phantom by filling in a questionnaire (based on a 5-point Likert scale) Results - The Age of participants ranged from 24 to 55 years, 14 male participants, 18 were right-handed. Participants were surgical residents and surgeons with an average of 10-50 blind CVC procedures and 20-50 ultrasound guided CVC procedures. The phantom was rated moderate (mean, 3 out of 5) from realistic perspective and good (mean, 4 out of 5) from procedural perspective. Especially training of eye hand coordination and the overall opinion was rated good (mean, 4 out of 5). Conclusion - The phantom used in our study was rated good by twenty independent medical professionals. Especially training of eye-hand-coordination was rated good. These findings confirm the feasibility of these, easy to make, affordable home-made phantoms for US-guided puncture training. However, there are no results on the training efficacy for dual handed movements or eye-hand coordination when participating in a training program on this model. A training program is in the making and further study will be necessary to evaluate the efficacy of training on this model.

Developing, Implementing, and Evaluating a Multimedia Patient Decision Aid Program to Reform the Informed Consent Process of a Peripherally Inserted Central Venous Catheter Procedure: Protocol for Quality Improvement.

BackgroundInformed consent has considerable clinical, ethical, and legal implications for patient safety and liability. Little information is available about the use of multimedia patient decision aids (PtDA) in the consent process for therapeutic invasive procedures such as the peripherally inserted central venous catheter (PICC). In addition, none of the available studies have designed their multimedia PtDAs based on the Agency for Healthcare Research and Quality’s (AHRQ) comprehensive guide for informed consent.ObjectiveThis paper describes a patient-centered, systematic, multidisciplinary approach to develop, implement, and alpha test a multimedia PtDA to reform the informed consent process of a PICC for patients in 10 acute and intensive care units.MethodsThe development, implementation, and evaluation processes of the PtDA followed the phases in the Multimedia Production Framework: preproduction, production, and postproduction. Within this framework, we applied the criteria for judging the quality of PtDAs, the AHRQ’s Health Literacy Universal Precautions Toolkit, and the AHRQ’s Patient Education Materials Assessment Tool Guide. The methodology was guided by the Interprofessional Shared Decision-Making Model and the AHRQ’s Making Informed Consent an Informed Choice guide. In the preproduction phase, we (1) reviewed the current consent form; (2) observed 18 consent processes; (3) surveyed the vascular access team (N=6 nurses) about their perception of the current process; (4) surveyed 30 patients for knowledge recall and retention, overall satisfaction, and attitude toward using a multimedia PtDA; and (5) wrote and reviewed the script for the multimedia program. The production phase focused on filming the PtDA in English and Spanish languages. The postproduction phase included integrating the multimedia programs into the care processes, developing a modified workflow for the consent process, and alpha testing of the English and Spanish PtDAs by (1) a group of 5 patients for clarity and understandability of the information; (2) nurses using the AHRQ’s Patient Education Materials Assessment Tool Audio and Video; and (3) by the multidisciplinary change team.ResultsBased on the alpha testing, patients indicated that the content was easy to follow and read; nurses provided positive feedback, and their comments were mainly related to the changes in the workflow in the consent process of the PICC after using the PtDA; and the multidisciplinary change team suggested edits related to changing a few scenes. The final multimedia program consisted of 7 min and 37 s demonstrating detailed information about the PICC.ConclusionsA systematic development of PtDAs for nonurgent invasive procedures may eliminate many limitations of the conventional consent process by ensuring comprehensive, standardized, and easy-to-comprehend information and providing sufficient time for the patients to reflect on the information. To be effective, PtDAs should follow a systematic, patient-centered, evidence-based, and rigorous approach in the development, implementation, and evaluation processes.International Registered Report Identifier (IRRID)RR1-10.2196/10709

Effect of a Multimedia Patient Decision Aid to Supplement the Informed Consent Process of a Peripherally Inserted Central Venous Catheter Procedure: Pre-Post Quasi-Experimental Study.

