Internal Jugular Central Venous Catheter Research Articles

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.

Resident accuracy in locating the common femoral vein in normal weight vs. obese patients

Objectives: Ultrasound guidance increases the success of internal jugular central venous catheter (CVC) placement. The common femoral vein (CFV) is considered an easier site and physicians frequently place CFV CVCs using anatomical landmark guidance. No research has demonstrated the effect of patient weight on placement of a femoral CVC. The authors hypothesized that resident physicians could determine by anatomical landmarks the insertion site of a femoral CVC in normal and overweight adults. Methods: Investigators consented adult patients in the Emergency Department to serve as study models. Patients were grouped by BMI: Normal (BMI (BMI > 25). PGYI-III Emergency Medicine residents who volunteered to participate were included. Residents inspected and palpated the inguinal regions on a patient and marked the patient’s skin directly over the CFV. A faculty member assessed success using a 10 MHz linear probe (Sonosite Micro Maxx) centered over the mark. The attempt was successful if the mark was directly over the CFV and unsuccessful if distal, lateral, or medial to the CFV. Results: Nineteen residents (6 PGYI, 7 PGY II, and 6 PGYIII) assessed 17 patients. There were 43 attempts on Normal patients and 57 attempts on Overweight patients. The success rate on Normal patients was 74% and on Overweight patients was 42% (p = 0.0021). Conclusion: Residents were more successful in correctly identifying the CFV by anatomical landmarks in Normal patients. Training year had no effect on success. Ultrasound guidance may increase the success rate of placing a femoral CVC in patients with BMI > 25.

English

BACKGROUND: Context: A central venous line access is very importance in management of the critically ill patients even though, it may carry a risk of complications. AIMS: Objective of this study is to assess and compare success rate, attempts of cannulation and complications like inadvertent arterial puncture, hematoma, and pneumothorax occurred during the Central Venous Catheter (CVC) placement using ultrasound guidance (USG) & anatomical landmark guidance (ALG). SETTINGS AND DESIGN: The prospective randomized study was carried out in 64 patients for right sided internal jugular vein CVC placement. Using computer generated randomization chart, all patients were divided randomly into two groups: Group USG and Group ALG. METHODS AND MATERIAL: Right sided internal jugular vein (IJV) was cannulated with the guidance of ultrasound and anatomical landmark, respectively in group USG and group ALG. Patients were observed & data were recorded for success rate, no. of attempts, and complications like inadvertent arterial puncture, hematoma, and pneumothorax STATISTICAL ANALYSIS USED : Database was analysed using graphpad prism 5 software. RESULTS: Success rate is 31 out of 32 (96.88%) in group USG while 24 out of 32 (75%) in group ALG (p =0.031). Placement of central venous catheter with 1st attempt is 28 out of 32 (87.50%) in group USG while 18 out of 32 (56.25%) in group ALG (p =0.012). Hematoma and overall complications are 0 versus 6 (18.75%) in group USG & ALG respectively. CONCLUSIONS: Ultrasound guided central venous catheter placement is easy, safer & prudent approach than the anatomical landmark guided central venous catheter placement. KEY MESSAGES: We believe that Ultrasound guidance should be encouraged for all central venous catheter placements in patients & thereby improving patient's safety and quality care.

Electrocautery induced artifactual ST segment depression in leads II, III and aVF on intra operative 5-lead electrocardiogram

