Internal Jugular Venous Access Research Articles

A Rare Malposition of a Left Internal Jugular Central Venous Catheter into the Left Internal Mammary Vein.

We describe a case of left internal jugular central venous access with rare malpositioning into the internal mammary vein. Despite various confirmatory measures at the time of placement including ultrasonography of the internal jugular vein, as well as blood gas analysis consistent with venous blood by oxygen saturation and good venous flow in all three ports of the catheter, subsequent imaging confirmed misplacement into the internal mammary vein. Central venous access is a frequently used procedure by emergency physicians for a variety of indications. Emergency physicians must be facile with both the technical process of central venous catheter placement, as well as possible pitfalls and complications of the procedure. Common complications, such as bleeding, pneumothorax, arterial injury, infection, and hematomas, are usually well known; less frequently encountered is malposition of the catheter despite seemingly appropriate placement.

Patient, Operator, and Procedural Characteristics of Guidewire Retention as a Complication of Vascular Catheter Insertion.

Pre-specified observational analysis as part of a quality improvement study of consecutive guidewire retention events across a multihospital health system from August 2007 to October 2015. Ten hospitals within the Cleveland Clinic Health System in Ohio, United States. Consecutive all-comers who experienced guidewire retention after vascular catheter insertion. None. Data were manually obtained from the electronic medical records and reviewed for potential contributing factors for guidewire retention, stratified into patient, operator, and procedural characteristics. A total of 24 events were identified. Overall, the median age was 74 years, 58% were males, and the median body mass index was 26.5 kg/m2. A total of 12 (50%) individuals were sedated during the procedure. Most incidents (10 [42%]) occurred in internal jugular venous access sites. The majority of cases (13 [54%]) were performed or supervised by an attending. Among all cases, three (12%) were performed by first-year trainees, seven (29%) by residents, three (12%) by fellows, and four (17%) by certified nurse practitioners. Overall, 16 (67%) events occurred during regular working hours (8 amto 5 pm). In total, 22 (92%) guidewires were inserted nonemergently, with two (8%) during a cardiac arrest. Ultrasound guidance was used in all but one case. Guidewire retention can occur even in the presence of optimal patient, operator, and procedural circumstances, highlighting the need for constant awareness of this risk. Efforts to eliminate this important complication will require attention to issues surrounding the technical performance of the procedure.

Comparison between internal jugular vein access using midline catheter and peripheral intravenous access during cardiopulmonary resuscitation in adults.

Vascular access is an important procedure for drug administration during the resuscitation of a patient with cardiac arrest; however, it can be challenging under emergent conditions. This study aimed to investigate the efficiency of ultrasound-guided internal jugular venous access using a midline catheter versus peripheral intravenous access during cardiopulmonary resuscitation. This was a prospective single-center observational study among patients who received cardiopulmonary resuscitation. The primary outcomes were the success rate of first attempt and the time taken for vascular access via the internal jugular and peripheral veins. We also measured the diameter of the internal jugular and peripheral veins at the access point and the distance from the access point to the heart. In all, 20 patients were included in the study. Internal jugular and peripheral venous access had a first-attempt success rate of 85% and 65%, respectively (p = 0.152). The time to access the internal jugular and peripheral veins was 46.4 ± 40.5 s and 28.8 ± 14.7 s, respectively (p = 0.081). The diameter of the internal jugular and peripheral veins was 10.8 ± 2.6 mm and 2.8 ± 0.8 mm, respectively (p < 0.001). The distance from the vascular access point to the heart was 20.3 ± 4.7 cm and 48.8 ± 13.1 cm for the internal jugular and peripheral veins, respectively (p < 0.001). There was a trend toward higher success rates in the internal jugular vein rather than the peripheral intravenous approach, which was not statistically significant.