BackgroundInformed consent is a complex process to help patients engage in care processes and reach the best treatment decisions. There are many limitations to the conventional consent process that is based on oral discussion of information related to treatment procedures by the health care provider. A conclusive body of research supports the effectiveness of multimedia patient decision aids (PtDAs) in the consent process in terms of patient satisfaction, increased knowledge about the procedure, reduced anxiety level, and higher engagement in the decision making. Little information is available about the effectiveness of multimedia PtDAs in the consent process of invasive therapeutic procedures such as the peripherally inserted central venous catheter (PICC).ObjectiveThe objective of this study was to examine the effectiveness of a multimedia PtDA in supplementing the consent process of the PICC for patients in 10 acute and intensive care units in terms of knowledge recall, knowledge retention, satisfaction with the consent process, and satisfaction with the PICC multimedia PtDA.MethodsThis pre-post quasi-experimental study included 130 patients for whom a PICC was ordered. Patients in the control group (n=65) received the conventional consent process for the PICC, while those in the intervention group (n=65) received the multimedia PtDA to support the consent process of a PICC. All patients were surveyed for knowledge recall and retention about the procedure and satisfaction with the consent process. Patients in the intervention group were also surveyed for their satisfaction with the multimedia PtDA.ResultsCompared with the control group, patients in the intervention group scored around 2 points higher on knowledge recall (t125=4.9, P<.001) and knowledge retention (t126=4.8, P<.001). All patients in the intervention group were highly satisfied with the multimedia PtDA, with a mean score of >4.5 out of 5 on all items. Items with the highest mean scores were related to the effect of the multimedia PtDA on knowledge retention (mean 4.9 [SD 0.2]), patient readiness to learn (mean 4.8 [SD 0.5]), complete understanding of the procedure-related complications (mean 4.8 [SD 0.4]), and patient role in maintaining the safety of the PICC (mean 4.8 [SD 0.5]). Patients in the two groups were highly satisfied with the consent process. However, 15% (10/65) patients in the control group reported that the following information was omitted from the discussion: patient and provider roles in the safety of the PICC, other treatment options, and common side effects. Furthermore, 2 patients commented that they were not ready to engage in the discussion.ConclusionsThe multimedia PtDA is an effective standardized, structured, self-paced learning tool to supplement the consent process of the PICC and improve patient satisfaction with the process, knowledge recall, and knowledge retention.

Use of Bedside Ultrasonography and Saline Flush Technique for Evaluation of Central Venous Catheter Placement in Children.

Our study investigated the reliability of appearance of rapid atrial swirl flow (RASF) by ultrasonography (US) in the right atrium (RA), which occurred as a result of rapid isotonic saline infusion (RISI) into the central venous catheter (CVC), in predicting catheter tip position. This prospective observational study included 95 CVC procedures performed on 77 pediatric patients (41 boys and 36 girls) with a median age of 0.6 (0.29-1.53) years. Seventy-three (76.84%) catheter tips were found to be correctly placed, and 22 (23.15%) catheter tips were misplaced. While ultrasonographic examination revealed RASF in the RA after 93 catheterization procedures, it was not observed after two catheterization procedures. One of these two catheters was an arterial catheter, and the other was a catheter that was directed toward the subclavian vein after curling around itself. There was no significant difference between the groups with incorrect and correct positioned catheter tip in terms of the appearance of RASF by US after RISI. There was no significant difference between the groups with upward (n = 8) and downward (n = 86) positioned catheter tip in terms of the time until the first appearance of RASF after RISI and the phase of RASF (P > 0.05). There was a significant difference between these two groups in terms of the disappearance time of RASF in the RA (P < 0.001). The mean disappearance time of RASF was 3 (2-3) s for downward positioned catheters and 5 (4-7) s for upward positioned catheters, respectively. When the cut-off for the disappearance time of RASF was set to 3 s, US had a sensitivity of 85.71% and a specificity of 77.91% for detecting upward positioned catheters. In conclusion, the appearance of RASF in the RA in a short time by US is not a reliable finding for correct positioning of the CVC tip in the pediatric patient group. The fact that the disappearance time of RASF in the RA is longer than 3 s indicates upward positioned CVCs. These catheters must never be used without radiological confirmation. In CVCs in which the disappearance time of RASF in the RA is shorter than 3 s, we think that the catheter can be used until radiological confirmation in emergency cases. According to the available literature, our study is the first study in children. There is a need for new studies on this subject.

