Jugular Central Venous Catheter Research Articles

Risk of bleeding after ultrasound-guided jugular central venous catheter insertion in severely thrombocytopenic oncologic patients

IntroductionWe sought to assess the incidence and risk factors of bleeding after ultrasound-guided internal jugular (USGIJ) catheter insertion in severely thrombocytopenic cancer patients, as safe platelet (PLT) count threshold remains controversial. MethodsRetrospective study of 52 patients with hematologic malignancies and severe thrombocytopenia who underwent USGIJ catheter insertion between 2014 and 2016. Group A included patients with prophylactic PLT transfusion and Group B without. Statistical analysis was performed. ResultsGroup A included 28 patients and Group B 24. Baseline characteristics were equally distributed. Median catheter size was 12 Fr and tunneled in 20/52 patients. Median PLT count was not statistically different between the groups, before transfusion and after the procedure. Postoperative minor bleeding occurred in 10/52 patients, similar between groups. Lower PLT count, larger catheter caliber and trend for AML diagnosis were identified as risk factors for bleeding. Age, gender, BMI, renal dysfunction and tunneled insertion were not significant. ConclusionIncidence of minor bleeding is low in severely thrombocytopenic patients after USGIJ catheter insertion. Prophylactic platelet transfusion may be reserved for patients with identified risk factors.

Investigating the Effect of Simulator Functional Fidelity and Personalized Feedback on Central Venous Catheterization Training

To compare the effect of simulator functional fidelity (manikin vs a Dynamic Haptic Robotic Trainer [DHRT]) and personalized feedback on surgical resident self-efficacy and self-ratings of performance during ultrasound-guided internal jugular central venous catheterization (IJ CVC) training. In addition, we seek to explore how self-ratings of performance compare to objective performance scores generated by the DHRT system. Participants were randomly assigned to either manikin or DHRT IJ CVC training over a 6-month period. Self-efficacy surveys were distributed before and following training. Training consisted of a pretest, 22 practice IJ CVC needle insertion attempts, 2 full-line practice attempts, and a posttest. Participants provided self-ratings of performance for each needle insertion and were presented with feedback from either an upper level resident (manikin) or a personalized learning system (DHRT). A study was conducted from July 2016 to February 2017 through a surgical skills training program at Hershey Medical Center in Hershey, Pennsylvania. Twenty-six first-year surgical residents were recruited for the study. Individuals were informed that IJ CVC training procedures would be consistent regardless of participation in the study and that participation was optional. All recruited residents opted to participate in the study. Residents in both groups significantly improved their self-efficacy scores from pretest to posttest (p < 0.01). Residents in the manikin group consistently provided higher self-ratings of performance (p < 0.001). Residents in the DHRT group recorded more feedback on errors (228 instances) than the manikin group (144 instances). Self-ratings of performance on the DHRT system were able to significantly predict the objective score of the DHRT system (R2 = 0.223, p < 0.001). Simulation training with the DHRT system and the personalized learning feedback can improve resident self-efficacy with IJ CVC procedures and provide sufficient feedback to allow residents to accurately assess their own performance.

Keloid formation on neck after jugular central venous catheter placement: An unsightly unusual complication in a young female.

Keloid formation on neck after jugular central venous catheter placement: An unsightly unusual complication in a young female.

International Scope of Emergency Ultrasound: Barriers in Applying Ultrasound to Guide Central Line Placement by Providers in Nairobi, Kenya.

Background While ultrasound (US) use for internal jugular central venous catheter (CVC) placement is standard of care in North America, most developing countries have not adopted this practice. Previous surveys of North American physicians have identified lack of training and equipment availability as the most important barriers to the use of US. Objective We sought to identify perceived barriers to the use of US to guide CVC insertion in a resource-constrained environment. Methods Prior to an US-guided CVC placement training course conducted at the Aga Khan University Hospital in Nairobi, Kenya, physicians were asked to complete a survey to determine previous experience and perceived barriers. Survey responses were analyzed using summary statistics and the Rank-Sum test based on different specialty, gender, and previous US experience. Results There were 23 physicians who completed the course and the survey. 52% (95% CI: 0.30–0.73) had put in >20 CVCs. 21.7% (95% CI: 0.08–0.44) of participants had previous US training, but none in the use of US for CVC insertion. The respondents expressed agreement with statements describing the ease of the use and improved success rate with US guidance. There was less agreement to statements describing the relative convenience and cost effectiveness of US CVC placement compared to the landmark technique. The main perceived barriers to utilization of US guidance included lack of training and limited availability of US equipment and sterile sheaths. Conclusion Perceived barriers to US-guided CVC placement in our population closely mirrored those found among North American physicians, including lack of training and limited availability of US machines and equipment. These barriers have the potential to be addressed by targeted educational and administrative interventions.

