Internal Jugular Central Venous Catheter Research Articles

Low Approach Internal Jugular Central Venous Catheters: Optimizing Catheter Performance and Patient Experience

Bilirubin-induced neurologic dysfunction (BIND) is the constellation of neurologic sequelae following milder degrees of neonatal hyperbilirubinemia than are associated with kernicterus. Clinically, BIND may manifest after the neonatal period as developmental delay, cognitive impairment, disordered executive function, and behavioral and psychiatric disorders. However, there is controversy regarding the relative contribution of neonatal hyperbilirubinemia versus other risk factors to the development of later neurodevelopmental disorders in children with BIND. In this review, we focus on the empiric data from the past 25 years regarding neurodevelopmental outcomes and BIND, including specific effects on developmental delay, cognition, speech and language development, executive function, and the neurobehavioral disorders, such as attention deficit/hyperactivity disorder and autism.

Simulation Improves Procedural Protocol Adherence During Central Venous Catheter Placement: A Randomized Controlled Trial.

Simulation training may improve proficiency at and reduce complications from central venous catheter (CVC) placement, but the scope of simulation's effect remains unclear. This randomized controlled trial evaluated the effects of a pragmatic CVC simulation program on procedural protocol adherence, technical skill, and patient outcomes. Internal medicine interns were randomized to standard training for CVC insertion or standard training plus simulation-based mastery training. Standard training involved a lecture, a video-based online module, and instruction by the supervising physician during actual CVC insertions. Intervention-group subjects additionally underwent supervised training on a venous access simulator until they demonstrated procedural competence. Raters evaluated interns' performance during internal jugular CVC placement on actual patients in the medical intensive care unit. Generalized estimating equations were used to account for outcome clustering within trainees. We observed 52 interns placing 87 CVCs. Simulation-trained interns exhibited better adherence to prescribed procedural technique than interns who received only standard training (P = 0.024). There were no significant differences detected in first-attempt or overall cannulation success rates, mean needle passes, global assessment scores, or complication rates. Simulation training added to standard training improved protocol adherence during CVC insertion by novice practitioners. This study may have been too small to detect meaningful differences in venous cannulation proficiency and other clinical outcomes, highlighting the difficulty of patient-centered simulation research in settings where poor outcomes are rare. For high-performing systems, where protocol deviations may provide an important proxy for rare procedural complications, simulation may improve CVC insertion quality and safety.

12 Intraosseous Vascular Access Catheter Appears Safe During Extended Dwell: A Preliminary Report

Despite relatively few documented complications associated with intraosseous (IO) vascular access, the US Food and Drug Administration (FDA) restricts catheter dwell time to 24 hours for IO devices. This may contribute to placement of central venous catheters for difficult vascular access patients in whom an IO placement would otherwise suffice, contributing to an increased risk for complications and costs. Many clinicians have requested that the IO catheter dwell time be extended to at least 48 hours. A study was designed to determine the safety of IO access when the catheter is left in place for up to 48 hours. The study protocol is being conducted under an Investigational Device Exemption granted by the FDA and was approved by IntegReview Ethical Review Board. Consenting adult volunteers (target N=120) with renal impairment and/or diabetes were randomized to have an IO catheter (Arrow EZ-IO Intraosseous Vascular Access System,Teleflex Inc., Reading, PA) placed in the proximal humerus or proximal tibia by a trained physician. At the discretion of the investigator, subjects were administered midazolam and fentanyl to mitigate anxiety associated with IO insertion and the pain associated with the initial flush. With a slow continuous saline infusion administered by infusion pump, subjects remained in a secured early phase research unit for 48 hours. IO infusion pain was managed initially with IO lidocaine injections, then as needed with oral acetaminophen. For more severe pain, intravenous/intramuscular Toradol or oral hydrocodone/acetaminophen were administered. After 48 hours, an IO aspirate sample was obtained from the in-situ catheter for culturing and an x-ray was taken of the IO insertion site after removal. After 30 days, subjects returned for physical examination and x-ray imaging of the insertion site. As of April 2015, 24 subjects have completed the study with one subject in follow-up. There have been no serious adverse events or complications associated with the IO catheters. The IO aspirate culture reports have shown no growth of microorganisms associated with osteomyelitis; there has been no radiographic evidence of osteomyelitis or other abnormalities associated with the IO catheter. Pain associated with IO catheter dwell and infusion has been well managed with the additional medications (acetaminophen, Toradol, and hydrocodone/acetaminophen); a finding previously unreported. Preliminary results indicate that IO vascular access can be safely maintained for a period up to 48 hours without risk of osteomyelitis or other serious adverse events. Extended dwell time and increased IO access utilization could result in avoidance of serious complications and costs associated with peripherally inserted central catheters (PICC lines), as well as femoral, subclavian, and internal jugular central venous catheters being placed due to difficult vascular access, when central venous access may not be clinically necessary. Using additional analgesics for IO infusion pain management may be more effective than the current standard of only administering lidocaine into the IO space.