To the Editor, We describe a case of electrocautery-induced artifactual inferior wall ischemic changes in a 31 year old male patient with chronic kidney disease (CKD) undergoing repeat live donor kidney transplantation. He was a known case of CKD since last 7 years and undergone live donor kidney transplantation 6 years back. He was on maintenance hemodialysis twice a week again since a year. He was continued to be hypertensive since last 10 years even after kidney transplantation and was on three anti hypertensive medications. He had dyspnea on exertion class II and New York Heart Association status II. His preoperative 12-lead electrocardiogram (ECG) showed normal sinus rhythm with left ventricular hypertrophy (LVH). Echocardiogram reported concentric LVH, mild mitral regurgitation, mild pulmonary artery hypertension, minimal pericardial effusion and left ventricular ejection fraction of 40 %. All anti hypertensive medications were continued till morning on day of surgery. In the operating room, 5-lead ECG, pulse oximetry and non-invasive blood pressure monitoring was applied on non-fistula arm. Anesthesia was induced with fentanyl, propofol and atracurium. Right internal jugular central venous catheter was placed under ultrasound guidance and surgery was allowed to start. Immediately after skin incision, ST segment depression was noted in lead II (Fig. 1a). He was hemodynamically stable with blood pressure of 147/89 mm Hg and pulse rate of 88 per minute. ST segment depressions were temporary and intermittent with the use of unipolar electrocautery by surgeon. Correct placement of ECG electrodes was confirmed and all lead ECG view was seen on monitor to look at other leads for similar changes. It was noticed that ST segment depressions were present in lead II, III and aVF with slight ST elevation in aVR (Fig. 1b). These intermittent and temporary ECG changes were present and reproducible throughout the surgery. Electrocautery (anode) plate was applied on posterior aspect of upper part of right thigh, quite away from the ECG electrodes. Monitor used was one attached to Datex-Ohmeda S/5 Avance anesthesia workstation and was in routine use without similar occurrence in other cases. Post operative his 12-lead ECG was same as preoperative and enzyme marker (troponin T, troponin I and CK-MB) were negative for ischemia or infarction. Electrocautery induced artifact in intraoperative ECG showing ST changes have been reported previously. Jain et al. [1, 2] reported electrocautery induced ST segment depression in two different patients with coronary artery disease undergoing non cardiac surgeries. In an another case reported by Jain et al. [3] showed ST segment elevation in lead V5 with concurrent ST depression in lead II, in a CKD patient undergoing cadaveric kidney transplantation. Similar ST segment depression was also reported by Ketchey et al. [4]. In present case ST segment depressions were noted in lead II, III and aVF, and this point toward diagnosis of inferior wall ischemia or it can be a mirror image of ischemia in another area (e.g. anterior ischemia) or other non-ischemic diseases. Being an American society of anesthesiologist physical status grade III patient, kidney transplant recipient patient is always at great suspicion for perioperative cardiac arrhythmias, myocardial ischemia and infarction. The five S. L. Solanki (&) K. Kishore V. K. Goyal Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae-Bareilly Road, Lucknow 226014, India e-mail: me_sohans@yahoo.co.in

Dialysis Access Flow Phenomenon Demonstrated via an Internal Jugular Central Venous Catheter Uniquely Positioned within a Superior Vena Cava Stenosis

Dialysis Access Flow Phenomenon Demonstrated <i>via</i> an Internal Jugular Central Venous Catheter Uniquely Positioned within a Superior Vena Cava Stenosis

Vertebral Artery Thrombosis and Subsequent Stroke Following Attempted Internal Jugular Central Venous Catheterization

Complications arising from internal jugular venous catheterization are uncommon. Injury to the carotid artery is reported as one of the more common injuries. Vertebral artery injuries are rare and include pseudoaneurysm formation, arteriovenous fistulas, lacerations, and dissection with thrombus formation. Occasionally, such injuries initially go unnoticed and have the potential to cause catastrophic outcomes, leaving clinicians and families wondering what transpired. A thorough autopsy can not only help discern the cause of death, but also help to bring closure to the family. Here we present a case of an unexpected death 3 days following surgery for idiopathic scoliosis in a 17-year-old male. During the surgical procedure, a right internal jugular venous catheterization was attempted but aborted after several failed tries. Twenty-four hours after the procedure, the patient became obtunded and progressed to brain death. At autopsy, he was found to have a right transmural vertebral artery puncture wound with thrombosis leading to a massive posterior circulatory stroke.

Systematic review: is real-time ultrasonic-guided central line placement by ED physicians more successful than the traditional landmark approach?

IntroductionThe superiority of ultrasonic-guided compared with landmark-guided central venous catheter (CVC) placement is not well documented in the Emergency Department.ObjectiveTo systematically review the literature comparing success rates between ultrasonic- and...

Hospital-wide assessment of compliance with central venous catheter dressing recommendations

This hospital-wide assessment of central venous catheter (CVC) site maintenance evaluated a total of 420CVC sites and found deficiencies in 31%. Internal jugular CVC dressings were the most frequently deficient type (P= 0.001). No correlation between CVC site maintenance and central line-associated bloodstream infections was detected (Spearman's correlation coefficient= 0.007; P= 0.98).

