Central Venous Catheter Tip Position Research Articles

Feasibility of a new ultrasound guided procedure to ensure the correct position of the central venous catheter tip

BackgroundSafety of central venous catheter (CVC) placement relies on some general aspects, including selection of the right vessel, correct lumen targeting while inserting the needle, check the position of catheter tip, and post-procedure check for complications. All these four points can be guided by bedside ultrasound, but the best technique to ensure the position of the CVC tip is still uncertain. MethodsWe investigated feasibility of a novel ultrasound technique consisting of focused view of guidewire tip in the cavoatrial junction (CAJ) to calculate the CVC depth in adult patients needing CVC placement in emergency. Direct visualization of the guidewire in the CAJ was used to calculate how deep the CVC needed to be inserted. In those patients without a valid CAJ window, a bubble test in the right atrium was performed to position the CVC tip. In all cases chest radiography confirmed the CVC position. ResultsThe procedure was performed in 37 patients and CVC was correctly placed in all cases. Within the group, in 25 patients the CVC depth (21.5 ± 6.0 cm) was successfully measured. In other 11 patients the correct CVC tip position was confirmed by the bubble test. In only one case it was not possible to use ultrasound for incomplete CAJ and right atrium views. ConclusionsThis study confirms the feasibility of a new ultrasound method to ensure the correct CVC tip position. This protocol could potentially become a standard method reducing costs, post-procedural irradiation, and time of CVC placement in emergency.

A retrospective study of subcutaneous anchor securement systems in oncology patients.

Maintaining optimal central venous catheter tip position requires reliable catheter securement. A vital decision about the choice of engineered securement device is often made by what is conveniently available in the insertion kit or default clinical routine. The importance of continuous securement for oncology patients prompted the need for an evaluation of securement options currently available. This study aimed to assess the effectiveness of two engineered securement devices to assist the oncology patient in reaching the end of their catheter need. A retrospective study was conducted to assess patients' ability to finish their therapy with one peripherally inserted central catheter. Implant and explant data for adult oncology patients was evaluated spanning 2007-2021. All patients received a PICC with either an adhesive securement device or a subcutaneous anchor securement system. Partial or complete dislodgement causing the unplanned removal of the PICC occurred at 12% for ASD and 0.4% for SASS (p < 0.0001). The probability of reaching the end of need with one PICC, regardless of the reason for premature removal, at 2 years for patients with an adhesive securement device was 68% (n = 944). For patients with a subcutaneous anchored securement device, it was over 95% (n = 8313). The difference in the probability of reaching the end of the need with one PICC between the two securement devices was calculated at (p < 0.0001). With over 9200 patients and more than a million catheter days, the results of this retrospective study demonstrate the SASS's superiority in assisting the patient to reach the end of need with a single PICC.

Comparison between ultrasound and chest X-ray to confirm central venous catheter tip position.

Mechanical central venous catheter (CVC) placement complications are mostly malposition or iatrogenic pneumothorax. Verification of catheter position by chest X-ray (CXR) is usually performed postoperatively. This prospective observational study assessed the diagnostic accuracy of peri-operative ultrasound and a 'bubble test' to detect malposition and pneumothorax. Sixty-one patients undergoing peri-operative CVC placement were included. An ultrasound protocol was used to directly visualise the CVC, perform the 'bubble test' and assess for the presence of pneumothorax. The time from agitated saline injection to visualisation of microbubbles in the right atrium was evaluated to determine the correct position of the CVC. The time required to perform the ultrasound assessment was compared to that of conducting the CXR. Chest X-ray identified 12 (19.7%) malpositions while ultrasound identified 8 (13.1%). Ultrasound showed a sensitivity of 0.85 (95% confidence interval [CI]: 0.72 to 0.93) and a specificity of 0.5 (95% CI: 0.16 to 0.84). The positive and negative predictive values were 0.92 (95% CI: 0.80 to 0.98) and 0.33 (95% CI: 0.10 to 0.65), respectively. No pneumothorax was identified on ultrasound and CXR. The median time for ultrasound assessment was significantly shorter at 4 min (interquartile range [IQR]: 3-6 min), compared to performing a CXR that required a median time of 29 min (IQR: 18-56 min) (p < 0.0001). This study showed that ultrasound produced a high sensitivity and moderate specificity in detecting CVC malposition. Ultrasound can improve efficiency when used as a rapid bedside screening test to detect CVC malposition.

