Position Of Central Venous Catheter Research Articles

Feasibility of a new ultrasound guided procedure to ensure the correct position of the central venous catheter tip

BackgroundSafety of central venous catheter (CVC) placement relies on some general aspects, including selection of the right vessel, correct lumen targeting while inserting the needle, check the position of catheter tip, and post-procedure check for complications. All these four points can be guided by bedside ultrasound, but the best technique to ensure the position of the CVC tip is still uncertain. MethodsWe investigated feasibility of a novel ultrasound technique consisting of focused view of guidewire tip in the cavoatrial junction (CAJ) to calculate the CVC depth in adult patients needing CVC placement in emergency. Direct visualization of the guidewire in the CAJ was used to calculate how deep the CVC needed to be inserted. In those patients without a valid CAJ window, a bubble test in the right atrium was performed to position the CVC tip. In all cases chest radiography confirmed the CVC position. ResultsThe procedure was performed in 37 patients and CVC was correctly placed in all cases. Within the group, in 25 patients the CVC depth (21.5 ± 6.0 cm) was successfully measured. In other 11 patients the correct CVC tip position was confirmed by the bubble test. In only one case it was not possible to use ultrasound for incomplete CAJ and right atrium views. ConclusionsThis study confirms the feasibility of a new ultrasound method to ensure the correct CVC tip position. This protocol could potentially become a standard method reducing costs, post-procedural irradiation, and time of CVC placement in emergency.

Optimal positioning of central venous catheters using intracavitary electrocardiogram: A narrative review

Central venous catheters (CVCs), either inserted centrally or peripherally (PICCs), are an essential therapeutic assist tool within and beyond critical care. The correct position of the tip of the CVC is important as suboptimal positioning may lead to complications. Chest X-ray remains the mainstay for tip position confirmation for the vast majority of CVCs. Intracavitary electrocardiogram (IC-ECG) is a validated method that can be utilized for this purpose. It is an accurate, easy-to-use, safer technique without radiation exposure. Its routine adoption in clinical practice is not universal. This narrative review discusses the techniques used for IC-ECG and their clinical implications.

A Simple and Safe Method for Checking the Position of Central Venous Catheters-A New and Reliable Threshold for Right Atrial Swirl Sign in Microbubbles Tests.

Background: Central venous catheters (CVCs) are indispensable tools in intensive care and emergency medicine. CVC malpositions still occur frequently and can cause various complications leading to increased patient mortality. A microbubbles test (MBT) can be used to confirm correct CVC positioning. However, there is serious doubt regarding whether the currently applied threshold of a 2 s push-to-bubbles time (PTB time) for rapid atrial swirl sign (RASS) in an MBT is reliable and accurate. The aim of the present study was to prove the quality of a new threshold: 1 s. Methods: Consecutive patients who were admitted to the intensive care unit (ICU) in a German neurological specialist hospital from 1 March 2021 to 20 July 2022 were enrolled. After ultrasound-guided CVC insertion, an MBT was performed, PTB time was measured, and RASS was interpreted. Additionally, a chest X-ray (CXR) was requested to check CVC position. Results: A total of 102 CVCs (98% jugular and 2% subclavian) were inserted in 102 patients (38% female and 62% male; median age: 66 years). Negative RASS (PTB time > 1 s) was observed in 2 out of 102 patients, resulting in an echocardiographic malposition rate of 2.0%. CXR confirmed the echocardiographic results. After correcting CVC position in the initially malpositioned CVCs, the PTB time was <1 s (positive RASS). The MBT protocol took about 0.5 min on average, while the CXR results were all available within 30 min. Sensitivity, specificity, and positive and negative predictive value were each 100% for the detection of CVC malpositions via an MBT using a threshold of 1 s compared to CXR. Conclusions: A new threshold of a 1 s PTB time for RASS in an MBT could detect CVC malpositions with excellent quality compared to CXR. Since the MBT was fast and safe and could be performed at the bedside, we propose that an MBT with the new and reliable threshold of 1 s should be routinely used in patient care.