Video-augmented feedback for procedural performance

Background: Resident programs must assess residents’ achievement of core competencies for clinical and procedural skills.Aims: Video-augmented feedback may facilitate procedural skill acquisition and promote more accurate self-assessment.Methods: A randomized controlled study to investigate whether video-augmented verbal feedback leads to increased procedural skill and improved accuracy of self-assessment compared to verbal only feedback. Participants were evaluated during procedural training for ultrasound guided internal jugular central venous catheter (US IJ CVC) placement. All participants received feedback based on a validated 30-point checklist for US IJ CVC placement and validated 6-point procedural global rating scale.Results: Scores in both groups improved by a mean of 9.6 points (95% CI: 7.8–11.4) on the 30-point checklist, with no difference between groups in mean score improvement on the global rating scale. In regards to self-assessment, participant self-rating diverged from faculty scoring, increasingly so after receiving feedback. Residents rated highly by faculty underestimated their skill, while those rated more poorly demonstrated increasing overestimation.Conclusions: Accuracy of self-assessment was not improved by addition of video. While feedback advanced the skill of the resident, video-augmented feedback did not enhance skill acquisition or improve accuracy of resident self-assessment compared to standard feedback.

Incidence of catheter-related venous thromboembolism in peripherally inserted central venous catheters vs tunneled chest central venous catheters in patients with hematologic malignancies.

e20684 Background: Common complications of central venous catheters (CVCs) include catheter-related venous thromboembolism (CR-VTE) and central line-associated blood stream infections (CLABSI). In an effort to decrease CR- VTE rates, in 5/2012 the Medical College of Wisconsin (MCW) HM group changed the placement of CVCs from brachiocephalic vein PICCs to tunneled chest internal jugular vein CVCs in all patients with HMs unless contraindicated. Methods: We report CR-VTE and CLABSI rates pre- and post-intervention between 1/2009-6/2013. Clinical data were collected through the electronic medical record. All comparisons were using Fisher’s exact Chi-square test. Results: From 1/2009-6/2013, 1,953 CVCs were placed in patients at MCW with HMs. The table shows the significant decrease in overall incidence of VTEs (p < 0.01) with stable incidence of CLABSIs (p = 0.15) following a change to placement of tunneled CVCs. There was no statistical difference between disease types. Conclusions: The HM group at MCW inst...

The S-Tunnel for tunnelled dialysis catheter: an alternative approach to the prevention of displacement.

Vascular access has been described in the literature anywhere from the 'Achilles Heel' to the 'Cornerstone' of haemodialysis. Displacement of a central venous catheter is not an uncommon occurrence. We discuss an alternative method of placement for the tunnelled central venous catheter to prevent displacement in those patients with excess anterior chest wall soft tissue. A new surgical technique for placement of a tunnelled central venous catheter was developed in an attempt to reduce the number of displacements. This involved the creation of a second tunnel at a 90° angle to the original retrograde tunnelled path. The authors have currently placed five 'S-Line' tunnelled central venous catheters with no reports of displacement or line infection over a period of 18 months. The 'S-Line' offers a simple, straightforward and most importantly safe method to reduce the incidence of tunnelled right internal jugular central venous catheter displacement.

Is long-axis view superior to short-axis view in ultrasound-guided central venous catheterization?