Abstract 231: Patient, Operator, And Procedural Characteristics Of Guidewire Retention As A Complication Of Vascular Catheter Insertion

Introduction: Guidewire retention after intravascular catheter insertion is considered a “never event.” Prior reports attribute this complication to various characteristics including uncooperative patients, operator inexperience, off-hour or emergent insertion, and underutilization of ultrasound guidance. In this descriptive analysis of consecutive events, we assessed the frequency of patient, operator, and procedural factors in guidewire retention. Methods: All consecutive incidents of guidewire retention across 10 hospitals within the Cleveland Clinic Health System in Ohio from August 2007 to October 2015 were prospectively identified and retrospectively analyzed. Data were manually obtained from the electronic medical records and reviewed for potential contributing factors for guidewire retention including patient, operator, and procedural characteristics. Results: A total of 24 guidewire retention events were identified. Overall, the median age was 74 years, 58% were males, and the median body mass index was 26.5 kg/m 2 . A total of 12 (50%) individuals were sedated during the procedure. Most incidents (10 [42%]) occurred in internal jugular venous access sites. The majority of cases (13 [54%]) were performed or supervised by an attending. Among all cases, 3 (12%) were performed by first-year trainees, 7 (29%) by residents, 3 (12%) by fellows, and 4 (17%) by certified nurse practitioners. Overall, 16 (67%) events occurred during regular working hours (8AM - 5PM). In total, 22 (92%) guidewires were inserted non-emergently, with 2 (8%) during a cardiac arrest. Ultrasound guidance was used in all but 1 case. Conclusion: Guidewire retention can occur even in the presence of optimal patient, operator, and procedural circumstances, highlighting the need for constant awareness of this risk. Efforts to eliminate this important complication will require attention to issues surrounding the technical performance of the procedure.

Contemporary rates of inferior vena cava filter thrombosis and risk factors

ObjectiveInferior vena cava (IVC) thrombosis is an uncommon complication associated with IVC filters (IVCFs), with studies reporting rates ranging from 1% to 31%. Few observational studies have described the risk factors associated with IVCF thrombosis, despite the significant clinical sequelae such as post-thrombotic syndrome, venous claudication, and venous ulceration. To better describe IVCF thrombosis and the risk factors, data were queried from Vascular Quality Initiative (VQI) participating centers. MethodsIVCF data were obtained from the international VQI database from 2013 to 2019. The patients included in the present analysis had 2 years of follow-up data available. The baseline demographics, medical comorbidities, medication, and procedural, anatomic, and postoperative variables were assessed using Kaplan-Meier survival curves with log-rank tests, Student's t tests, or Mann-Whitney U tests for IVCF thrombosis at 2 years. Cox regression analyses were used to identify independent predictors of IVCF thrombosis. A subgroup analysis of those who had presented with venous thromboembolism (VTE) was also performed. ResultsA total of 62 U.S. and Canadian VQI-participating centers included 12,874 cases of IVCF placement. Of the 5780 cases with 2 years of follow-up available, 78 (1.3%) had developed IVCF thrombosis. Those who had experienced IVCF thrombosis had had significantly lower rates of diabetes, coronary artery disease, preoperative antiplatelet medications, preoperative statin use, and lower rates of discharge and follow-up antiplatelet medications. On univariable analysis, the cases of IVCF thrombosis also had higher rates of pulmonary embolism and VTE on admission, internal jugular venous access (vs femoral vein access), temporary IVCF use, follow-up anticoagulation, follow-up IVCF complication, follow-up access site thrombosis, and rates of new or propagated deep vein thrombosis at follow-up, and longer postoperative hospital stays. Multivariable analysis demonstrated that the independent predictors of IVCF thrombosis included new or propagated deep vein thrombosis at follow-up (hazard ratio [HR], 16.3; 95% confident interval [CI], 9.8-27.3; P < .001), no antiplatelet therapy at follow-up (HR, 4.8; 95% CI, 1.9-12.5; P = .001), internal jugular venous access (HR, 2.2; 95% CI, 1.4-3.5; P = .001), the presence of VTE on admission (HR, 2.7; 95% CI, 1.4-5.1; P = .002), and temporary IVCF placement (HR, 2.5; 95% CI, 1.1-5.6; P = .031). In an analysis of the subgroup of patients with VTE on admission, similar predictive factors were identified in a multivariable model. Massive pulmonary embolism was also predictive of IVCF thrombosis in this subgroup. ConclusionsThe rate of IVCF thrombosis remained low in a contemporary international database. The results from the present study of >5000 patients with IVCFs suggest that antiplatelet therapy should be administered after IVCF placement to decreased the risk of IVCF thrombosis.