Using central venous pressure waveform to confirm the placement of an internal jugular central venous catheter in the intensive care unit

BackgroundA mobile chest X-ray is traditionally performed to confirm the position of an internal jugular central venous catheter (CVC) after placement in the intensive care unit (ICU). Using chest radiography to confirm CVC position often results in delays in authorising the use of the CVC, requires the deployment of additional human resources, and is costly. ObjectiveThis study aimed to determine the feasibility and accuracy of using the central venous pressure (CVP) waveform to confirm the placement of internal jugular CVCs. MethodsThis retrospective study was conducted in a single quaternary ICU over a 6-month period. We included adult patients who had internal jugular CVC inserted and CVP transduced as part of their routine care in the ICU. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CVP waveform analysis in confirming the position of internal jugular CVC relative to chest radiography were calculated. ResultsA total of 241 internal jugular CVCs were inserted (in 219 patients, 35.6% female), and the CVP waveform was assessed. In 231 cases, this suggested adequate placement in a central vein, which corresponded with a correct position on subsequent chest X-ray. On six occasions, the CVP waveforms were interpreted as suboptimal; however, on chest X-rays, the CVCs were noted to be in a suitable position (sensitivity: 97.5%). Four suboptimal CVP waveforms were obtained, and they correctly identified CVC malposition on subsequent chest X-ray (specificity: 100%). The average time from CVC insertion to radiological completion was 118 minutes. ConclusionCVP waveform analysis provides a feasible and reliable method for confirming adequate internal jugular CVC position. The use of chest radiography can be limited to cases where suboptimal CVP waveforms are obtained.

Feasibility Analysis of Ultrasound-Guided Placement of Tunneled Hemodialysis Catheters

Radiographic fluoroscopy is the current standard for placement of tunneled central venous catheters (CVCs) for hemodialysis. Radiographic fluoroscopy requires structural and personnel infrastructure and exposes the patient to ionizing radiation. Here, we investigate the feasibility of solely ultrasound-guided placement of tunneled central venous dialysis catheters (USCVCs). We evaluated prospectively collected single-center data regarding safety and catheter function of 134 consecutive patients who underwent USCVC implantation between 2020 and 2021. We used the inset guidewire to visualize the position of the catheter tip. In the case of inadequate visibility by ultrasound, we used intracardiac electrocardiography (ECG) recording or agitated saline. A total of 1844 catheter days were assessed. The optimal CVC position was defined as being within the upper right atrium (URA) and middle to deep right atrium. Of the 134 USCVCs, 87% were placed on the right side. The primary success rate for optimal tip position and catheter function was 98%. Of the USCVCs, 97% were placed solely by ultrasound. Regarding positioning, 6% were in the vena cava superior zone, 70% in the URA and 24% in the middle to deep right atrium, resulting in a rate of 94% with optimal positioning. Effective blood flow averaged 292 ± 39 ml/min. There were no immediate procedure-associated complications. Placement of CVC for hemodialysis solely by ultrasound is an effective alternative to fluoroscopy-assisted placement.

Analysis of Line and Tube Detection Performance of a Chest X-ray Deep Learning Model to Evaluate Hidden Stratification.

This retrospective case-control study evaluated the diagnostic performance of a commercially available chest radiography deep convolutional neural network (DCNN) in identifying the presence and position of central venous catheters, enteric tubes, and endotracheal tubes, in addition to a subgroup analysis of different types of lines/tubes. A held-out test dataset of 2568 studies was sourced from community radiology clinics and hospitals in Australia and the USA, and was then ground-truth labelled for the presence, position, and type of line or tube from the consensus of a thoracic specialist radiologist and an intensive care clinician. DCNN model performance for identifying and assessing the positioning of central venous catheters, enteric tubes, and endotracheal tubes over the entire dataset, as well as within each subgroup, was evaluated. The area under the receiver operating characteristic curve (AUC) was assessed. The DCNN algorithm displayed high performance in detecting the presence of lines and tubes in the test dataset with AUCs > 0.99, and good position classification performance over a subpopulation of ground truth positive cases with AUCs of 0.86-0.91. The subgroup analysis showed that model performance was robust across the various subtypes of lines or tubes, although position classification performance of peripherally inserted central catheters was relatively lower. Our findings indicated that the DCNN algorithm performed well in the detection and position classification of lines and tubes, supporting its use as an assistant for clinicians. Further work is required to evaluate performance in rarer scenarios, as well as in less common subgroups.