To evaluate whether using long-axis or short-axis view during ultrasound-guided internal jugular and subclavian central venous catheterization results in fewer skin breaks, decreased time to cannulation, and fewer posterior wall penetrations. Prospective, randomized crossover study. Urban emergency department with approximate annual census of 60,000. Emergency medicine resident physicians at the Denver Health Residency in Emergency Medicine, a postgraduate year 1-4 training program. Resident physicians blinded to the study hypothesis used ultrasound guidance to cannulate the internal jugular and subclavian of a human torso mannequin using the long-axis and short-axis views at each site. An ultrasound fellow recorded skin breaks, redirections, and time to cannulation. An experienced ultrasound fellow or attending used a convex 8-4 MHz transducer during cannulation to monitor the needle path and determine posterior wall penetration. Generalized linear mixed models with a random subject effect were used to compare time to cannulation, number of skin breaks and redirections, and posterior wall penetration of the long axis and short axis at each cannulation site. Twenty-eight resident physicians participated: eight postgraduate year 1, eight postgraduate year 2, five postgraduate year 3, and seven postgraduate year 4. The median (interquartile range) number of total internal jugular central venous catheters placed was 27 (interquartile range, 9-42) and subclavian was six catheters (interquartile range, 2-20). The median number of previous ultrasound-guided internal jugular catheters was 25 (interquartile range, 9-40), and ultrasound-guided subclavian catheters were three (interquartile range, 0-5). The long-axis view was associated with a significant decrease in the number of redirections at the internal jugular and subclavian sites, relative risk 0.4 (95% CI, 0.2-0.9) and relative risk 0.5 (95% CI, 0.3-0.7), respectively. There was no significant difference in the number of skin breaks between the long axis and short axis at the subclavian and internal jugular sites. The long-axis view for subclavian was associated with decreased time to cannulation; there was no significant difference in time between the short-axis and long-axis views at the internal jugular site. The prevalence of posterior wall penetration was internal jugular short axis 25%, internal jugular long axis 21%, subclavian short axis 64%, and subclavian long axis 39%. The odds of posterior wall penetration were significantly less in the subclavian long axis (odds ratio, 0.3; 95% CI, 0.1-0.9). The long-axis view for the internal jugular was more efficient than the short-axis view with fewer redirections. The long-axis view for subclavian central venous catheterization was also more efficient with decreased time to cannulation and fewer redirections. The long-axis approach to subclavian central venous catheterization is also associated with fewer posterior wall penetrations. Using the long-axis view for subclavian central venous catheterization and avoiding posterior wall penetrations may result in fewer central venous catheter-related complications.

Optimal insertion lengths of right and left internal jugular central venous catheters in children

Knowledge of the optimal lengths for central venous catheterization prior to the procedure may lessen the need for repositioning and prevent vascular complications. To establish the optimal lengths for non-tunneled central venous catheter insertion through the right and left internal jugular veins. We included 92 children who received US-guided central venous catheterization via right or left internal jugular veins in intensive care units. The calculated distance between the skin and carina was considered the optimal length for right and left internal jugular venous catheterization. Univariate and multivariate linear regression analyses was used to identify predictors. Age, height and weight showed significant correlations with optimal insertion lengths for right and left internal jugular vein approaches on univariate analysis, while height was the only significant independent predictor of optimal insertion length. The optimal insertion lengths (cm) suggested by our data are, for the right internal jugular vein 0.034 × height (cm) + 3.173, and for the left 0.072 × height (cm) + 2.113.

Board #102 - Research Abstract Comparing Standard Vs. Video-Based Teaching For Ultrasound-Guided Internal Jugular Central Venous Catheter Access For 4th Year Medical Students (Submission #8825)