Central catheter tip migration in critically ill patients.

Chest X-ray (CXR) is routinely required for assessing Central Venous Catheter (CVC) tip position after insertion, but there is limited data as to the movement of the tip location during hospitalization. We aimed to assess the migration of Central Venous Catheter (CVC) position, as a significant movement of catheter tip location may challenge some of the daily practice after insertion. Retrospective, single-center study, conducted in the Intensive Care and Cardiovascular Intensive Care Units in Tel Aviv Sourasky Medical Center 'Ichilov', Israel, between January and June 2019. We identified 101 patients with a CVC in the Right Internal Jugular (RIJ) with at least two CXRs during hospitalization. For each patient, we measured the CVC tip position below the carina level in the first and all consecutive CXRs. The average initial tip position was 1.52 (±1.9) cm (mean±SD) below the carina. The maximal migration distance from the initial insertion position was 1.9 (±1) cm (mean±SD). During follow-up of 2 to 5 days, 92% of all subject's CVCs remained within the range of the Superior Vena Cava to the top of the right atrium, regardless of the initial positioning. CVC tip position can migrate significantly during a patient's early hospitalization period regardless of primary location, although for most patients it will remain within a wide range of the top of the right atrium and the middle of the Superior Vena Cava (SVC), if accepted as well-positioned.

"Optimal" Central Venous Catheter Tip Position Does Not Increase Catheter Duration: A Retrospective Cohort Study.

Background Central venous cannulation provides venous access in different settings. Multiple guidelines and checklists still recommend confirmation of central venous catheter (CVC) tip position using a chest radiograph. The rationale is to detect and prevent complications thus optimizing CVC placement. Our primary hypothesis is that confirmation of catheter tip position by chest radiograph is not associated with increased catheter duration. Methods A retrospective cohort study was conducted with 921 patients included. Demographic, procedure and catheter data was obtained from adult patients that placed a CVC in the operating room. The catheter tip was independently classified as "optimal" or "malpositioned" independently by two researchers. Results Data from 921 CVC placements was collected. Patients who had a post-procedure chest radiograph(n=682, 74.0%) differed from those who did not in terms of co-morbidities (p=0.030), indication for CVC (p=0.023), duration of placement (p<0.001), number of punctured veins (p=0.036) and use of ultrasound (p<0.001). There was substantial agreement between researchers when classifying CVC tip as "optimal" or "malpositioned" (κ=0.632,p<0.001). No statistically significant difference was found between duration or complications of "optimal" CVCs compared to unknown tip/"malpositioned" CVCs. This study showed a 99% rate of clinically redundant chest radiographs according to Pikwer's criteria for radiographic examination. Conclusion No difference was found regarding catheter duration or complications when comparing "optimal" and unknown/"malpositioned" tip. This study illustrates some consequences of post-procedure radiographs and reinforces that the risks/benefits should be weighed and that chest radiograph should not be done by routine.

Additionally using transthoracic echocardiography during ultrasound-guided jugular central venous catheter placement and the odds of catheter misplacement in children: A before-and-after study.