#4216 FEASIBILITY ANALYSIS OF AN ULTRASOUND-GUIDED PLACEMENT OF TUNNELED HEMODIALYSIS CATHETERS

Abstract Background and Aims Radiographic fluoroscopy (RAD) is the current standard for placement of tunneled central venous catheters (CVC) for hemodialysis. RAD requires structural and personnel infrastructure and exposes the patient to ionizing radiation. Here, we investigate the feasibility of solely ultrasound-guided placement of tunneled central venous dialysis catheters. Method We evaluated prospectively collected single center data of 134 consecutive patients who underwent CVC implantation between 2020 and 2021 regarding feasibility, safety, and catheter function. We used the inset guidewire to visualize the position of the catheter tip. In the case of inadequate visibility by ultrasound, we additionally used intracardiac ECG recording or agitated saline. A total of 1844 catheter days were assessed. As a historical control, we analyzed the position of 50 CVCs placed by RAD. Optimal CVC position was defined to be in between the cavoatrial junction (CAJ) and the right atrium (RA), according to the guidelines. Results The catheters were placed on the right side in 117 (87%) cases. The primary success rate for optimal position and function was 97,7% (n = 131). Placement solely by ultrasound was possible in 130 (97%) cases. There were no immediate procedure-associated complications related to the new technique. Effective blood flow averaged 292 +/- 39 ml/min. Of all ultrasound-placed catheters, 6% were in the vena cava superior (RAD 24%), 70% in the CAJ (RAD 60%), and 24% in the RA (RAD 16%), resulting in a rate of 94% with optimal position. Conclusion Placement of CVCs for hemodialysis solely by ultrasound is an effective and safe alternative to fluoroscopy-assisted placement.

A worldwide survey on the variability in checking the tip position of pediatric central venous catheter.

A worldwide survey on the variability in checking the tip position of pediatric central venous catheter.

Achieving Optimal Central Venous Catheter Position: Evaluation of Radiographic Landmarks for Accuracy and Inter-observer Reliability in Locating the Cavoatrial Junction

Achieving Optimal Central Venous Catheter Position: Evaluation of Radiographic Landmarks for Accuracy and Inter-observer Reliability in Locating the Cavoatrial Junction

Central catheter tip migration in critically ill patients.

Chest X-ray (CXR) is routinely required for assessing Central Venous Catheter (CVC) tip position after insertion, but there is limited data as to the movement of the tip location during hospitalization. We aimed to assess the migration of Central Venous Catheter (CVC) position, as a significant movement of catheter tip location may challenge some of the daily practice after insertion. Retrospective, single-center study, conducted in the Intensive Care and Cardiovascular Intensive Care Units in Tel Aviv Sourasky Medical Center 'Ichilov', Israel, between January and June 2019. We identified 101 patients with a CVC in the Right Internal Jugular (RIJ) with at least two CXRs during hospitalization. For each patient, we measured the CVC tip position below the carina level in the first and all consecutive CXRs. The average initial tip position was 1.52 (±1.9) cm (mean±SD) below the carina. The maximal migration distance from the initial insertion position was 1.9 (±1) cm (mean±SD). During follow-up of 2 to 5 days, 92% of all subject's CVCs remained within the range of the Superior Vena Cava to the top of the right atrium, regardless of the initial positioning. CVC tip position can migrate significantly during a patient's early hospitalization period regardless of primary location, although for most patients it will remain within a wide range of the top of the right atrium and the middle of the Superior Vena Cava (SVC), if accepted as well-positioned.