Hypothesis Small group instruction of procedural skills is faculty intensive, and presents challenges when multiple instructors are required to train large numbers of learners. At our institution, incoming residents who want vascular access privileges undergo a protocolized ultrasound guided central line training program. Senior medical students have requested similar training, but faculty resources are not adequate to accommodate the large number of interested students. To meet student needs, we developed a self-directed video-based learning module to teach the skill of ultrasound guided internal jugular access (US-IJ) to our institutional standards. The objective of this study is to evaluate the efficacy of teaching US-IJ using high quality video compared to standard faculty led US-IJ teaching. The video enables learners to self-pace with the ability to rewind, pause, and fast-forward individual video segments. Methods Randomized controlled trial in the simulation center of an academic center, during a four-week senior medical student capstone course in March 2014. Each student completed a peripheral US IV training session and an online module. Subjects were randomly assigned to either faculty-led (standard) or video-guided (intervention) three-hour teaching sessions using vascular access manikins and ultrasound machines. Intervention group used an interactive video detailing procedural steps, following a standard checklist (55 items) established by our institution. The intervention group had the chance to interact with a faculty at the end of their session to address specific questions only. At the conclusion of each session, all students independently completed a video-recorded performance station of US-IJ placement. Two faculty instructors scored videos based on the checklist. Scores were compared using t-test. An independent instructor scored 20% of each group to calculate inter-rater reliability. Results Thirty-two MS-IV were enrolled in the study, 16 in each group. Five students were excluded (four did not attend and one encountered ultrasound recording failure). Fourteen students in the video group and 13 students in the standard group were included. The intervention group performed significantly more checklist items correctly (90%, 95%CI 86.5-93%) than did the standard group (81%, 95% CI 77.6-84.2%). (P = 0.0003) Conclusion US-IJ training using self-directed high quality video guided instruction may be superior to standard, faculty-guided instruction. Use of video eliminates instructional variability, decreases the demand on faculty time, and enables individual learners to work at their own pace. Furthermore, a larger number of learners can be accommodated. This is crucial in places where having continuous, standard, and high-quality instruction is considered a challenging problem. We recommend a larger study of vascular access training using video guidance be conducted. Disclosures The CLASS Center has received support in the form of equipment loans from Karl Storz. Claudia Ranniger owns stock in Intuitive Surgical (manufacturer of DaVinci Robot).

Application of the improved hospital gown with catheter fixer in fixing central venous catheter

Objective To explore the effect of improved hospital gown on fixing central venous catheter.Methods One hundred and twenty-one patients with internal jugular central venous catheter after abdominal surgery from April 2013 to October 2013 were chosen and divided into the observation group and the control group according to the date of operation .The observation group received the hospital gown with catheter fixer so as to fix central venous catheter , and the control group received the routine fixation method through the adhesive plaster .The fixation effect was compared between two groups .Results The average time of liquid smooth, catheter displacement , fixation catheter once again , catheter traction and film intact in the observation group were longer than those in the control group , and the differences were statistically significant （ t=3.01, 3.25,6.13,4.57,9.85, respectively;P〈0.05）.The patients’ comfortable and convenience in activity in the observation group were better than those in the control group , and the differences were statistically significant （Z=-9.38,-10.62, respectively;P〈0.01）.The rates of catheter infection and extubation were respectively 4.8%and 0.0%in the observation group, and were lower than 10.1%and 3.4%in the control group, and the differences were statistically significant （χ^2 =4.93,5.62, respectively;P〈0.05）.Conclusions The improved hospital gown with catheter fixer can fix the internal jugular central venous catheter well , reduce the rates of catheter infection and extubation , increase patients ’ comfortable and convenience in activity , and reduce the workload of nurses , it is worthy of clinical application . Key words: Department of general surgery; Abdominal surgery; Central venous catheter; Catheter infection; Improved hospital gown

319 Comparing Standard versus Video-Based Teaching for Ultrasound-Guided Internal Jugular Central Venous Catheter Access for Fourth-Year Medical Students

319 Comparing Standard versus Video-Based Teaching for Ultrasound-Guided Internal Jugular Central Venous Catheter Access for Fourth-Year Medical Students

Letter to editor on a rare central venous catheter malposition.