Small cell carcinoma presenting as a biatrial mass with obstructive physiology: a case report

BackgroundSmall cell carcinoma is a highly aggressive and often fatal cancer that most commonly arises in the lung, although it can occasionally arise from other sites, such as the gastrointestinal tract, prostate or cervix. Cardiac involvement, however, is extremely uncommon and therefore has been poorly documented in the literature.Case presentationWe describe a rare case of a 31-year-old male with small cell carcinoma presenting as a massive, 15-cm cardiac tumor invading the bilateral atria, interatrial septum, and pericardium without an apparent primary malignancy on PET CT and cardiac MRI. With extensive tissue necrosis, traditional methods of obtaining a right atrial endomyocardial biopsy via internal jugular venous access failed and a diagnosis was made via endoscopic ultrasound guided transesophageal fine needle aspiration of the left atrial mass. Due to the extensive tumor invasion, the patient was not a suitable candidate for surgical resection, debulking, or heart transplant. The patient was treated with etoposide, carboplatin, atezolizumab, and radiation therapy with initial monitoring in the intensive care unit due to concern that tumor lysis may cause rapid cardiac decompensation. Unfortunately, 4 months after chemoradiation therapy, the malignancy progressed and the patient passed away 6 months after the initial diagnosis.ConclusionWe describe a rare occurrence of small cell carcinoma presenting as a massive cardiac tumor without apparent primary malignancy. This case demonstrates useful alternative diagnostic strategies and treatment considerations for patients presenting with a rare cardiac mass.

Comparison of external jugular venous access with internal jugular venous access in pediatric shock

Background: Central venous access is usually preferred over the peripheral venous route when circulatory failure needs inotropes and vasopressors. However, in resource-limited settings with underskilled personnel, it is not feasible always and so patients are being treated with the peripheral venous route with variable results. We aimed to compare external jugular venous (EJV) access with internal jugular venous (IJV) access for effectiveness, ease of procedure, complications, and treatment cost in pediatric shock. Subjects and Methods: This was a prospective, nonrandomized, observational study from January 2014 to June 2015 in 66 pediatric patients with shock at a 7-bedded pediatric intensive care unit. Parents were explained about both routes. Depending on their affordability and consent, one route was chosen. Pertinent data were obtained, and analysis was done as per objectives. Results: EJV and IJV had 50 and 16 patients, respectively. Baseline characteristics were comparable. Death and discharge against medical advice rates are high in both the groups. No procedure-related life-threatening complications in any group and local site problems were similar in both the groups. Overall attempts and duration of procedure were similar in both the groups, and although the initial cost of the procedure of the IJV group was higher, overall final hospital bill had no significant difference. The median (Q1, Q3) hours of achieving shock-free status were 48 (24, 96) and 46 (12, 108) (P = 0.412). The median (Q1, Q3) improvement in base deficit at the end of 24 h was −4.5 (−8.1, 0.27) and −1.9 (−4.2, −0.6) (P = 0.259) in the EJV and IJV groups, respectively. Conclusion: For pediatric shock management, EJV access is an effective, easy, and cost economic procedure without significant complications as compared to IJV access.