Central venous catheter (CVC) misplacement is a major complication.1 To avoid CVC misplacement, real-time ultrasound (US) guidance is recommended for CVC placement in children.2, 3 Transthoracic echocardiography (TTE) can be additionally used to confirm correct CVC tip position.4, 5 Whether additionally using TTE during US-guided jugular CVC placement reduces the incidence of catheter misplacement remains scarcely described. We thus sought to test the hypothesis that additionally using TTE during US-guided jugular CVC placement reduces the odds of CVC misplacement in children. After approval by the ethics committee with waiver of informed consent, we performed a retrospective before-and-after study in children aged 0–6 years who received a jugular CVC during anesthetic induction for congenital heart disease surgery at the University Medical Center Hamburg-Eppendorf (Hamburg, Germany) between March 2015 and April 2020. In our institution, jugular CVCs in children having cardiac surgery are routinely placed using real-time US guidance since 2013. In October 2017, routine use of additional TTE during US-guided jugular CVC placement was implemented. In the 31-month “before period” (March 2015 to September 2017), anesthesiologists did not use TTE but chose the CVC insertion depth considering patient height (no-TTE-group). In the 31-month “after period” (October 2017 to April 2020), additional TTE (subcostal long-axis view) was routinely used during US-guided jugular CVC placement to confirm the correct position of the guidewire and the CVC tip (rapid saline flush test) (TTE-group) (Figure S1). During both study periods, chest x-ray was used to confirm correct CVC tip position after surgery. We categorized CVCs as misplaced when the CVC tip ended above the level of the superior vena cava in a noncentral vein or deep in the right atrium (Figure S2). We investigated the associations between CVC misplacement and TTE use by logistic regression for all patients including age as covariate—and separately for patients aged <1 year and 1–6 years. We report the odds ratios (OR) with 95% confidence intervals. We included 373 patients (156 no-TTE-group and 217 TTE-group) (Table S1). CVC misplacement occurred in 15/156 no-TTE-group patients (9.6%) and in 5/217 TTE-group patients (2.3%). The odds for CVC misplacement were 371% lower when TTE was used compared to when it was not used (p = .004, OR = 0.21 [0.067–0.57]) (Figure 1). Of all 373 patients, 229 (61%) were younger than 1 year. In these patients, CVC misplacement occurred in 8/76 no-TTE-group patients (11%) and in 4/153 TTE-group patients (2.6%). The odds for CVC misplacement were 319% lower when TTE was used (p = .023, OR = 0.24 [0.062–0.79]). Of all 373 patients, 144 (39%) were between 1 and 6 years old. In these patients, CVC misplacement occurred in 7/80 no-TTE-group patients (8.8%) and in 1/64 TTE-group patients (1.6%). The odds for CVC misplacement were 480% lower when TTE was used (p = .107, OR = 0.17 [0.0090–1.0]). In our study, additionally using TTE during US-guided jugular CVC placement in children reduced the odds for CVC misplacement by more than 300%—which obviously is clinically meaningful. In only about 1% of children, the subcostal long-axis view could not be obtained—and TTE could thus not be used to confirm the CVC tip position. In general, children provide an excellent acoustic window for TTE examination of the right atrium and the superior vena cava. Nevertheless, TTE requires technical skills and operator experience. Our results need to be interpreted in light of the inherent limitations of retrospective before-and-after studies. Additionally, we only included children with congenital heart disease, whose anatomy may differ from healthy children. However, as we excluded patients with irregular venous conformations, we assume that our findings can be transferred to pediatric patients in general. Additionally using TTE during US-guided jugular CVC placement reduces the odds of CVC misplacement in children aged 0–6 years. Clinicians should consider additionally using TTE during US-guided jugular CVC placement to increase patient safety. This work was supported solely from institutional and/or department sources. There are no conflicts of interest to declare. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Supporting Information Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Classification of Central Venous Catheter Tip Position on Chest X-ray Using Artificial Intelligence.