Dear Editor, We read A Rare Central Venous Catheter Malposition: A Case Report by Moeinipour et al. (1) with interest. Insertion of central venous catheters (CVCs) is without a doubt an essential component of both peri-operative and critical care monitoring and management (2). It is also considered as a fundamental skill to achieve Certificate of Completion of Training for any anaesthetic trainees in the United Kingdom (3). Insertion of CVCs is associated with complications in more than 15% of patients, mainly mechanically, from infection and from thromboembolic events (4). Hence, the importance of correct positioning of CVCs could not be undermined as malposition could lead to lethal consequences. There is currently no quoted incidence of malposition of central venous catheters into the left internal mammary (thoracic) vein from the literature. We also would like to report a rare case of a 69-year-old female who had a left internal jugular vein quad-lumen CVC inserted for venous access and iontropic support during her admission to the critical care unit. Left internal jugular vein was chosen to free up the right internal jugular vein for renal dialysis line. Apart from mild resistance when feeding the guide wire, the insertion was uneventful: full aseptic technique under ultrasound, first pass, seldinger technique using J-guide wire and blood was easily aspirated from all 4 lumen. Malposition was identified on the post-procedure chest x-ray with the catheter lying on the left side, parallel to the tracheal shadow, under the level of the carina (see Figure 1). This line was used without complications after initial hesitancy about its location. Subsequently, a renal dialysis line was inserted without any difficulties under ultrasound to the right internal jugular vein in the correct position (again checked by chest x-ray). The malposition was identified by non-contrast Computed Tomography (CT). Figure 1. A Chest X-ray showing the malposition of a left internal jugular central venous catheter down the left internal mammary (thoracic) vein Both of these cases lead us to believe that the incidence of this type of malposition may be more common than we think. It emphasises the importance to appreciate the anatomy of the left internal jugular vein and its course to the superior vena cava. In addition, during the insertion of CVCs to the left internal jugular vein, we should pay extra attention to ensure that we lead with the guide wire and catheter with the bevel aiming towards the right hand side to ensure it aim towards the right subclavian vein and therefore avoid turning into the left internal mammary (thoracic) vein. Resistance to guide wire insertion should raise a high index of suspicion for potential malpositioning. Finally, apart from the left internal mammary (thoracic) vein, another rare malposition of CVCs into a duplicated left-sided superior vena cava is also possible. A duplicated left-sided superior vena cava is seen in 0.3-0.5% of the normal population and in 4.4% of those with congenital heart disease (5). This anatomical variation could only be diagnosed by contrast CT.

Ultrasound assistance for central venous catheter placement in a pediatric emergency department improves placement success rates.

The use of ultrasound (US) has been shown to improve success rates and reduce complications of central venous catheter (CVC) placement in adult emergency department (ED) patients. The authors sought to determine if US assistance for CVC placement is associated with an increased success rate in pediatric ED patients. This was a retrospective cohort study of CVC placement in a pediatric ED from January 2003 to October 2011. Data were extracted from a procedure log created to record details entered by physicians at the time of CVC placement, including indication, location, complications, and information regarding use of US. All femoral vein and internal jugular vein CVC placement attempts performed by, assisted with, or directly supervised by pediatric emergency physicians (EPs) were included. Characteristics of procedures performed with and without US assistance were compared, controlling for patient and physician factors. The primary outcome was the success rate of CVC placement. There were 168 patients undergoing CVC placement attempts. The proportion of successful placement attempts was significantly higher when using US assistance (96 of 98) compared to those without (55 of 70; 98% vs. 79%, odds ratio [OR]= 13.1, 95% confidence interval [CI]=2.9 to 59.4). When controlling for patient- and physician-specific factors, success rates remained significantly higher. Ultrasound assistance was associated with greater likelihood of success in CVC placement in a pediatric ED.

Short-term and Long-term Impact of the Central Line Workshop on Resident Clinical Performance During Simulated Central Line Placement

The Central Line Workshop (CLW) was introduced at our institution to better train residents in safe placement of the central venous catheter (CVC). This study sought to determine if immediate performance improvements from the CLW are sustained 3 months after the training for residents with various levels of experience. Twenty-six emergency medicine residents completed the CLW, which includes online modules and experiential sessions in anatomy, ultrasound, sterile technique, and procedural task training. Demonstration of the synthesis of these skills including placement of both internal jugular and subclavian CVCs was assessed using a task trainer. Each resident was also tested approximately 3 months before and 3 months after the CLW. Residents were assessed using a validated CVC proficiency scale. Residents' CVC proficiency scores (percentage of items performed correctly during the assessment station) improved after CLW (0.6 vs. 0.93, P < 0.05). At 3 months after CLW testing, there was apparent skill decay from the CLW but overall improvement compared with baseline testing (0.6 vs. 0.8, P < 0.05). There was no significant difference in procedure time after CLW training. The postgraduate year 1 group showed the greatest improvement of CVC skill after CLW training. Resident CVC placement performance improved immediately after the CLW. Although performance 3 months after the CLW revealed evidence of skill decay, it was improved when compared with initial baseline assessment. Novice learners had the greatest benefit from the CLW.