ARE GADGETS SAVIOURS IN SALVAGING SICK CASES – ULTRASOUND FOR BOTH NERVE BLOCKS AND VASCULAR ACCESS IN A CASE OF SEPTIC SHOCK

Diabetes mellitus and diabetic foot syndrome presents to us with varying degrees of sepsis. We present a 52-year-old male with chronic diabetes with fore foot sepsis in shock. His blood sugar was controlled with insulin and the other parameters were normal. The blood pressure was around 90/50 mm Hg with noradrenaline support of 0.5 mic/kg/min. We secured a right internal jugular venous access with ultrasound (USG). The volume status as assessed by USG of the IVC was satisfactory. We administered popliteal sciatic nerve block along with saphenous nerve block visualizing the nerves with USG. The amputation of forefoot went on for 1 h where the hemodynamics remained stable at 100/70 mmHg. After the surgery was over, the patient was shifted to sick cubicle and in the next 6 h, the inotrope support was weaned off. The control of sugars was continuously monitored and kept under control. Any other form of neuraxial block could have been detrimental to him in the presence of hemodynamic imbalance. Such precise deposition of local anesthetics in the sciatic nerve is very difficult without the use of USG. We conclude that advanced gadgets may bring back hope in salvaging sick patients.

Pulmonary Artery Intervention for Submassive Pulmonary Embolism From an Arm Superficial Venous Access.

Pulmonary embolism (PE) endovascular interventions are often approached from an internal jugular or femoral venous access. There are multiple advantages of right basilic vein (RBV) access for both patient and operator, especially in the setting of morbid obesity. We hereby describe the case of a 48-year-old, morbidly obese man who presented with acute respiratory insufficiency and was found to have bilateral submassive subocclusive PE, worse on the right. The right ventricular to left ventricular ratio was 2.1 and troponin was elevated. A 7 Fr sheath was placed in the RBV under ultrasound guidance. Selective bilateral pulmonary arteriography was then performed. A 106 x 12 cm EKOS catheter was placed in the segment of highest thrombotic burden for a 6-hour protocol of catheter-directed ultrasound-facilitated thrombolytic therapy. The patient recovered well on a direct oral anticoagulant and his acute symptoms resolved. Treating massive/submassive PE from a RBV access offers the convenience and safety of superficial venous access (for patient and operator), better patient comfort, less venous stasis during therapy with ability to ambulate, less potential for bleeding and vascular complications, less potential for operator radiation exposure when compared with the jugular approach, and better operator ergonomics.

Deep sedation for transvenous lead extraction: a large single-centre experience.

Transvenous lead extraction for cardiac implantable electronic devices (CIED) is of growing importance. Nevertheless, the optimal anaesthetic approach, general anaesthesia vs. deep sedation (DS), remains unresolved. We describe our tertiary centre experience of the feasibility and safety of DS. Extraction procedures were performed in the electrophysiology (EP) laboratory by two experienced electrophysiologists. We used intravenous Fentanyl, Midazolam, and Propofol for DS. A stepwise approach with locking stylets, dilator sheaths, and mechanical sheaths via subclavian, femoral, or internal jugular venous access was utilized. Patient characteristics and procedural data were collected. Logistic regression models were used to identify parameters associated with sedation-related complications. Extraction of 476 leads (dwelling time/patient 88 ± 49 months, 30% ICD leads) was performed in 220 patients (64 ± 17 years, 80% male). Deep sedation was initiated with bolus administration of Fentanyl, Midazolam, and Propofol; mean doses 0.34 ± 0.12 μg/kg, 24.3 ± 6.8 μg/kg, and 0.26 ± 0.13 mg/kg, respectively. Deep sedation was maintained with continuous Propofol infusion (initial dose 3.7 ± 1.1 mg/kg/h; subsequently increased to 4.7 ± 1.2 mg/kg/h with 3.9 ± 2.6 adjustments) and boluses of Midazolam and Fentanyl as indicated. Sedation-related episodes of hypotension, requiring vasopressors, and hypoxia, requiring additional airway management, occurred in 25 (11.4%) and 5 (2.3%) patients, respectively. These were managed without adverse consequences. Five patients (2.3%) experienced major intraprocedural complications; there were no procedure-related deaths. All of our logistic regression models indicated intraprocedural support was associated with administration higher Fentanyl doses. Transvenous lead extraction under DS in the EP laboratory is a safe procedure with high success rates when performed by experienced staff.

