Final Catheter Position Research Articles

Transesophageal echocardiography for thoracic spinal cord imaging and confirmation of epidural catheter placement in pediatrics

IntroductionTransesophageal echocardiography (TEE) use continues to expand to include extracardiac applications. However, there is limited research investigating the use of TEE as a tool to confirm the position of the epidural catheter. This prospective observational study aimed to evaluate whether TEE could be used to visualize the anatomy of the thoracic spinal canal in pediatrics. A subsequent prospective case series was conducted to evaluate whether TEE could be used to assist in the placement of epidural catheters in pediatric surgical patients. MethodsSeventy-five patients (50 pediatric and 25 adult subjects) were enrolled. The operators attempted to identify four structures (spinal cord, cerebrospinal fluid, dura mater, epidural space) within the thoracic spinal canal with TEE. After demonstrating the feasibility of this technique for observing the spinal anatomy, 20 pediatric surgical patients were enrolled in a case series. These patients had epidural catheter placement, and the final catheter position was confirmed with TEE. ResultsThe total number of thoracic spinal segment visualized in pediatric patients was 542 out of 550 (99%) segments, and 191 out of 275 (70%) segments in adult subjects (difference, 29% [95% confidence interval, 23–34]; p < 0.001). Additionally, a case series of 20 pediatric surgical patients demonstrated successful caudal or epidural catheter placement at target spinal level in 17 cases. ConclusionsThis observational study demonstrated the successful visualization of the thoracic spinal cord at virtually every level in pediatric patients. A subsequent case series demonstrated that TEE could be used to successfully confirm the position of the epidural catheter in the targeted thoracic spinal segment for pediatric surgical patients.

CE Article: Use of an Evidence-Based Protocol for Repositioning Peripherally Inserted Central Catheters (PICCs) in Children and Adults

Highlights Abstract Introduction: Achieving and maintaining optimal peripherally inserted central catheter (PICC) tip position can be challenging. At any time during therapies, the final catheter position can be altered due to changes in patient condition and intrathoracic pressure. Aim: To determine if the use of a standardized protocol with power flush option for repositioning the PICC tips will reduce the number of withdrawal interventions or exchange procedures. Methods: Johns Hopkins evidence-based practice (EBP) methodology was used to evaluate literature published in the past 5 years. A standardized protocol was developed and implemented in patients with malpositioned PICCs. The outcome measures were the successful repositioning of the catheter and costs for the procedure. Results: In 4 months, 43 (93%) of 46 (14 adult/32 pediatric) catheters were successfully repositioned. The withdrawal method was used to reposition 34 (73.9%). In 12 patients where a power flush was used, 9 (75%) were successfully repositioned. These changes resulted in decreased delays in treatment and financial savings of $235,210 in personnel time and supplies. Discussion: The standardized protocol provided an alternative to previous practices, extending dwell time, decreasing treatment delay, and unnecessary procedures, showing significant savings for the institution. Conclusions: The Vascular Access Team use of an evidence-based protocol was successful in reducing catheter exchange and withdrawals in malpositioned catheters among adult and pediatric populations. Relevance to Clinical Practice: The implementation of a standardized EBP to address malpositioned catheters resulted in the decreased need for catheter exchange, reduced delays in treatment, and cost savings.

High accuracy of external ventricular drainage placement using anatomical landmarks

BackgroundThe conventional approach for external ventricular drainage (EVD) application is the freehand method. Technical devices can improve the accuracy of placement, but they have not yet replaced anatomical landmarks owing to the cost and effort that they entail. There is disagreement as to whether freehand EVD application is safe enough to be accepted as a standard technique. Many authors have investigated the final catheter position in retrospect. They describe variable rates of malpositioning. However, few studies have assessed in how far cranial surface anatomy has really been respected during burr-hole drilling and catheter insertion. The aim of this study was to investigate parameters that might play a part in determining the final intracranial catheter position. MethodsIn all, 100 pre- and postprocedural thin-layer computed-tomography (CT) scans of EVD patients were analysed with the help of JiveX® and OsiriX Lite® software. A series of anatomical and catheter-related parameters, including inter alia intraventricular blood, midline shift, burr-hole location and catheter entrance angle, were correlated with the final catheter position. ResultsA majority of EVDs show an optimal or nearly optimal position. Only the deviation of catheter entrance angle has a significant influence on catheter malpositioning. The burr-hole location can vary within an area of several centimetres around the coronary suture. ConclusionsThe freehand application of EVD is safe as long as the intracranial anatomy is not disfigured to a large extent, the surface measurements are carried out precisely and the puncturing is done perpendicularly to the skull.