Hemodialysis catheter-related infection: rates, risk factors and pathogens.

The main complication of central venous catheter (CVC) in hemodialysis is infection. Identifying CVC related infection (CVC-RI) risk factors and causative micro-organisms is important for setting prevention policies. There were no data regarding CVC-RI in hemodialysis in Algeria. To determine rates of CVC-RI in hemodialysis in Setif university hospital, risk factors and causative microorganisms, we conducted a prospective study from November 2014 to May 2015 involving patients with CVC in hemodialysis. Micro-organisms isolated from semi quantitative culture of CVC and blood culture were identified and tested for antibiotic susceptibility using the automated MicroScan system (DADE Behring, Sacramento, CA, USA). Chi-square test was performed to compare demographic and clinical variables (age, sex, comorbidities, duration of CVC, insertion site) in the groups of patients with and without CVC-RI. P<0.05 was considered statistically significant. All analyses were performed using SPSS V17 for Windows statistical package (SPSS Inc., Chicago, IL, USA). 94 patients and 152 CVC procedures were analyzed. 34 CVC-RI were documented with an incidence of 16.6 per 1000 CVC-days. Incidence of CVC related bloodstream infection (CVC-RBI) was 10.8 per 1000 CVC-days. Independent risk factors associated with CVC-RI were diabetes (P=0.01) and duration of catheterization (P= 0.01). Causative micro-organisms were: Klebsiella pneumoniae 26.5%, coagulase-negative staphylococci 23.5% and Staphylococcus aureus 23.5%. Micro-organisms were multidrug-resistant (MDR). Mortality was statistically associated to inadequate antibiotic therapy. The duration of CVC should be reduced by creation of fistulas. More compliance to hygiene measure is needed for decreasing CVC-RI and resistance rate.

Infraclavicular axillary vein cannulation using ultrasound in a mechanically ventilated general intensive care population.

Central venous catheter (CVC) insertion is commonly undertaken in the ICU. The use of ultrasound (US) to facilitate CVC insertion is standard and is supported by guidelines. Because the subclavian vein cannot be insonated where it underlies the clavicle, its use as a CVC site is now less common. The axillary vein, however, can be seen on US just distal to the subclavian vein and placement of a CVC at this site gives a result which is functionally indistinguishable from a subclavian CVC. We evaluated placement of US-guided axillary CVCs in mechanically ventilated intensive care patients. Data were collected for 125 consecutive US-guided axillary CVC procedures in ventilated patients in an adult intensive care setting. All lines were inserted using real-time US guidance with an out-of-plane technique. One hundred and twenty-five procedures occurred in 119 patients. Successful line placement was achieved in 117 out of 125 (94%) procedures. Complications included four procedures that required repeating due to catheter malposition and one arterial puncture. The median number of attempts per procedure was one (IQR 1 to 2). Thirty-nine (31%) patients had a body mass index of 30 or above, 43 (34%) patients had a coagulopathy and 70 (56%) patients had significant ventilator dependence (FiO2 of 0.5 or above, or positive end expiratory pressure 10 cmH20 or above). The technique of US-guided axillary CVC access can be undertaken successfully in ventilated intensive care patients, even in challenging circumstances. Taken together with existing work on the utility and safety of this technique, we suggest that it be adopted more widely in the intensive care population.

Venous anomalies as potentially lethal risk factors during ordinary catheterization

Venous malformations are rare but possible findings too, constituting a further risk factor for central venous catheter procedures. Herein we describe a case of death because of an innominate vein perforation by a catheter that incidentally was tucked into a sacciform malformation. Even if the technology advancement is constantly offering us new investigation tools, up to now diagnostic options are limited in the detection of those malformations that could potentially lead to dramatic complications as the described one. The present work raises the awareness about rare venous anomalies and their potential clinical implications. A proper literature review and diagnostic implementation proposal are reported.