03:36 PM Abstract No. 47 Outcomes of tunneled internal jugular venous catheters in children younger than 3 months of age

There is limited data on complications of central lines in younger infants. The purpose of this study is to identify factors which may affect complication rates of tunneled internal jugular (IJ) venous catheters placed in neonates and infants under 3 months of age. This is a retrospective review of patients 90 days of age and under who underwent tunneled IJ venous catheter placements in the pediatric interventional radiology department at a single institution over a 4-year period. Patient demographics, device characteristics, procedural factors, and clinical follow-up were collected for each catheter placed. Complication rates, fluoroscopy times, and procedural times were analyzed based on patient age, weight at time of placement, side of placement, and technique (single-incision or conventional). Complication types (line malfunction, malpositioning, or infection) were analyzed based on duration of placement and method of resolution. 65 lines were placed in 63 patients with a total dwell time of 2,799 line days. A total of 15 complications were observed which required either replacement over a wire or removal (total complication rate 23%). Complications included 3 line malfunctions, 8 malpositioned lines, and 4 infections. There were 7 complications (including 1 infection) that occurred within 30 days of line placement. Catheters placed using the single-incision technique (20) had a statistically significant lower rate of complications compared with conventional technique (45); (5% vs 31%, p = 0.03). Although not statistically significant, patients under 30 days of age had a higher complication rate compared to older patients (27% vs 22%), patients weighing less than 5 kg had a higher complication rate compared to heavier patients (25% vs 20%), and left IJ catheters had a longer average procedure time compared to the right (39 minutes vs 24 minutes). When caring for patients less than 3 months of age who require tunneled internal jugular venous access, a single-incision technique may lead to lower rates of complication. It is also important to be aware of factors which may lead to a higher rate of complication, such as younger age and lighter weight.

USE OF PROTEK DUO TANDEM HEART FOR PERCUTANEOUS RIGHT VENTRICULAR SUPPORT IN VARIOUS CLINICAL SETTINGS: A CASE SERIES

The Protek Duo is a novel dual lumen cannula that is inserted percutaneously via internal jugular (IJ) venous access. The proximal inflow lumen is positioned in the right atrium and the distal outflow lumen is positioned in the main pulmonary artery. These lumens are connected with the para-

Utility of intracardiac echocardiography during transvenous lead extraction

Transvenous lead extraction (TLE) carries a significant risk of intraprocedural complications. Phased-array intracardiac echocardiography (ICE) is widely used during cardiac procedures; however, its utility during TLE has not been well described. We sought to define the utility of ICE imaging during TLE. Fifty patients referred for TLE were included. Patients underwent ICE imaging before and throughout TLE. Clinical characteristics of the patients, ICE findings, and procedural outcomes were collected and analyzed. Of the 50 patients, 18 (36%) were found to have visible binding sites in the ICE field of view; 13 (26%) had intracardiac binding sites only, and 5 (10%) had both superior vena cava (SVC) and intracardiac binding sites. Lead-adherent echodensities (LAEs) were found in 36 patients (72%), of whom 7 (14%) had bacteremia. Patients with SVC and/or intracardiac binding sites were more likely to have a complex extraction, defined as that requiring the use of internal jugular or femoral venous access, advancement of extraction apparatus beyond the SVC, disruption of lead structure during the procedure, or resulting in major complications (56% vs 0%; P ≤ .0001). ICE imaging during TLE can be used to assess the presence of lead binding sites, LAEs, and procedural complications. LAEs were found in the majority of patients, mostly in the absence of bacteremia. The presence of ICE-detected lead binding sites is predictive of a more complex extraction procedure.

How useful is ultrasound guidance for internal jugular venous access in children?