Assessment of the Tip Position of Central Venous Catheters Inserted Using Peres' Height Formula.

The tip of a central venous catheter (CVC) should be positioned in the proximity of the cavo-atrial junction (CAJ)where thelower third of the superior vena cava (SVC) and the upperright atrium (RA) are located to prevent life-threatening complications. This study aimed to determine the accuracy of Peres' height formula in predicting the correct insertion depth of CVC. Methods:A total of 332 patients were enrolled in this prospective observational study. All CVCs were inserted using Peres' formula. The 'correct' tip position of CVC was the placement of the CVC tip 1 cm above and 1 cm below the carina inCXR. Rates of correct placements for each side and site of catheter insertions, gender, and body mass index (BMI) differences were evaluated. The correct placement rate of all catheters was 74.4%. There were statistically significant correlations between the correct placement of right-sided jugular and subclavian catheters (p<0.001) and left-sided jugular and subclavian catheters (p=0.014). There was a statistically significant difference in male patients (p=0.047). Higher BMI resulted in a lower rate of correct placement with no statistically significant difference (p=0.457). Peres' formula can be easily used to determine the correct position of CVC tips with a success rate in the Turkish population. However, practitioners should be aware of the low accuracy rate ofPeres' formula in female patients (68.5%) and patients with BMI over 35 kg/m2 (62.5%).

Validity of ultrasonography in detection of central venous catheter position and pneumothorax compared to portable chest X-ray

Validity of ultrasonography in detection of central venous catheter position and pneumothorax compared to portable chest X-ray

Classification of Central Venous Catheter Tip Position on Chest X-ray Using Artificial Intelligence.

Recent studies utilizing deep convolutional neural networks (CNN) have described the central venous catheter (CVC) on chest radiography images. However, there have been no studies for the classification of the CVC tip position with a definite criterion on the chest radiograph. This study aimed to develop an algorithm for the automatic classification of proper depth with the application of automatic segmentation of the trachea and the CVC on chest radiographs using a deep CNN. This was a retrospective study that used plain chest supine anteroposterior radiographs. The trachea and CVC were segmented on images and three labels (shallow, proper, and deep position) were assigned based on the vertical distance between the tracheal carina and CVC tip. We used a two-stage approach model for the automatic segmentation of the trachea and CVC with U-net++ and automatic classification of CVC placement with EfficientNet B4. The primary outcome was a successful three-label classification through five-fold validations with segmented images and a test with segmentation-free images. Of a total of 808 images, 207 images were manually segmented and the overall accuracy of the five-fold validation for the classification of three-class labels (mean (SD)) of five-fold validation was 0.76 (0.03). In the test for classification with 601 segmentation-free images, the average accuracy, precision, recall, and F1-score were 0.82, 0.73, 0.73, and 0.73, respectively. We achieved the highest accuracy value of 0.91 in the shallow position label, while the highest F1-score was 0.82 in the deep position label. A deep CNN can achieve a comparative performance in the classification of the CVC position based on the distance from the carina to the CVC tip as well as automatic segmentation of the trachea and CVC on plain chest radiographs.

Economic Evaluation of Ultrasound-guided Central Venous Catheter Confirmation vs Chest Radiography in Critically Ill Patients: A Labor Cost Model.