Extrapleural Hematoma: A Complication of Jugular Vein Cannulation

SESSION TITLE: Disorders of the Pleura SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: For centuries, central venous catheters (CVC) have been used as a means of assessing a patients cardiovascular hemodynamics and administering noxious medications. While the role of CVC in managing critically ill patients is indispensable, we must be cognizant of its complications. In this case report, hemodynamic instability complicates a surgical procedure, and the need for central venous access inadvertently leads to the development of an extrapleural hematoma (EPH). CASE PRESENTATION: We present a case of a 78 year old female, whose medical history of atrial fibrillation and transient ischemic attacks placed her at high risk of an ischemic cerebral event (CHA2DS2-VASc scoring). Her recurrent episodes of severe epistaxis precluded her from receiving anticoagulation therapy, and a left atrial appendage closure device (Watchman) was pursued as an alternative for stroke prevention. Sustained intraoperative hypotension necessitated the placement of a right-sided internal jugular CVC for the delivery of norepinephrine to regain hemodynamic stability. Without the availability of ultrasound guidance, anatomic landmarks led to successful cannulation after a failed first attempt. Post procedural chest x-ray (CXR) revealed a near complete opacification of the right hemithorax and CT scan of the chest confirmed a large apical hematoma (Image 1). Thoracoscopic surgery was performed for clot evacuation due to persistence of the EPH despite the placement of chest tubes and conservative medical management. Subsequent CXR revealed a complete resolution of the EPH (Image 2), and she was liberated from mechanical ventilation and vasopressor support. DISCUSSION: The lung parenchyma is surrounded by a physiologic visceral and parietal pleura which lies deep to the endothoracic fascia (ETF). The ETF is the outermost layer of the thoracic cavity and extends from the most inferior portions of the lung to the superior thoracic aperture to encase the lung apices. When diagnosed, the inciting event that precipitates an EPH is typically a penetrating injury to the chest or blunt trauma with injury to the ribs. Damage to the intercostal vasculature leads to the extravasation of blood into the physiologic space that lies between the ETF and the innermost intercostal musculature. This space occupying lesion displaces the ETF centrally, leading to a characteristic “fat stripe” seen on CT scans. CONCLUSIONS: EPH are a pleural space disease and a potential complication of CVC placement. Although a rare occurrence, the disruption in cardiopulmonary physiology can lead to life-threatening complications unless detected early. Reference #1: Chung, JH, Carr RB, Stern EJ. Extrapleural hematomas: imaging appearance, classification, and clinical significance. Journal of Thoracic Imaging. 2011:26:218-223 Reference #2: Aquino, S., Chiles, C., Oaks, T. Displaced extrapleural fat as revealed by CT scanning: evidence of extrapleural hematoma. American Journal of Radiology, 1997. DISCLOSURE: The following authors have nothing to disclose: Christopher Lee, Reenal Patel, Christian Castaneda, Olumayowa Abe, Samarth Beri No Product/Research Disclosure Information

Personalized Learning in Medical Education: Designing a User Interface for a Dynamic Haptic Robotic Trainer for Central Venous Catheterization.

While Virtual Reality (VR) has emerged as a viable method for training new medical residents, it has not yet reached all areas of training. One area lacking such development is surgical residency programs where there are large learning curves associated with skill development. In order to address this gap, a Dynamic Haptic Robotic Trainer (DHRT) was developed to help train surgical residents in the placement of ultrasound guided Internal Jugular Central Venous Catheters and to incorporate personalized learning. In order to accomplish this, a 2-part study was conducted to: (1) systematically analyze the feedback given to 18 third year medical students by trained professionals to identify the items necessary for a personalized learning system and (2) develop and experimentally test the usability of the personalized learning interface within the DHRT system. The results can be used to inform the design of VR and personalized learning systems within the medical community.

Single-stick tunneled central venous access using the jugular veins in infants weighing less than 5kg.