Recent studies utilizing deep convolutional neural networks (CNN) have described the central venous catheter (CVC) on chest radiography images. However, there have been no studies for the classification of the CVC tip position with a definite criterion on the chest radiograph. This study aimed to develop an algorithm for the automatic classification of proper depth with the application of automatic segmentation of the trachea and the CVC on chest radiographs using a deep CNN. This was a retrospective study that used plain chest supine anteroposterior radiographs. The trachea and CVC were segmented on images and three labels (shallow, proper, and deep position) were assigned based on the vertical distance between the tracheal carina and CVC tip. We used a two-stage approach model for the automatic segmentation of the trachea and CVC with U-net++ and automatic classification of CVC placement with EfficientNet B4. The primary outcome was a successful three-label classification through five-fold validations with segmented images and a test with segmentation-free images. Of a total of 808 images, 207 images were manually segmented and the overall accuracy of the five-fold validation for the classification of three-class labels (mean (SD)) of five-fold validation was 0.76 (0.03). In the test for classification with 601 segmentation-free images, the average accuracy, precision, recall, and F1-score were 0.82, 0.73, 0.73, and 0.73, respectively. We achieved the highest accuracy value of 0.91 in the shallow position label, while the highest F1-score was 0.82 in the deep position label. A deep CNN can achieve a comparative performance in the classification of the CVC position based on the distance from the carina to the CVC tip as well as automatic segmentation of the trachea and CVC on plain chest radiographs.

Development of a radiopaque tiltmeter to improve reproducibility for Fowler's position on chest radiography

IntroductionWe have developed a novel radiopaque tiltmeter (ROT) that can indicate patient tilt during a radiography examination and display it on X-ray images. This study evaluated the effect of variation of patient tilt on the reproducibility of Fowler's position for chest radiography and the accuracy of the ROT. MethodsWe evaluated the reproducibility of Fowler's position based on changes from the first day in the central venous catheter (CVC) tip position and the cardiothoracic ratio (CTR) with and without a digital tiltmeter to verify its efficacy in patients who underwent mobile chest radiography. The ROT contains radiopaque liquid consisting of white barium sulfate solution and oil and has a scale bar of 15°–75° with increments of 15° to indicate ROT tilt. The ROT tilt was increased from 10° to 80° in increments of 10°. We then evaluated (1) the difference between the ROT tilt and the tilt measured with a digital tiltmeter, and (2) the ROT tilt displayed on the X-ray image. ResultsWith regard to reproducibility in Fowler's position, changes in the CVC tip position were 2.8 ± 3.9 mm and 10.7 ± 10.6 mm with and without the tiltmeter, respectively (p < 0.05) and the respective rates of change in the CTR were 0.7% ± 0.6% and 4.0% ± 2.1% (p < 0.05). Differences between the ROT tilt and the tilt measured by the digital tiltmeter were within ±2.5°. All ROT tilts displayed on the X-ray images were recognized exactly as each tilt. ConclusionOur novel ROT had the potential to accurately indicate patient tilt during chest radiography, which could be helpful in terms of reproducibility and precise follow-up. Implications for practiceUse of the ROT for determination of patient tilt can improve reproducibility in Fowler's position, allowing more accurate serial X-ray imaging.

Internal Jugular Central Venous Catheter Tip Migration: Patient and Procedural Factors.