Thrombosis associated with right internal jugular central venous catheters: A prospective observational study

Background and Aims:Central venous catheters (CVC) are essential in a critical care setting. Thrombosis is one of the very important associated complications that can lead to increased morbidity and mortality. The aim of this study was to find out the incidence of thrombosis in right-sided internal jugular vein (IJV) CVC with the help of color Doppler duplex sonography, its extent, risk factors and clinical impact.Materials and Methods:One hundred consecutive patients having right-sided IJV CVC were included in the study. Color Doppler sonography was performed on the 3rd and 6th days after CVC insertion. The size of the thrombus was noted. Presence of diabetes mellitus, hypertension or smoking was noted. Presence of any hypertonic solution and thromboprophylaxis for Deep vein thrombosis (DVT) were also noted.Results:Thrombus was detected in 33 of 100 (33.0%) patients. The incidence in males was 32.86% and in females was 33.33%. Males had a significantly higher incidence of small thrombus (P = 0.05), whereas females had a significantly higher incidence of large thrombus (P = 0.05). DVT thromboprophylaxis was not effective for CVC-related thrombosis. Hypertonic solution, presence of diabetes, hypertension or history of smoking did not increase the risk of thrombosis.Conclusion:CVC-related thrombosis is common and has the potential for serious complications. Females appear to be at a higher risk for larger thrombus formation. DVT thromboprophylaxis does not confer protection for CVC-related thrombosis. Color Doppler duplex sonography provides with an easily available, noninvasive means of detecting a thrombus. More studies are needed to establish a consensus for prophylaxis and treatment of asymptomatic CVC-related thrombosis.

Sonographic and Clinical Features of Upper Extremity Deep Venous Thrombosis in Critical Care Patients

Background-Aim. Upper extremity deep vein thrombosis (UEDVT) is an increasingly recognized problem in the critically ill. We sought to identify the prevalence of and risk factors for UEDVT, and to characterize sonographically detected thrombi in the critical care setting. Patients and Methods. Three hundred and twenty patients receiving a subclavian or internal jugular central venous catheter (CVC) were included. When an UEDVT was detected, therapeutic anticoagulation was started. Additionally, a standardized ultrasound scan was performed to detect the extent of the thrombus. Images were interpreted offline by two independent readers. Results. Thirty-six (11.25%) patients had UEDVT and a complete scan was performed. One (2.7%) of these patients died, and 2 had pulmonary embolism (5.5%). Risk factors associated with UEDVT were presence of CVC [(odds ratio (OR) 2.716, P = 0.007)], malignancy (OR 1.483, P = 0.036), total parenteral nutrition (OR 1.399, P = 0.035), hypercoagulable state (OR 1.284, P = 0.045), and obesity (OR 1.191, P = 0.049). Eight thrombi were chronic, and 28 were acute. We describe a new sonographic sign which characterized acute thrombosis: a double hyperechoic line at the interface between the thrombus and the venous wall; but its clinical significance remains to be defined. Conclusion. Presence of CVC was a strong predictor for the development of UEDVT in a cohort of critical care patients; however, the rate of subsequent PE and related mortality was low.

Unexpected Collateral Effects of Simulation-Based Medical Education

Internal medicine residents who complete simulation-based education (SBE) in central venous catheter (CVC) insertion acquire improved skills that yield better patient care outcomes. The collateral effects of SBE on the skills of residents who have not yet experienced SBE are unknown. In this retrospective, observational study, the authors used a checklist to test the internal jugular and subclavian CVC insertion skills of 102 Northwestern University second- and third-year internal medicine residents before they received simulation training. The authors compared, across consecutive academic years (2007-2008, 2008-2009, 2009-2010), mean pretraining scores and the percent of trainees who met or surpassed a minimum passing score (MPS). Mean internal jugular pretest scores improved from 46.7% (standard deviation = 20.8%) in 2007 to 55.7% (±22.5%) in 2008 and 70.8% (±22.4%) in 2009 (P < .001). Mean subclavian pretest scores changed from 48.3% (±25.5%) in 2007 to 45.6% (±31.0%) in 2008 and 63.6% (±27.3%) in 2009 (P = .04). The percentage of residents who met or surpassed the MPS before training for internal jugular insertion was 7% in 2007, 16% in 2008, and 38% in 2009 (P = .004); for subclavian insertion, the percentage was 11% in 2007, 19% in 2008, and 38% in 2009 (P = .028). SBE for senior residents had an effect on junior trainees, as evidenced by pretraining CVC insertion skill improvement across three consecutive years. SBE for a targeted group of residents has implications for skill acquisition among other trainees.