Despite the demonstrated feasibility of the single-stick technique in the femoral vein, its use in neonates and infants for placing central lines in internal and external jugular veins has not been reported. Describe and assess the safety and efficacy of tunneled jugular central venous catheter placement performed under ultrasound (US) and fluoroscopic guidance in neonates and infants weighing <5kg using the single-stick technique at three tertiary pediatric hospitals. Thirty-three children weighing less than 5kg received tunneled central venous access in either internal or external jugular veins using the single-stick technique. Patient history, procedural records and clinical follow-up documents were retrospectively reviewed. Complication rates were compared to those of 41 patients receiving single-stick femoral central lines. Technical complications occurred during one (3.0%) jugular placement with the patient having a failed right-side attempt with subsequent successful left-side placement. The catheters did not last the entire course of treatment in three (9.1%) patients with jugular lines. One patient had the catheter removed due to concern for infection, one catheter was accidentally removed during dressing changes, and one catheter was displaced and subsequently exchanged. Of patients receiving femoral central lines, 1 (2.4%) had a technical complication and 5 catheters (12.2%) did not last the entire course of treatment. The placement of tunneled central venous catheters in neonates/infants <5kg is safe and technically feasible using the internal/external jugular vein via the single-stick technique. By theoretically reducing the risks of catheter infection by avoiding the diaper area and thrombosis by using larger veins, it may be preferable in certain patient populations.

Simulation-based training program with deliberate practice for ultrasound-guided jugular central venous catheter placement.

Current evidence supports the utility of simulation training for bedside procedures such as ultrasound-guided jugular central venous catheter (CVC) insertion. However, a standardized methodology to teach procedural skills has not been determined yet. The aim of this study was to evaluate the effectiveness of a simulation-based training program for improving novice technical performance during ultrasound-guided internal jugular CVC placement. Postgraduate year 1 (PGY-1) residents from anesthesiology, emergency medicine, cardiology, ICU, and nephrology specialties were trained in four deliberate practice sessions. Learning objectives included principles of ultrasound (US), preparation (gown, glove, draping), procedural skills I (US scanning and puncture), and procedural skills II (catheter insertion). CVC technical proficiency was tested pre- and post-training using hand-motion analysis with the Imperial College Surgical Assessment Device (ICSAD) and a global rating scale (GRS). Thirty-five PGY-1 residents successfully completed the program. These novices' GRS scores improved significantly after the training (P < 0.001). Total path length measured with the ICSAD decreased significantly after the training (P = 0.008). Procedural time decreased significantly after training from 387 (310-501) seconds to 200 (157-261) seconds (median and interquartile range) (P = 0.029). This simulation-training program based on deliberate practice significantly increased the technical skills of residents in US-guided short-axis, out-of-plane internal jugular CVC placement. Data also confirm the validity of the ICSAD as an assessment tool for ultrasound-guided internal jugular CVC placement learning.

Ultrasound as a Screening Tool for Central Venous Catheter Positioning and Exclusion of Pneumothorax.

Although real-time ultrasound guidance during central venous catheter insertion has become a standard of care, postinsertion chest radiograph remains the gold standard to confirm central venous catheter tip position and rule out associated lung complications like pneumothorax. We hypothesize that a combination of transthoracic echocardiography and lung ultrasound is noninferior to chest radiograph when used to accurately assess central venous catheter positioning and screen for pneumothorax. All operating rooms and surgical and trauma ICUs at the institution. Single-center, prospective noninferiority study. Patients receiving ultrasound-guided subclavian or internal jugular central venous catheters. During ultrasound-guided central venous catheter placement, correct positioning of central venous catheter was accomplished by real-time visualization of the guide wire and positive right atrial swirl sign using the subcostal four-chamber view. After insertion, pneumothorax was ruled out by the presence of lung sliding and seashore sign on M-mode. Data analysis was done for 137 patients. Chest radiograph ruled out pneumothorax in 137 of 137 patients (100%). Lung ultrasound was performed in 123 of 137 patients and successfully screened for pneumothorax in 123 of 123 (100%). Chest radiograph approximated accurate catheter tip position in 136 of 137 patients (99.3%). Adequate subcostal four-chamber views could not be obtained in 13 patients. Accurate positioning of central venous catheter with ultrasound was then confirmed in 121 of 124 patients (97.6%) as described previously. Transthoracic echocardiography and lung ultrasound are noninferior to chest x-ray for screening of pneumothorax and accurate central venous catheter positioning. Thus, the point of care use of ultrasound can reduce central venous catheter insertion to use time, exposure to radiation, and improve patient safety.