04:21 PM Abstract No. 362 Time to reevaluate the wings? A case series of thrombotic complications of Angel® catheters

Pre and post market experience with the Angel® catheter to evaluate efficacy, complication rates, and management strategy. Retrospective search of our database yielded 11 patients who underwent Angel® catheter placement from January 2016 to July 2018 with subsequent involvement of the interventional radiology service. Patient demographics, primary diagnosis, length of hospital stay, days from admission to catheter placement, days from catheter placement to removal, approach, catheter insertion length, time from placement to anticoagulation, specialty of operator, level of training, clot burden prior to retrieval, final catheter position, presence of imaging-proven deep venous thrombosis (DVT) whilst catheter in place, need for additional procedures, and complications of Angel® catheter were recorded (Table 1). All 11 patients (9 men, 2 women) underwent Angel® catheter placement at bedside under ultrasound guidance by 11 non-radiologist physicians (100%) of which 9 (81.8%) were in-training. Principal reason for admission was intracranial hemorrhage (ICH) for all patients with 9 due to trauma. Mean catheter insertion length was 25.3±4.2 cm. Catheters were left in place on average 13±3.4 days prior to first removal attempt with 8 of 11 (72.7%) catheters thrombosed at that time. 6 out of 11 (54.6%) required suprarenal IVC filter before removal while 7 of 11 (63.6%) overall required additional procedures prior to or for removal. Catheter placement to start of anticoagulation was 12.3±4.4 days. Admission to catheter placement was 4.1±1.9 days while overall length of stay was 46.5±26.6 days. One patient required contralateral replacement following unintentional removal while another patient had pulmonary embolism despite catheter placement. Based on our limited experience, Angel® catheter is associated with a high rate of caval thrombosis, need for additional invasive procedures, and increased morbidity.Table 1Angel® Catheter PerformanceCharacteristicsNoIndications Contraindication to pharmacologic prophylaxis11 (100%) Trauma9 Non-traumatic ICH2Facility location of catheter placement ICU bedside11 (100%)Approach: Right femoral11 Left femoral1*Operator Specialty: Non-radiologist11 (100%)Operator level of training: In training9 (81.82%)Time between admission and device insertion (days)4.09 ± 1.92Time between insertion and removal (days)13 ± 3.44Time between placement and starting anticoagulation (days)12.3 ± 4.4Average insertion length (cm)25.33 ± 4.21Final catheter position on abdominal radiograph T122 L1-L26 L2-L32 L3-L41DVT on Doppler ultrasound while catheter in place4 Right3 Left1Clot detection before retrieval Total8 (72.73%)Clot burden Extensive4 Large0 Moderate1 Small3Accidental catheter removal1Pulmonary embolism1No. requiring additional procedures: Overall7 (63.63%) Suprarenal filter placement6 (54.55%)*Accidental catheter removalDVT, deep vein thrombosis; ICH, intracranial hemorrhage; ICU, intensive care unit. Open table in a new tab

A new method to estimate catheter length for esophageal multichannel intraluminal impedance monitoring in children.

Multichannel intraluminal impedance combined with pH (MII-pH) is the gold standard test for diagnosing gastro-esophageal reflux disease (GERD). It provides an opportunity to study acid and non-acid GOR and temporal association between symptoms and reflux. Accurate catheter placement is essential to prevent erroneous recording of reflux events. The aims of our study were to assess the accuracy of our devised method in predicting the catheter length for MII-pH in children (Great Ormond Street Hospital (GOSH) Table) and to compare the results with Strobel and Monreau methods. Retrospective review of all records of infants and children who underwent MII-pH studies between January to October 2014. Desired catheter position was calculated using Strobel, Monreau and GOSH formulas and compared to X ray position. One hundred and forty-four children were included; mean age was 5.1 (±4.5) years, 73 males and 71 females. In the whole group, the correlation between desired catheter position and GOSH Table was 0.95, for Strobel was 0.84, and Monreau was 0.85. In the first group (age <3 years), the correlation was: GOSH Table 0.91, Strobel 0.56, and Monreau 0.6; in the second group (3-10 years): GOSH Table 0.78, Strobel 0.82, and Monreau 0.82; the third group (>10 years): GOSH 0.81, Strobel 0.43, and Monreau 0.43. GOSH Table is an accurate method to estimate the insertion length of MII-pH catheters from nares to a point of approximately two vertebral bodies above the diaphragm in children. Although radiography is required to confirm final catheter position, using GOSH Table will reduce the need for repeated catheter manipulation after initial insertion and will reduce the use of a mathematically complicated formulae.