IntroductionDespite evidence suggesting that point-of-care ultrasound (POCUS) is faster and non-inferior for confirming position and excluding pneumothorax after central venous catheter (CVC) placement compared to traditional radiography, millions of chest radiographs (CXR) are performed annually for this purpose. Whether the use of POCUS results in cost savings compared to CXR is less clear but could represent a relative advantage in implementation efforts. Our objective in this study was to evaluate the labor cost difference for POCUS-guided vs CXR-guided CVC position confirmation practices.MethodsWe developed a model to evaluate the per patient difference in labor cost between POCUS-guided vs CXR-guided CVC confirmation at our local urban, tertiary academic institution. We used internal cost data from our institution to populate the variables in our model.ResultsThe estimated labor cost per patient was $18.48 using CXR compared to $14.66 for POCUS, resulting in a net direct cost savings of $3.82 (21%) per patient using POCUS for CVC confirmation.ConclusionIn this study comparing the labor costs of two approaches for CVC confirmation, the more efficient alternative (POCUS-guided) is not more expensive than traditional CXR. Performing an economic analysis framed in terms of labor costs and work efficiency may influence stakeholders and facilitate earlier adoption of POCUS for CVC confirmation.

Dose-Related Analysis in Percutaneous Central Venous Catheters Insertion: Experience of a Pediatric Interventional Radiology Center.

Background: There are many techniques for long-term central venous catheter (CVC) placement, but none of them are specific for pediatric patients or focused on the delivered dose of ionizing radiation. Materials and Methods: This retrospective study examined a sample of pediatric patients who received percutaneous long-term CVC positioning in a tertiary care pediatric hospital. Effective dose, dose-area product (DAP) and length of time of exposition during the procedure were determined, using an appropriate technical procedure, exam and program set of the angiograph, and compared with an unpaired t-test analysis. Results: The study included 1410 enrolled patients, with a median age of 10 years (range 0.2–18 years), between 2016 and 2019. In 2016 (318 pts), the mean effective dose was 0.13 mSv and the mean DAP dose was 18.95 µGy/m2 In 2017 (353 pts), the mean effective dose was 0.11 mSv and the mean DAP dose was 17.26 µGy/m2. In 2018 (351 pts), the mean effective dose was 0.05 mSv and the mean DAP dose was 7.23 µGy/m2. In 2019 (388 pts), the mean effective dose was 0.02 mSv and the mean DAP dose was 3.10 µGy/m2. Conclusions: Medical and technical expertise led to a remarkable reduction in the radiation dose. Therefore, the authors’ hypothesis is that US- and fluoroscopy-guided percutaneous long-term CVC insertion technique is safer, more cost-effective and lower in terms of radiation exposure if correctly applied, compared to surgical or percutaneous by direct puncture techniques.

Inadequate positioning of central venous catheters inserted at intensive care units.

To evaluate the positioning of the distal tip of central venous catheters and the factors that contributed to inadequate positioning in patients admitted to intensive care. This is a cross-sectional study, with a sample of 246 medical records of patients admitted to intensive care units. A catheter position analysis form was used as an instrument for data collection. It was seen that 86.2% of catheters used in intensive care were centrally inserted in the internal jugular veins, 74.4% were double-lumen catheter, and ultrasound was employed for puncture technique in 84.6% of cases. Of the distal ends of the catheters, 53.7% were at the cavoatrial junction (correct position). According to statistical tests, there was a positive correlation between the inadequate positioning of the distal extremity with the central insertion catheter (p=0.012). Patients with presumptive diagnosis associated with COVID-19 showed a positive correlation with inappropriate positioning of the catheter distal tip (p=0.017). There are extrinsic factors related to improper positioning of the distal tip of catheters, such as the type of catheter used, the patients' diagnosis and the puncture with insertion in the left jugular vein.