Bacteremia Caused by Ciprofloxacin-Resistant Salmonella Serotype Kentucky: A Case Report and the Review of Literature

Salmonella infections can be seen in four clinical types, namely gastroenteritis, bacteremia/sepsis, enteric fever and carriage. These infections can result in uncomplicated diarrhea in most cases, but can lead to invasive disease requiring antimicrobial therapy and can be life-threatening in elderly or immunocomprimised patients. Broad-spectrum cephalosporins and fluoroquinolones are crucial options in the treatment of the invasive infections. Ciprofloxacin resistance is rarely seen in non-typhoid Salmonella enterica isolates, and only in S. Typhimurium, S. Choleraesuis and S. Schwarzengrund. In this report, we aimed to discuss a patient infected with ciprofloxacin-resistant Salmonella Kentucky under the light of data from our country and the world. A 52-year-old male patient wih acute myocardial infarction was hospitalized in intensive care unit of cardiovasculer surgery for left ventricular assist device (LVAD) implantation for the treatment of left ventricular disfunction. On the seventh day of LVAD and coronary artery bypass grafting (CABG), the patient presented high fever and productive cough. His physical examination revealed hyperemia around the insertion point of right jugular central venous catheter (CVC) and a serous discharge from the insertion point of LVAD located just below the inferior edge of sternum. Empiric IV cefoperazone/sulbactam (SCF) therapy was started with the prediagnosis of pneumonia and bloodstream infection. The blood samples taken from peripheral veins and CVC, and swabs taken from LVAD insertion point for culture when the patient was febrile, revealed the growth of bacteria with S type and lactose-negative colonies on EMB and SS media. Biochemical characteristics of the isolate were as follows: lactose fermentation negative, H2S positive, IMVIC (-,+,-,+), urease negative, lysine/ornithine decarboxylase positive and motile. The bacteria was then identified as Salmonella enterica serotype Kentucky (8,20;i;z6) by agglutination tests. Antibiotic susceptibility tests were conducted according to CLSI guidelines and it was found as ampicillin- and ciprofloxacin-resistant. Ciprofloxacin resistance of the isolate was confirmed with E-test. Stool culture was performed to investigate the source of infection, and S. Kentucky was isolated. On the 15th day of SCF treatment, LVAD was taken out, and tissue cultures taken from the fibrillar tissues between pericardial layers during surgery, also yielded S. Kentucky growth. On the second day of SCF therapy the patient's fever returned normal and on the seventh day, CBC and CRP values were normalized. Nevertheless, the clinical situation of the patient worsened gradually and on the 40th day he was intubated due to low oxygen saturation and pleural effusion. His antibiotherapy was stopped on 42nd day as the blood cultures were negative and his clinical situation was attributed to cardiac failure. The patient died four days after the antibiotherapy has stopped due to cardiac reasons. To our knowledge, this is the first reported case infected with ciprofloxacin-resistant Salmonella Kentucky in our country.

Ultrasound Identification of the Guidewire in the Brachiocephalic Vein for the Prevention of Inadvertent Arterial Catheterization During Internal Jugular Central Venous Catheter Placement.