The aim of this study was to determine whether US reduces number of puncture attempts, procedure time, and complication rate during IJV access in children. A prospective study was performed in children (age ≤18years) admitted to our institution, from September 2013 to July 2014, with indications for central venous access. Patients meeting the inclusion criteria were randomized to the US-guided or control groups. The same physician performed all IJV cannulations in both groups. The end-points for comparison were: length of time to venous access, number of attempts, and rate of complications. Fifty-one patients were included: 23 in the US-guided group and 28 in the control group. There were no between-group differences in weight, age, or sex. In the US-guided group, the number of punctures needed to achieve IJV access (median [interquartile range], 3 [2-5] vs. 1 [1, 2]; P<0.001), time to achievement of venous access, and complication rate (39% vs. 4.3%, P<0.009) were significantly lower. US guidance is a useful adjunct to central venous access in children, facilitating the procedure, decreasing time to cannulation, and increasing safety. Prospective randomized study. 1.

Randomized comparison of three transducer orientation approaches for ultrasound guided internal jugular venous cannulation

BackgroundUltrasound-guided internal jugular venous access increases the rate of successful cannulation and reduces the incidence of complications, compared with the landmark technique. Three transducer orientation approaches have been proposed for this procedure: short-axis (SAX), long-axis (LAX) and oblique-axis (OAX). Our goal was to assess and compare the performance of these approaches. MethodsA prospective randomized clinical trial was conducted in one teaching hospital. Patients aged 18 yr or above, who were undergoing ultrasound-guided internal jugular cannulation, were randomly assigned to one of three intervention groups: SAX, LAX and OAX group. The main outcome measure was successful cannulation on first needle pass. Incidence of mechanical complications was also registered. Restricted randomization was computer-generated. ResultsIn total, 220 patients were analysed (SAX n+73, LAX n+75, OAX n+72). Cannulation was successful on first needle pass in 51 (69.9%) SAX patients, 39 (52%) LAX patients and 53 (73.6%) OAX patients. First needle pass failure was higher in the LAX group than in the OAX group (adjusted OR 3.7, 95% CI 1.71–8.0, P+0.002). A higher mechanical complication rate was observed in the SAX group (15.1%) than in the OAX (6.9%) and LAX (4%) groups (P+0.047). ConclusionsAs OAX showed a higher first needle pass success rate than LAX and a lower mechanical complications rate than SAX, we recommend it as the standard approach when performing ultrasound-guided internal jugular venous access. Further clinical studies are needed to confirm this conclusion. Clinical trial registrationNCT 01966354

Percutaneous Cannulation in Predominantly Venoarterial Extracorporeal Membrane Oxygenation by Intensivists

Critical Care Medicine www.ccmjournal.org e595 The authors reply: The letter by Burrell et al (1) describing the percutaneous cannulation experience by intensivists at Alfred Hospital provides important information for intensivists involved in extracorporeal life support (ECLS) programs and nicely complements our reported experience (2). Our ECLS program has historically provided predominantly respiratory support, and our cardiac support experience is more limited. Our ECLS experience consists mostly of venovenous cannulation with a smaller venoarterial cohort. Burrell et al (1) describe their cannulation experience, which includes a large venoarterial cohort. Aspects of the Alfred Hospital experience deserve mention. The first is their success with arterial cannulation with a low complication rate. Arterial cannulation entails more inherent risk than venous because arterial injury can lead to substantial more morbidity than venous injury. The 8% arterial complication rate reported, although higher than their venous rate (2%), is not unexpected and would not be considered excessive. Some of their complications required surgical management, so the availability of surgical services would seem advisable. Another aspect is the larger number of intensivists (16) available to perform cannulations. Although this would seem to dilute the experience of each intensivist, the approach of having more than one intensivist cannulating a given patient (as we do) increases the exposure to the procedure and helps maintain cannulation skills. secured. A second patient’s internal jugular venous access cannula was accidentally dislodged and removed but was resecured without major consequence. Overall average ECMO duration was 4 ± 4 days for VA ECMO and 14 ± 4 days for VV ECMO. Survival to hospital discharge was 73 of 122 (60%) for VA ECMO (including extracorporeal CPR) and 32 of 45 (71%) for VV ECMO. In total, seven of 167 patients (4%) had hemorrhagic or ischemic stroke, and there was one blood stream infection, and one confirmed cannula related infection. In conclusion, intensivist-led cannulation is also possible for a predominantly VA ECMO service and is associated with an acceptable complication rate. The authors have disclosed that they do not have any potential conflicts of interest.