Phrenic nerve injury after image-guided insertion of a tunnelled right internal jugular central venous catheter

Central venous catheters (CVC) are now commonly inserted by radiologists. Although complications are infrequent, they must be avoided where possible and recognized when they occur. We present a 10-year-old boy who developed right hemidiaphragmatic paralysis, requiring surgical plication, following US-guided insertion of a tunnelled right internal jugular CVC. The needle trajectory for internal jugular puncture must be planned to avoid the phrenic nerve.

Cardiac Surgery Without Blood Products in a Jehovah's Witness Child With Factor VII Deficiency

In the case reported here, the situation was complicated by a congenital deficiency of factor VII (FVII), which increased the risk of surgical and postoperative bleeding. Perioperative rotational thromboelastometry coagulation monitoring avoided empiric prophylactic treatment with recombinant activated FVII (rFVIIa). CASE REPORT A 5-year-old girl weighing 37.8 lb of the JW faith without cardiologic symptoms or a history of bleeding episodes had been diagnosed with ostium secundum atrial septal defect (ASD) by echocardiogram and was scheduled for transcatheter device closure of the defect. The transesophageal echocardiographic study and cardiac catheterization confirmed a 16-mm diameter defect (Qp:Qs ratio of 2.4:1) and contraindicated transcatheter device closure due to insufficient rims and the extension of the defect into the inferior vena cava. The patient was scheduled for ASD closure with CPB. The patient’s parents, also JWs, did not authorize the use of whole blood or blood components (ie, packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate), but accepted the use of coagulation factor concentrates (ie, fibrinogen, factor VIIa, and prothrombin complex), erythropoietin, intravenous iron, and cell salvage. Preoperative routine tests showed a hemoglobin (Hb) concentration of 12.5 g/dL, hematocrit of 36.6%, a mild iron deficit (iron: 45 g/dL, transferrin: 253 mg/dL, transferrin saturation: 14%, ferritin: 40 ng/mL, and total iron-binding capacity: 321 g/dL), and an abnormal prothrombin time (PT) of 15 seconds (63% activity, international normalized ratio 1.3) with a normal activated partial thromboplastin time. After the confirmation of prolonged PT, further investigations revealed a mild FVII deficiency (43.3% activity), whereas all other coagulation factors were within the normal range. Surgery was scheduled 13 days later to allow adequate preparation of the patient and to avoid the administration of blood products during the procedure. Treatment was initiated with a short preoperative course of 7 doses of subcutaneous human recombinant erythropoietin (r-HuEPO) at a dosage of 600 U/kg every other day. At the start of erythropoietin treatment, the maximum single intravenous dose of ferric carboxymaltose (255 mg) was administered in a 15-minute infusion to prevent relative iron deficiency. The patient also received oral supplements of vitamin B12 and folic acid throughout the preoperative period. A complete blood count and coagulation panel were obtained the day before surgery, showing an increase in Hb of 2 g/dL. The PT remained prolonged because of the FVII deficiency. Laboratory findings from preoperative and postoperative tests are summarized in Table 1. Anesthesia management consisted of induction with sevoflurane in oxygen and air, followed by fentanyl and cisatracurium administration to facilitate endotracheal intubation, and maintenance with remifentanil, 0.25 g/kg/min, and 2% sevoflurane in an oxygen/air mixture. A radial arterial catheter and a right internal jugular central venous catheter were inserted for invasive pressure monitoring. Near-infrared spectroscopy and bispectral index were used for neurologic monitoring. After heparin administration and cannulation, a direct suturing of the edges of the ASD was performed under moderate hypothermic (32°C) CPB (36 minutes) with a cross-clamp time of 18 minutes. After rewarming, modified ultrafiltration, and protamine administration, weaning from CPB was achieved uneventfully using a continuous infusion of low-dose dopamine (3 g/kg/min). Preoperative erythropoietin treatment was combined with fibrinolytic prophylaxis intraoperatively (tranexamic acid given in a bolus dose of 15 mg/kg before surgical incision), a meticulous surgical technique, a crystalloid low-volume priming CPB circuit (500 mL), modified ultrafiltration (500 mL), and a reduction in the number and volume of blood samples for laboratory tests. During and immediately after surgery, coagulation was monitored with rotational thromboelastometry (ROTEM; TEM International, GmbH, Munich, Germany), which made the administration of coagulation factor concentrates unnecessary (Table 2). Bleeding was not heavier than normal. The chest drains were removed 48 hours after surgery with a total volume of 106 mL. The patient was discharged from the pediatric intensive care unit on day 2 after the surgery and was sent home on day 6. No transfusions of blood products were administered.