Imaging the guidewire with ultrasonography in the internal jugular vein during central venous catheterization often is used to verify proper guidewire placement and to aid in prevention of inadvertent arterial catheterization. It is known, however, that inadvertent arterial catheterization can occur despite imaging the guidewire in the internal jugular vein because the guidewire may continue through the far wall of the internal jugular vein and into an adjacent artery. We propose confirmation of the guidewire in the brachiocephalic vein with ultrasonography as a more reliable method of confirming proper guidewire placement. A prospective feasibility study of 200 adult cardiothoracic surgery patients undergoing internal jugular vein catheterization was performed to determine whether the guidewire could be imaged with ultrasonography in the brachiocephalic vein. The guidewire was imaged in the internal jugular vein in a short-axis view, and the transducer was then angled caudally under the clavicle, following the guidewire into the brachiocephalic vein. The right internal jugular vein was catheterized in 193 patients and the left internal jugular in 7 patients. The brachiocephalic vein was successfully imaged in all but 2 patients. In 3 patients, the guidewire could not be clearly identified in the brachiocephalic vein because of interference from the leads of a heart rhythm device (pacemaker or defibrillator) or preexisting catheter. In 2 patients, the guidewire was not seen initially in the brachiocephalic vein because of coiling in the internal jugular vein, and in 1 patient because of the guidewire passing into the right subclavian vein, but all 3 were subsequently imaged in the brachiocephalic vein after repositioning. During internal jugular vein catheterization, the brachiocephalic vein was imaged with ultrasonography in 99% of patients (the lower 1-sided 99% confidence limit is 96%). The guidewire was imaged in the brachiocephalic vein in all cases except when leads from a heart rhythm device caused interference, although in some patients with leads, the guidewire could be imaged without difficulty. The absence of the guidewire from the brachiocephalic vein was indicative of a malpositioned guidewire.

Routine Chest Radiography Is Not Necessary After Ultrasound-Guided Right Internal Jugular Vein Catheterization.

Central venous catheter placement is a common procedure performed on critically ill patients. Routine postprocedure chest radiographs are considered standard practice. We hypothesize that the rate of clinically relevant complications detected on chest radiographs following ultrasound-guided right internal jugular vein catheterization is exceedingly low. Retrospective chart review. Adult ICUs, emergency departments, and general practice units at an academic tertiary care hospital system. All 1,322 ultrasound-guided right internal jugular vein central venous catheter attempts at an academic tertiary care hospital system over a 1-year period. None. Data from standardized procedure notes and postprocedure chest radiographs were extracted and individually reviewed to verify the presence of pneumothorax or misplacement, and any intervention performed for either complication. The overall success rate of ultrasound-guided right internal jugular vein central venous catheter placement was 96.9% with an average of 1.3 attempts. There was only one pneumothorax (0.1% [95% CI, 0-0.4%]), and the rate of catheter misplacement requiring repositioning or replacement was 1.0% (95% CI, 0.6-1.7%). There were no arterial placements found on chest radiographs. Multivariate regression analysis showed no correlation between high-risk patient characteristics and composite complication rate. In a large teaching hospital system, the overall rate of clinically relevant complications detected on chest radiographs following ultrasound-guided right internal jugular vein catheterization is exceedingly low. Routine chest radiograph after this common procedure is an unnecessary use of resources and may delay resuscitation of critically ill patients.

IMPROVING MEDICAL EDUCATION: SIMULATING CHANGES IN PATIENT ANATOMY USING DYNAMIC HAPTIC FEEDBACK.

Virtual simulation is an emerging field in medical education. Research suggests that simulation reduces complication rates and improves learning gains for medical residents. One benefit of simulators is their allowance for more realistic and dynamic patient anatomies. While potentially useful throughout medical education, few studies have explored the impact of dynamic haptic simulators on medical training. In light of this research void, this study was developed to examine how a Dynamic-Haptic Robotic Trainer (DHRT) impacts medical student self-efficacy and skill gains compared to traditional simulators developed to train students in Internal Jugular Central Venous Catheter (IJ CVC) placement. The study was conducted with 18 third year medical students with no prior CVC insertion experience who underwent a pre-test, simulator training (manikin, robotic, or mixed) and post-test. The results revealed the DHRT as a useful method for training CVC skills and supports further research on dynamic haptic trainers in medical education.

Attending Physician Adherence to a 29-Component Central Venous Catheter Bundle Checklist During Simulated Procedures.