Abstract No.: ABS2471: Comparison of landmark versus ECG-guided technique for correct insertion of central venous catheter in paediatric patients undergoing cardiothoracic surgery

Background & Aims:Central venous catheters (CVC), commonly indicated in paediatric patients during cardiac surgeries can cause various complications if not correctly positioned. Objective of this study was to compare correct placement of the CVC tip using anatomical landmark technique with ECG-guided technique.Methods:A prospective, randomised interventional study was conducted on 72 patients of <12 years age, randomly allotted to two groups of 36 patients each (landmark and ECG). After induction, central venous cannulation was performed in right IJV in all patients using either of the techniques. Post operative chest X rays were obtained in all patients and correct position of CVC was checked. CVC tip position within 0.5cm above/ below or at carina was considered as correct position. Analyses were performed using Student’s t-tests and Chi square-tests.Results:It was found that 22 (61.11%) in the landmark group were positioned correctly as compared to 33 (91.67%) in the ECG group (p = 0.006). The mean depth of CVC insertion was 9.05±1.66 in landmark group and 8.26±1.41 in the ECG group (p= 0.032). The landmark group had 12 (33.33%) participants with complications during the procedure, compared to 3 (8.33%) in the ECG-guided group (p = 0.020).Conclusion:ECG-guided technique was found to be more accurate for CVC tip placement than the anatomical landmark technique. ECG-guided technique had less complications than the anatomical landmark technique. Hence, ECG-guided CVC placement is relatively accurate, efficient, and safe.ParameterLandmark Group (n=36)ECG Group (n=36) P Age (in years)6.56±3.646.50±3.480.947Sex (M/F)21/1520/161.00Height (cm)114.04±22.95112.79±22.580.816Weight (kg)19.33±9.4019.83±8.480.810

Implementation of ultrasound after central venous catheter insertion: A qualitative study in early adopters.

The adoption rate of point of care ultrasound (POCUS) for the confirmation of central venous catheter (CVC) positioning and exclusion of post procedure pneumothorax is low despite advantages in workflow compared to traditional chest X-ray (CXR). To explore why, we convened focus groups to address barriers and facilitators of implementation for POCUS guided CVC confirmation and de-implementation of post-procedure CXR. We conducted focus groups with emergency medicine and critical care providers to discuss current practices in POCUS for CVC confirmation. The semi-structured focus group interview guide was informed by the Consolidated Framework for Implementation Research (CFIR). We performed qualitative content analysis of the resulting transcripts using a consensual qualitative research approach (NVivo software), aiming to identify priority categories that describe the barriers and facilitators of POCUS guided CVC confirmation. The coding dictionary of barriers and facilitators consisted of 21 codes from the focus group discussions. Our qualitative analysis revealed that 12 codes emerged spontaneously (inductively) within the focus group discussions and aligned directly to CFIR constructs. Common barriers included provider influences (e.g. knowledge and beliefs about POCUS for CVC confirmation), external network (e.g. societal guidelines, ancillary staff, and consultants), and inertia (habit or reflexive processes). Common facilitators included ultrasound protocol advantage and champions. Time and provider outcomes (cognitive offload, ownership, and independence) emerged as early barriers but late facilitators. Our qualitative analysis demonstrates real and perceived barriers against implementation of POCUS for CVC position confirmation and pneumothorax exclusion. Our findings discovered organizational and personal constructs that will inform development of multifaceted strategies toward implementation of POCUS after CVC insertion.

Mediastinal contrast extravasation after injection via central venous catheter with follow-up venography: a case report

A central venous catheter can occasionally be used for contrast injection during a CT scan, with mediastinal contrast extravasation as a possible rare complication in this setting. According to the published cases, interventional venography has never been performed to assess the venous system directly. We present a case of mediastinal contrast extravasation with follow-up venography, which clearly depicted a subintimal leak and no evidence of sustained extravasation. The contrast was reabsorbed shortly after the extravasation with no adverse effects for the patient. The presented case illustrates the importance of recognition of proper positioning of central venous catheters before performing angiographies with relatively high flow velocity, such as CT angiography, as well as the importance of performing staff being familiar with different aspects of working with central venous catheters.

Chest radiography for simplified evaluation of central venous catheter tip positioning for safe and accurate haemodynamic monitoring: a retrospective observational study

ObjectivesThe tip-to-carina (TC) distance on a simple chest X-ray (CXR) has proven value in the determination of correct central venous catheter (CVC) positioning. However, previous studies have mostly focused on...