Dissemination of a simulation-based mastery learning intervention reduces central line-associated bloodstream infections

BackgroundApproximately 41 000 central line-associated bloodstream infections (CLABSI) occur annually in US hospitals. We previously developed a simulation-based mastery learning (SBML) curriculum in central venous catheter (CVC) insertion that significantly...

Central Vascular Catheter Placement Evaluation Using Saline Flush and Bedside Echocardiography

Central venous catheter (CVC) placement is a common procedure in critical care management. The authors set out to determine echocardiographic features during a saline flush of any type of CVC. The hypothesis was that the presence of a rapid saline swirl in the right atrium on bedside echocardiography would confirm correct placement of the CVC tip, similar to the accuracy of the postplacement chest radiograph (CXR). This was a prospective convenience sample of emergency department (ED) and intensive care unit (ICU) patients who had CVCs placed. Investigators used subcostal or apical four-chamber echocardiography windows to evaluate the onset and appearance of turbulent flow in the right atrium when the distal port of the CVC was flushed with 10mL of saline. Onset was rated as "immediate" (within 2seconds), "delayed" (2 to 6seconds), or "absent" (did not appear within 6seconds). Appearance was rated as "prominent," "speckling," or "absent." Digital video review was used later to objectively determine precise timing of turbulence onset. The rapid atrial swirl sign (RASS) was defined as the echo appearance of turbulence entering the right atrium immediately (within 2seconds) after the saline flush of the CVC distal port. The observance of RASS ("positive") was considered "negative" for CVC malposition. Echocardiographic results were compared to CVC tip locations within predetermined zones on the CXR. Superior vena cava (SVC) region was considered the optimal CVC tip position for subclavian and internal jugular CVC. Left CVC tips within the mid left innominate vein were also considered appropriately placed. A total of 142 patients enrolled, yielding 152 CVCs. Two CVCs were excluded from analysis due to incomplete data. Both CXR and echocardiographic images for 107 internal jugular CVCs and 28 subclavian CVCs were available for analysis. Saline flush echo evaluations were also performed on 15 femoral CVCs. Either 16-cm triple-lumen or 20-cm PreSep CVCs were used. CVC malposition was discovered on CXR in four of 135 (3.0%) of the subclavian and internal jugular CVCs. RASS for subclavian and internal jugular CVC evaluations versus CXR results for CVC tip malposition yielded 75% sensitivity, 100% specificity, positive predictive value (PPV) 100% (95% confidence interval [CI]=29.24% to 100%), and negative predictive value (NPV) 99.24% (95% CI=95.85% to 99.98%). Mean (±SD) time for onset of saline flush turbulence was 1.1 (±0.3) seconds for subclavian and internal jugular CVC tips within the target CXR zone. The rapid appearance of prominent turbulence in the right atrium on echocardiography after CVC saline flush serves as a precise bedside screening test of optimal CVC tip position.

Board 305 - Research Abstract Dissemination of a Simulation-Based Mastery Learning Intervention Reduces Central Line-Associated Bloodstream Infections (Submission #202)