Safety aspects in patients on hemodialysis with catheters.

Central venous catheter (CVC)-related problems, risks and safety hazards are partly caused by different characteristics of the CVC-based access and their performance features. This chapter covers those issues in a chronological order, from factors related to the choice of the CVC, insertion site and insertion procedure itself, over those associated with CVC use and their monitoring up to safety hazards of interventional procedures. Not discussed are CVC infections as they are covered in a separate chapter in this book.

Development and Evaluation of a Program for the Use of Ultrasound for Central Venous Catheter Placement in a Pediatric Emergency Department

A growing body of literature supports the use of ultrasound (US) to assist central venous catheter (CVC) placement, and in many settings, this has become the standard of care. However, this remains a relatively new and uncommonly performed procedure for pediatric emergency medicine physicians. This study aims to describe the change over time in percentage of CVC procedures performed with US assistance per 10,000 patient visits in a pediatric emergency department. We describe the development of an emergency US program in a pediatric emergency department and investigate how US use for CVC placement in internal jugular and femoral veins changed from July 2007, when US became available, until December 2011. Data related to CVC procedures were obtained from a procedure database maintained for quality assurance purposes. The percentage of CVC procedures performed with US assistance increased significantly over time (P < 0.001). The development of an emergency US program was associated with significantly increased physician use of US for CVC placement.

Increased Fluoroscopy Time for Central Venous Catheter Placement by Radiology Residents versus Staff Radiologists

To evaluate differences in interventional radiology procedural fluoroscopy time (FT) for radiology residents versus staff radiologists, using central venous catheter (CVC) placement as an index service. To minimize interservice and complexity variables, stand-alone temporary internal jugular CVC procedures were targeted for analysis. Reports and images from 1,067 temporary CVC services from 2 hospitals over 2 years were reviewed as part of a quality improvement initiative. Insertion site, catheter type (eg, smaller triple lumen versus larger hemodialysis), resident identifier, staff identifier, and documented FT were compiled and analyzed. Applying clinical (eg, concomitant venous angioplasty) and anatomic (eg, femoral access) exclusions, 537 cases with complete CVC procedure records were available for analysis. Radiology residents and staff radiologists were primary operators in 128 and 409 procedures, respectively. Distribution of resident procedures (82% right, 66% large lumen) was similar to that of staff (79% right, 63% large lumen). Mean FT of resident services was twice as long as that of staff services (1.24 minutes versus 0.63 minutes, P < .0001). Resident FT was independent of supervising staff radiologist. Increasing years of training for residents did not significantly reduce FT. When CVCs are placed by radiology residents, FT is double that for identical procedures performed by staff radiologists. Similar discrepancies likely exist for other interventional radiologic procedures. Residency training programs should initiate measures to monitor and manage fluoroscopy during interventional procedures to minimize radiation dose to patients, trainees, and other staff.

Side matters: An intriguing case of persistent left superior vena-cava

Persistent left superior vena cava, usually an incidental finding, is the most common thoracic vein anatomical variation draining into the coronary sinus. Central venous catheter procedures may be complicated secondary to the presence of a persistent left superior vena cava, leading to life-threatening complications such as arrhythmias, cardiogenic shock, and cardiac arrest. We present a case of persistent superior vena cava diagnosed on transthoracic echocardiogram (TTE) in a patient with congestive heart failure. A dilated coronary sinus was identified on TTE, followed by injection of agitated saline into the left antecubital vein resulting in filling of the coronary sinus prior to the right atrium-an indication of persistent left superior vena-cava. This also was confirmed on cardiac computed tomography. Such a diagnosis is critical in patients who may undergo central venous catheter procedures such as our patient's potential requirement for an implantable cardiovertor defibrillator due to severe global left ventricular systolic dysfunction. The presence of a persistent left superior vena cava should always be suspected when the guidewire takes a left-sided downward course towards the right atrium at the level of the coronary sinus. Therefore, special attention should be paid to the imaging work-up prior to central venous catheter procedures.