Patient with Posterior Mediastinal Mass Requiring Urgent Cardiopulmonary Bypass

T HE literature on anesthetic concerns and perioperative care of patients with mediastinal masses has focused almost exclusively on anterior mediastinal masses. Posterior mediastinal masses traditionally have been suggested to carry a low risk of anesthetic implications. We present the case of a patient with a posterior mediastinal mass who experienced hemodynamic and respiratory decompensation upon induction of general anesthesia and required urgent transition to cardiopulmonary bypass (CPB). Our case illustrates the importance of real-time imaging provided by transesophageal echocardiography (TEE) in explaining the etiology of intractable hemodynamic instability and a new finding of significant pericardial and left pleural effusion not seen on preoperative imaging. TEE made clear the urgent need to initiate CPB because it revealed a near total compression of the left atrium, which was obstructing delivery of volume to the left ventricle. In addition, this case demonstrates the inadequacy of “stand-by” CPB and the need for every institution to establish an interdisciplinary team to develop, before surgery, a formal plan for the perioperative care of patients with mediastinal masses.

Near miss intra-arterial injection via a dual transducer pressure monitoring set

We write regarding a potential hazard of using a dual transducer pressure monitoring set for arterial and central venous catheters. A 20-G right radial arterial catheter (Becton, Dickinson and Company Critical Care Systems Pte Ltd., Franklin Lakes, NJ, USA) and a right internal jugular quad-lumen central venous catheter (Arrow-Howes, Uxbridge, UK) were connected to a dual transducer pressure monitoring set (Edwards Lifesciences Ltd., Irvine, CA, USA), attached to a common 500-ml flushing bag of 0.9% sodium chloride held at a pressure of 300 mmHg. We subsequently noted that a milky substance was being infused down the arterial limb of the transducer set and was approximately 30 cm from reaching the radial artery. Closer inspection revealed propofol and alfentanil infusion pumps were connected via a ‘Y’ connector to the integral three-way stopcock present on the venous limb of the pressure monitoring set, downstream to the flushing device. This three-way stopcock was open, with all three connections communicating. The propofol, presumably with the alfentanil, had flowed in a retrograde direction up the venous limb of the transducer set into the common flushing bag, from where they were flushed down the arterial limb towards the arterial catheter. Inspection of the transducer set revealed no fault and the flushing fluid was maintained at a pressure 300 mmHg. However, there had been intermittent problems flushing several of the central line lumens during the preceding 24 h. We postulate that at some point, the resistance of the central line lumen must have increased through blocking or kinking or perhaps the three-way stopcock may have been temporarily closed to the patient, allowing retrograde flow of the propofol and alfentanil up the venous limb of the transducer set. A PubMed search found a similar incident reported in the correspondence section of Anaesthesia involving an intra-arterial injection of intravenous contrast agent through a dual transducer pressure monitoring set [1]. We wonder if intra-arterial injection of drugs via dual transducer pressure monitoring sets may occur more frequently than is reported. We reviewed our local practice following this incident. We have decided to eliminate the risk by using separate single transducer monitoring sets for arterial and central venous catheters. The use of dual transducer pressure monitoring sets requires vigilance and care when using the injection port of the venous limb for drug delivery. No external funding and no competing interests declared.

Endovascular Coiling of an Internal Mammary Artery Pseudoaneurysm Following Placement of an Internal Jugular Central Venous Catheter

We discuss an interesting case of a right internal mammary artery pseudoaneurysm discovered after an attempted right internal jugular venous catheter placement. Such injury to the internal mammary artery is a rare complication of traumatic injuries to the chest, sternotomies, and central venous catheter placements. It has been reported after subclavian line placements, but not after an internal jugular catheterization.