Introduction/Background Approximately 41,000 central line-associated bloodstream infections (CLABSI) occur yearly in U.S. hospitals.1 Despite strategies such as checklists, many hospitals have not been able to reduce CLABSI rates.2 We previously developed a simulation-based mastery learning (SBML) curriculum in central venous catheter (CVC) insertion that significantly reduced CLABSI rates.3 The aim of the current study was to measure the effect of dissemination and implementation of the SBML curriculum developed at a tertiary care medical center on trainee skills and CLABSI rates at a community hospital. Methods We performed a cohort study of all internal medicine and emergency medicine residents before their intensive care unit (ICU) rotation at Mercy Hospital (an academic community hospital) from September 2010 to May 2012. Residents underwent a CVC SBML curriculum before their ICU rotation. We evaluated residents simulated internal jugular (IJ) and subclavian (SC) CVC insertion skills before and after the educational intervention using a 29 item checklist. All residents were required to meet or exceed a minimum passing score at post-test before completion of training. Subsequently, we evaluated the effects of the SBML training program on CLABSI rates at Mercy hospital. We compared CLABSI rates from October 2008 to August 2010 (pre-intervention) to September 2010 to May 2012 (post-intervention). Results The mean IJ pretest score was 35.5% (10.29/29, SD = 8.30) compared to a post-test mean of 93.0% (26.96/29, SD = 1.50; P < 0.001). The mean SC pretest score was 23.0% (6.68/29; SD = 9.58) and increased to 96.1% (27.88/29, SD = 1.41) at post-test (P < 0.001). There were 3.82 infections per 1000 catheter-days (20 infections in 5235 catheter-days) in the ICU in the 23 months before the educational intervention. During the 21 months after the intervention there were 1.29 infections per 1000 catheter-days (6 infections in 4670 catheter days). Patients in the ICU had significantly fewer CLABSIs after the SBML intervention (P = 0.019). The incidence rate ratio was 0.257 (95% CI, 0.089-0.742) after controlling for APACHE III scores. Conclusion This study demonstrates successful dissemination and implementation of a CVC SBML curriculum at a community academic hospital. The intervention significantly improved resident CVC insertion skills and reduced CLABSI rates. This collaboration illustrates how medical educators can use evidence-based training Methods to improve patient care.

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.

A review of 5434 percutaneous pediatric central venous catheters inserted by anesthesiologists

To review the results of an anesthesiologist led pediatric percutaneous central venous access service. Prospective data on percutaneous pediatric central venous catheter (CVC) insertions were collected over 22 years. Data included age, gender, weight, previous central CVCs, venous thromboses, investigations for great vein patency, type of CVC, external diameter, previous CVC insertions, intended use, operator identity, and the vein into which the CVC was inserted. The default technique was internal jugular vein cannulation using landmark technique (LT). Complication was defined as the following: failure to cannulate any vein, hemothorax, pneumothorax, right atrial perforation, extravenous wire positioning or CVC position and whether the patient was taken back to theater for CVC repositioning. Five thousand four hundred and thirty-four percutaneous CVC insertion procedures were performed on 3954 patients. One-third involved children <1 year of age (n = 1823: 34%). Five thousand one hundred and twenty-five CVCs (95.3%) were inserted into internal jugular veins. The majority were tunneled CVCs (n = 5190: 96.2%). The perioperative complication rate was 1.3%. Successful cannulation occurred in 99.5% of patients. Failure was more likely in children <3 kg, during large bore hemodialysis CVC insertions and during the first 4 years of the service - the latter suggesting a learning curve. Ninety-nine percent of CVCs were inserted using LTs. This study demonstrates a high success rate and low complication rate during pediatric percutaneous internal jugular vein CVC insertions by trained anesthesiologists using LTs. Smaller children, hemodialysis CVCs, and the team's learning curve were identified as risk factors for insertion failure.

Unrecognised guide wire migration during internal jugular cannulation and its retrieval – A Case Report

The objective of this article is to report a case of unrecognised missed guide wire diagnosed two months after right internal jugular cannulation and which was successfully retrieved from the right femoral vein. The case record of a patient that had retained intravenous guide wire was reviewed with relevant literature. A 40-yr-old female had an emergency left thoracotomy on account of haemorrhagic pleural effusion. A right internal jugular central venous catheter (CVC) insertion was performed for resuscitation and haemodynamic monitoring before induction of anaesthesia. A follow-up thoraco-abdominal Computed tomography (CT) scan taken after 8 weeks showed a pigtail intravascular metallic foreign body traversing the distal superior vena cava, right atrium, inferior vena cava, and ending at the right femoral vein. The guide wire was successfully removed via a right femoral venotomy under local anaesthesia. Intravascular loss of a guide wire is a rare complication of CVC insertion. If basic precautionary measures were taken, the loss of guide wire would have been avoided.