CT Fluoroscopy-guided Aspiration of Intracerebral Hematomas: Technique and Outcomes

ObjectiveThe authors evaluated the feasibility and targeting accuracy of CT fluoroscopy (CTF)-guided catheter placement and aspiration of intracerebral hematoma (ICH)s.Materials and MethodsNine patients (mean age, 63.3 ± 15.3 years) were treated by CTF-guided hematoma aspiration under local anesthesia. The targeting errors in the lesion center, volume of the aspirated hematoma, accuracy of the final catheter position, procedure time, and clinical outcomes were evaluated.ResultsAll catheters were successfully placed in the center of the hematoma. The mean volume of the aspirated hematoma was 20.6 ± 8.8 mL (pre-treatment, 44.7 ± 20.1 mL; post-treatment, 24.1 ± 13.8 mL). The average procedure time was 25.1 minutes (range, 18-32 minutes). In one case with a scanty residual hematoma, the catheter was removed at the end of the procedure. In the remaining eight cases, the catheter was left in the residual hematoma for drainage and all catheter tips were accurately located in the final position. There were no procedure-related complications, including rebleeding and infection.ConclusionCTF-guided ICH aspiration is a feasible, quick, and accurate procedure which could substitute for stereotactic methods. The accurate catheter position provided by real-time observation enables an effective aspiration and drainage of hematomas.

Placement of coiled catheters into the paravertebral space*

There are conflicting results with regard to the use of catheter-based techniques for continuous paravertebral block. Local anaesthetic spread within the paravertebral space is limited and the clinical effect is often variable. Discrepancies between needle tip position and final catheter position can also be problematic. The aim of this proof-of-concept study was to assess the reliability of placing a newly developed coiled catheter in human cadavers. Sixty Tuohy needles and coiled catheters were placed under ultrasound guidance, three on each side of the thoracic vertebral column in 10 human cadavers. Computed tomography was used to assess needle tip and catheter tip locations. No catheter was misplaced into the epidural, pleural or prevertebral spaces. The mean (SD) distance between catheter tips and needle tips was 8.2 (4.9) mm. The median (IQR [range]) caudo-cephalad spread of contrast dye injectate through a subset of 20 catheters was 4 (4-5[3-8]) thoracic segments. All catheters were removed without incident. Precise paravertebral catheter placement can be achieved using ultrasound-guided placement of a coiled catheter.

Multislice Computed Tomographic Angiography for Preinterventional Planning of Port Placement for Intra-Arterial Hepatic Infusion Chemotherapy

To determine the impact of preinterventional multislice computed tomographic angiography (MSCTA) on the interventional management of patients scheduled for hepatic port placement. A total of 21 patients with metastatic colorectal cancer confined to the liver were referred for interventional placement of an intra-arterial hepatic port system and underwent triphasic MSCT of the abdomen. The arterial phase images were processed to reveal the arterial anatomy, to identify anomalies, and to prospectively plan the interventional management. Ten anatomical characteristics of the liver blood supply, which were considered to be crucial for the interventional procedure, were analyzed per patient (presence, origin, and configuration of liver arteries, angles, and distances to connected vessels). Based on these data, 6 predictions on the interventional procedure were made, including final catheter position, catheter type, the necessity for guiding catheter, expenditure of time, and the need for changing the standard implantation procedure. All findings were correlated with catheter angiography during the port placement. Normal vascular anatomy of the hepatic arteries was seen in 43% of the patients. As vascular variants, most frequently, we found an accessory right artery (19%), a replaced right artery arising from the superior mesenteric artery (14%), or a left hepatic artery, fed by the left gastric artery, in combination with a middle hepatic artery arising from the right hepatic artery (10%). The correct detailed anatomical description compared with angiographic findings was provided by an MSCTA image analysis in 20 of 21 patients (sensitivity = 0.98, specificity = 0.99; chi2 = 1.024, P = 0.311; 95% confidence interval (CI) = 95.24; 76.18-99.88). The prospective planning of the angiographic management, including the appropriate choice of the port catheter based on MSCTA, was correct in 17 of 21 patients (sensitivity = 0.71, specificity = 0.76; chi2 = 2.487, P = 0.115; 95% CI = 80.95; 58.09-94.55). The MSCTA is effective for planning interventional port implantation in patients considered for hepatic arterial infusion chemotherapy.

Continuous plexus and peripheral nerve blocks for postoperative analgesia.

Continuous plexus and peripheral nerve blocks for postoperative analgesia.

Changes in Tunneled Catheter Tip Position when a Patient Is Upright

To determine the relative changes in position of tunneled catheters from supine to upright patient position and factors affecting catheter tip migration. One hundred forty-six different tunneled catheters were placed through the subclavian or jugular veins radiologically, and catheter positions were documented with use of cine radiography at the time of placement. Follow-up chest radiographs were obtained with the patient in the upright position within 48 hours after placement. Catheter tip positions were numbered from 1 to 8, with 1 representing the innominate/superior vena cava junction and 8, the lower right atrium. Patient sex and weight, the site of catheter entry, and the size and type of catheter were correlated with the relative change in position on the follow-up chest radiogrpahs. There was a statistically significant (P < .0001) change in catheter position on the follow-up chest radiographs, with a mean difference of 1.5 catheter positions (usually mid-right atrium initially to low superior vena cava on follow-up). Catheter tip migration was greater for catheters in the subclavian veins, in females, and in obese patients. The catheter tip migrates significantly from the initial position at the time of placement as compared to when the patient assumes the upright position. This knowledge is important in achieving the desired final catheter position.