Vascular Access Challenge on a Patient with Cerebral Palsy and Severe Kyphoscoliosis

We report a case of vascular assess challenge on a patient with severe kyphoscoliosis and joint contractures. Multiple internal jugular (IJ) central venous catheters (CVC) and a peripherally inserted central catheter (PICC) catheterization were attempted via ultrasound guidance and all resulted in malposition. The PICC attempt fortuitously pushed a malpositioned IJ into the correct position. Computed tomography (CT) demonstrated a narrow thoracic inlet with no definite venous stenoses. Therefore, severe chest wall deformity, a narrow thoracic inlet and inadequate positioning of the patient secondary to his contractures all contributed to the malposition of the PICC and CVCs.

Simulation-based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit*

To determine the effect of a simulation-based mastery learning model on central venous catheter insertion skill and the prevalence of procedure-related complications in a medical intensive care unit over a 1-yr period. Observational cohort study of an educational intervention. Tertiary-care urban teaching hospital. One hundred three internal medicine and emergency medicine residents. Twenty-seven residents were traditionally trained and did not receive simulation-based education. These residents were surveyed regarding complications and procedural self-confidence on actual central venous catheters they inserted in the medical intensive care unit. Subsequently, 76 residents completed simulation-based training in internal jugular and subclavian central venous catheter insertions. Simulator-trained residents were expected to meet or exceed a minimum passing score set by an expert panel and measured by performance on a skills checklist (given both before and after the educational intervention), using a central venous catheter simulator. Simulator-trained residents also took a written pre and posttest. Simulator-trained residents were surveyed regarding complications and procedural self-confidence on actual central venous catheters they inserted in the medical intensive care unit. Simulator-trained residents reported fewer needle passes (p < .0005), arterial punctures (p < .0005), catheter adjustments (p = .002), and higher success rates (p = .005) for actual central venous catheters inserted in the medical intensive care unit than traditionally trained residents. At clinical skills examination pretest, 12 (16%) of 76 simulator-trained residents met the minimum passing score for internal jugular central venous catheter insertion and 11 (14%) of 76 residents met the minimum passing score for subclavian central venous catheter insertion: mean (internal jugular) = 50.6%, SD = 23.4%; mean (subclavian) = 48.4%, SD = 26.8%. After simulation training, all residents met or exceeded the minimum passing score at posttest: mean (internal jugular) = 93.9%, SD = 10.2; mean (subclavian) = 91.5%, SD = 17.1 (p < .0005). Written examination performance improved from mean = 70.3%, SD = 7.7%, to 84.8%, SD = 4.8% (p < .0005). A simulation-based mastery learning program increased residents' skills in simulated central venous catheter insertion and decreased complications related to central venous catheter insertions in actual patient care.

Use of simulation‐based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit

Central venous catheter (CVC) insertions are performed frequently by internal medicine residents. Complications, including arterial puncture and pneumothorax, decrease when operators use fewer needle passes to insert the CVC. In this study, we evaluated the effect of simulation-based mastery learning on CVC insertion skill. This was a cohort study of internal jugular (IJ) and subclavian (SC) CVC insertions by 41 internal medicine residents rotating through the medical intensive care unit (MICU) over a five-month period. Thirteen traditionally-trained residents were surveyed about the number of needle passes, complications, and procedural self-confidence on CVCs inserted in the MICU. Concurrently, 28 residents completed simulation-based training in IJ and SC CVC insertions. Simulator-trained residents were expected to perform CVC insertions to mastery standards on a central line simulator. Simulator-trained residents then rotated through the MICU and were surveyed regarding CVC placement. The impact of simulation training was assessed by comparing group survey results. No resident met the minimum passing score (MPS) (79.1%) for CVC insertion at baseline: mean (M) (IJ) = 48.4%, standard deviation (SD) = 23.1, M(SC) = 45.2%, SD = 26.3. All residents met or exceeded the MPS at testing after simulation training: M(IJ) = 94.8%, SD = 10.0, M(SC) = 91.1%, SD = 17.8 (p < 0.001). In the MICU, simulator-trained residents required fewer needle passes to insert a CVC than traditionally-trained residents: M = 1.79, SD = 1.0 versus M = 2.78, SD = 1.77 (p = 0.04). Simulator-trained residents displayed more self-confidence about their procedural skills: (M = 81, SD = 11 versus M = 68, SD = 20, p = 0.02). Simulation-based mastery learning increased residents' skills in simulated CVC insertion, decreased the number of needle passes when performing actual procedures, and increased resident self-confidence.