Ultrasonography-guided central venous port placement with subclavian vein access in pediatric oncology patients

Background/PurposeTo evaluate the technical success and complications of image-guided central venous port (CVP) placement with subclavian vein (SCV) access in pediatric oncology population. Materials and methodsNinety-two children (52 boys, 40 girls; mean age, 8.5years) underwent CVP implantation under local anesthesia with conscious sedation. SCV access was firstly attempted under ultrasonographic guidance and CVP implantation was performed under fluoroscopic guidance. Technical success, peri-procedural (<24h) complication, and post-procedural (>24h) complication were assessed. ResultsIn total, 102 CVPs were implanted in 92 children with a mean catheter time of 364days (total, 38,224days; range, 14–1911days). In three small children, conversion of SCV access to internal jugular vein access yielded a primary technical success rate of 97.1% and overall technical success rate of 100%. Three minor peri-procedural complications were observed (2.9%) and seven post-procedural infectious complications occurred (infection rate, 6.7%; 0.18/1000 catheter days). No pneumothorax, catheter malposition, venous thrombosis, or mortality occurred. ConclusionImage-guided CVP placement with SCV access in a pediatric population was performed with high technical success and low complication rate without general anesthesia. This procedure can be taken into account as a choice of procedure when internal jugular venous access is not possible.

Retrospective analysis of incidence of complications of central venous catheterization at an intensive care unit

Objectives: To compare mechanical, infectious, and thrombotic complications of internal jugular; subclavian and femoral venous catheterization at an post surgical and medical intensive care unitsMethods: It is a retrospective study in which the data from the medical records was evaluated and analyzed. Data, such as sex, date of insertion and removal, failure to place, malposition, complications and site of central venous catheterization were recorded. Landmark-based central venous catheterization using seldinger technique was performed under all aseptic precautions in 597 patients in postsurgical and medicine intensive care units. Central venous catheterization by three different routes i.e. IJV, SV and femoral vein were performed in critically ill patients.Results: Incidence of mechanical, infectious, and thromboembolic complications of central venous catheterization was 8.71%, 7.37 %, and 2.68% respectively. Incidences of different mechanical complications are as follows, arterial puncture4.18%, hematoma 3.18%, pneumothorax 1 %, haemothorax 0.33% .Incidence of central venous catheter with failure to place at various sites were 11.72 %. Incidences of central venous catheter with malposition at various sites were 6.36%.Conclusion: We found that complication rates of CVC insertion at our hospital are similar to those reported previously. Based on our experience, internal jugular venous access is associated with a low rate of mechanical complications like arterial punctures, hematoma, pneumothorax, thrombosis. Incidence with infection was least with subclavian cannulation.

Factors that Predict Increased Catheter Tip Movement in Left Internal Jugular Vein Implantable Venous Access Ports upon Standing

To determine the characteristics that predict catheter tip movement with positional changes in patients with left-sided, internal jugular vein (IJV) implantable venous access ports. A retrospective review revealed 264 patients with left IJV ports placed at one academic institution from 2008 to 2013 with follow-up upright chest radiographs. Demographic information was recorded and anatomic measurements were made on both procedural fluoroscopic imaging and upright chest radiographs. Multivariate regression analysis was performed to determine which factors had statistically significant relationships with catheter tip movement distance. Mean catheter tip movement was 1.49 ± 1.97 cm. There was a statistically significant positive relationship between catheter tip movement distance and age (p = 0.03), body mass index (BMI) (p = 0.02), innominate vein angle (p<0.01) and dual- compared to single-lumen ports (p = 0.02). Port pocket location, venous access site and gender did not demonstrate statistical significance. The factors associated with increased positional catheter tip movement for left IJV ports include patient age, BMI, innominate vein angle and dual- vs single-lumen port. This information can be useful in determining initial placement position and avoiding complications associated with catheter malposition.

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).