Central venous catheter insertions may lead to preventable adverse events. Attending physicians' central venous catheter insertion skills are not assessed routinely. We aimed to compare attending physicians' simulated central venous catheterinsertion performance to published competency standards. Prospective cohort study of attending physicians' simulated internal jugular and subclavian central venous catheter insertion skills versus a historical comparison group of residents who participated in simulation training. Fifty-eight Veterans Affairs Medical Centers from February 2014 to December 2014 during a 2-day simulation-based education curriculum and two academic medical centers in Chicago. A total of 108 experienced attending physicians and 143 internal medicine and emergency medicine residents. None. Using a previously published central venous catheter insertion skills checklist, we compared Veterans Affairs Medical Centers attending physicians' simulated central venous catheter insertion performance to the same simulated performance by internal medicine and emergency medicine residents from two academic centers. Attending physician performance was compared to residents' baseline and posttest (after simulation training) performance. Minimum passing scores were set previously by an expert panel. Attending physicians performed higher on the internal jugular (median, 75.86% items correct; interquartile range, 68.97-86.21) and subclavian (median, 83.00%; interquartile range, 59.00-86.21) assessments compared to residents' internal jugular (median, 37.04% items correct; interquartile range, 22.22-68.97) and subclavian (median, 33.33%; interquartile range, 0.00-70.37; both p < 0.001) baseline assessments. Overall simulated performance was poor because only 12 of 67 attending physicians (17.9%) met or exceeded the minimum passing score for internal jugular central venous catheter insertion and only 11 of 47 (23.4%) met or exceeded the minimum passing score for subclavian central venous catheter insertion. Resident posttest performance after simulation training was significantly higher than attending physician performance (internal jugular: median, 96%; interquartile range, 93.10-100.00; subclavian: median, 100%; interquartile range, 96.00-100.00; both p < 0.001). This study demonstrates highly variable simulated central venous catheter insertion performance among a national cohort of experienced attending physicians. Hospitals, healthcare systems, and governing bodies should recognize that even experienced physicians require periodic clinical skill assessment and retraining.

Comparative effectiveness of 30% trisodium citrate and heparin lock solution in preventing infection and dysfunction of hemodialysis catheters: a randomized controlled trial (CITRIM trial).

Central venous catheters (CVC) are the only option when hemodialysis is needed for patients without definitive vascular access. However, CVC is associated with complications, such as infection, thrombosis, and dysfunction, leading to higher mortality and expenditures. The aim of this study was to compare the effectiveness of 30% trisodium citrate (TSC30%) with heparin as CVC lock solutions in preventing catheter-related bloodstream infections (CRBSI) and dysfunction in hemodialysis patients. Randomized, double-blind controlled trial comparing the event-free survival of non-tunneled CVC locked with heparin or TSC30% in adult hemodialysis patients. The study included 464 catheters, 233 in heparin group, and 231 in TSC30% group. The CRBSI-free survival of TSC30% group was significantly shorter than that of heparin group. When stratified by insertion site, heparin was better than TSC30% only in subclavian CVC. The dysfunction-free survival was not different between groups in the main analysis, but there is also a shorter survival among subclavian CVC locked with TSC30% in stratified analysis. There was no difference on CRBSI-free or dysfunction-free survival between jugular vein CVC locked with heparin or 30% citrate. However, subclavian CVC locked with 30% citrate presented shorter event-free survival. This difference may be related to anatomical and positional effects, CVC design, and hydraulic aspects of the lock solution. CLINICALTRIALS. NCT02563041.

Use of ultrasound guidance for central venous catheterization: a national survey of intensivists and hospitalists

PurposeThe purpose of the study is to evaluate the frequency and barriers to use of ultrasound guidance for central venous catheter (CVC) insertion by physicians specializing in critical care and hospital medicine. Materials and methodsA national cross-sectional electronic survey of intensivists and hospitalists was administered from November 2014 to January 2015. ResultsThe survey response rate was 5.9% (1013/17 233). Moderate to very frequent use of ultrasound guidance varied by site: internal jugular vein (80%), subclavian vein (31%), and femoral vein (45%). Nearly all physicians (99%) who insert internal jugular CVCs daily use ultrasound guidance, whereas only 46% of physicians who insert subclavian CVCs daily use ultrasound guidance. Use of real-time ultrasound guidance varied by insertion site: internal jugular vein (73%), subclavian vein (28%), and femoral vein (42%). Most physicians (59%) reported not being comfortable with real-time needle tracking at the subclavian site. The most frequently reported barriers to use of ultrasound guidance were (1) limited availability of ultrasound equipment (28%), (2) perception of increased total procedure time (22%), and (3) concern for loss of landmark skills (13%). ConclusionsMost intensivists routinely use ultrasound guidance to insert internal jugular CVCs but not subclavian CVCs. The most commonly reported barrier to ultrasound use was limited access to an ultrasound machine.

Validation of a performance checklist for ultrasound-guided internal jugular central lines for use in procedural instruction and assessment

Purpose of the studyTools created to measure procedural competency must be tested in their intended environment against an established standard in order to be validated. We previously created a checklist...

LO088: Development of a simulation-based curriculum for ultrasound-guided internal jugular central venous catheterization

Introduction / Innovation Concept: Insertion of an internal jugular (IJ) central venous catheter (CVC) under ultrasound guidance (USG) is a complex skill that requires considerable practice in order to achieve technical proficiency. Simulation allows novices to engage in structured and high volume repetitive practice of USG IJ CVC insertion and to work through a predictable pattern of errors prior to real patient encounters. Based on earlier work on learning curves for CVC insertion, this curriculum uses a model of simulation-based high volume deliberate practice of the fundamental skills of USG CVC insertion, and was designed with careful consideration of the conditions associated with optimal learning and improvement of performance. Methods: Eight residents (post graduate year 2) from the Departments of Emergency Medicine and Anesthesiology engaged in deliberate practice of USG CVC insertion during three two-hour sessions, at 2-week intervals. Progress of the residents was monitored with direct observation and regular hand motion analysis (HMA), which was compared to performance metrics set by a local expert. Curriculum, Tool, or Material: Students reviewed online introductory ultrasound video and articles outlining internal jugular (IJ) and femoral CVC insertion prior to the first session. Session 1 focused on ultrasound skills including knobology, transducer movement, and needle tracking. This was followed by 60 minutes of deliberate practice of the skills of USG CVC insertion on both femoral and IJ models. During sessions 2/3, students practiced complete gowning and draping using sterile technique. This was followed again by deliberate practice of the skills of USG CVC insertion on both femoral and IJ models. Students received coaching and feedback throughout all sessions, with HMA assessment of USG IJ CVC insertion at the beginning and end of each session. After three training sessions, consisting of 85 total attempts, 5/8 residents surpassed the expert benchmark for probe hand motion, 6/8 for needle hand motion, and 1/8 for total procedure time, with the remaining residents approaching the expert benchmark for each metric. Conclusion: We have successfully developed a simulation-based curriculum for USG IJ CVC placement. Residents demonstrated continuous improvement in each session, approaching or exceeding the expert benchmarks by the end of the third session.

P147: International scope of emergency ultrasound: barriers to utilizing ultrasound to guide central venous catheter placement by providers in Kenya

Introduction: While ultrasound (U/S) use for internal jugular central venous catheter (CVC) placement is standard of care in many institutions in North America, most developing countries have not adopted this practice. Previous surveys of American physicians who are not currently using U/S to place CVCs have identified lack of training and equipment availability as the most important barriers to the use of U/S. We sought to identify Kenyan physicians’ perceived barriers to the use of U/S to guide CVC insertion in a resource-constrained environment. Methods: The study was conducted at the Aga Khan University Hospital in Nairobi, Kenya. Physicians participating in a one-hour course teaching U/S guided CVC placement were asked to complete a survey before beginning training, which was used to assess previous experience with U/S, and evaluate perceived barriers to U/S. Survey responses were analyzed using summary statistics and the Rank-Sum test to compare the difference between participants’ responses based on different specialty, gender and previous history of using U/S. Results: There were 23 physicians who completed the course and the survey. They included 6 internal medicine, 5 critical care, 5 anesthesia, 2 emergency medicine and 5 physicians from other specialties. The mean length of practice was 5 years. 52% (95% CI: 0.30-0.73) had put in &gt;20 CVCs. 21.7% (95% CI: 0.08-0.44) of participants had previous U/S training, but none have received any training on the use of U/S for CVC insertion. The respondents expressed agreement on the ease of the use, improved success rate, and decreased failure rate with U/S guidance. However, less agreement was found regarding the perceived superior convenience and cost effectiveness of U/S CVC placement (see Figure). The lack of training or comfort with the U/S and the availability of U/S and equipment to maintain sterility were reported as the main barriers for use. Neither previous U/S experience nor specialty of the respondent significantly affected responses. Conclusion: Barriers to the use of U/S guidance for the placement of CVCs in Nairobi, Kenya are similar to those found among American physicians. These include training and comfort level with U/S in placement of CVCs, as well as resources required for U/S equipment and to keep the field sterile.

36th International Symposium on Intensive Care and Emergency Medicine : Brussels, Belgium. 15-18 March 2016.

36th International Symposium on Intensive Care and Emergency Medicine : Brussels, Belgium. 15-18 March 2016.