Background: The ideal central venous catheter (CVC) tip position placement is controversial, and CVCs do not remain in a fixed position after placement. This study evaluates both patient and procedural factors which may influence CVC tip migration and subsequent catheter dysfunction. Materials and Methods: This study evaluates CVC placements at a single institution. Patient age, gender, body mass index (BMI), catheter laterality, CVC type and indication for central venous access were recorded. Catheter tip location relative to the carina was measured at time of placement and removal utilizing supine fluoroscopic imaging. Patients’ electronic medical records were reviewed for evidence of catheter dysfunction. Statistical analysis was performed utilizing odds ratios and two tailed Student’s t-test. Results: 177 patients were included (101 female; mean age 55; mean BMI 29.2). Catheter types included 122 ports, 50 tunneled large bore central venous catheters (≥9 French), and 5 tunneled small bore central venous catheters (<9 French). 127 were right sided catheters, and 50 were left sided. Left sided CVCs had a mean cranial tip migration of 3.2 cm (standard deviation ±2.9 cm) compared to 0.8 cm (standard deviation ±1.9 cm) for right sided catheters (p = 0.000008). Catheters that migrated cranially by >2 cm had more than 7× greater risk of dysfunction compared to catheters that migrated ≤2 cm (odds ratio of 7.2; p = 0.0001). Left sided CVCs were significantly more likely to have >2 cm of cranial migration (odds ratio 6.9, 95% CI 3.4–14.2, p < 0.0001) and had a higher rate of dysfunction, likely due to this cranial migration (32% vs. 4.7%; p = 0.00001). Gender and BMI were not found to be associated with catheter dysfunction or an increased odds ratio of >2 cm cranial migration. Conclusions: Left-sided CVCs migrate an average of 2.4 cm cranially more than right-sided catheters. Additionally, when migration occurs, left-sided catheters are more likely to be dysfunctional. These suggest that lower initial placement may be beneficial in left-sided catheters.

Study on the Safety and Accuracy of Intracavitary Electrocardiography and Ultrasound in the Peripherally Inserted Central Venous Catheter tip positioning of Breast Cancer Patients

This study aims to explore the safety and accuracy of the intracavitary electrocardiography and ultrasound in the peripherally inserted central venous catheter tip positioning of breast cancer patients. A total of 176 breast cancer patients who were treated in the breast surgery department of our hospital from January 2018 to January 2019 were selected. They were randomly divided into the Electrocardiogram-UI group (n=88) and the control group (n=88). In the Electrocardiogram-UI group, the peripherally inserted central venous catheter tip positioning was under the guidance of the bedside Electrocardiogram combined with ultrasound, while the peripherally inserted central venous catheter insertion in the control group was performed by the traditional technology. The accuracy of peripherally inserted central venous catheter tip positioning, psychological state, anxiety, pain degree, and complications were compared between the two groups after surgery. The results showed that the positioning accuracy rate of the catheter tip in the Electrocardiogram-UI group was 99.40 %, while that in the control group was 92.10 %. In the control group, the accuracy rate of the catheter tip positioning in the 6th, 7th and 8th ribs was 20.30 %, 64.10 %, and 14.70 % respectively, while that in the Electrocardiogram-UI group was 32.20 %, 40.30 % and 19.60 % respectively, with a significant difference between the two groups. And 24 h before the catheter insertion, there was no significant difference in the anxiety scores between the two groups. However, 24 h after the catheter insertion, the anxiety and pain scores in the Electrocardiogram-UI group were significantly lower than that of the control group. In terms of the complications, in the first w, two patients in the Electrocardiogram-UI group had thrombosis, while four patients in the control group. No patients had the symptoms of the chest discomfort, arrhythmia, or infection in both groups. At the end of three and six mo, the incidence of thrombosis in the Electrocardiogram-UI group was significantly lower than that of the control group. The peripherally inserted central venous catheter tip positioning technology guided by Electrocardiogram combined with ultrasound is an ideal method for peripherally inserted central venous catheter insertion. It can improve the quality of life of the breast cancer patients and promote the prognosis of the breast cancer patients.

Evaluation of the Efficacy of Ultrasound in Detecting Correct Placement of Central Venous Catheter and Determining the Elimination of the Need for Chest Radiography

Abstract Background and Aims Ultrasound guidance of central venous catheter (CVC) insertion improves the safety and efficacy of its placement, but still it may not ensure correct placement of catheter tip. In our study, we aimed to identify the correct placement of CVC tip and to detect mechanical complications, by visualizing it in real time with the help of sonography and comparing this to the chest X-ray findings. Patients and Methods This was a cross-sectional observational study conducted on 80 patients with American Society of Anesthesiologists grades 1 and 2, in the age group of 18 to 65 years, who required central venous catheterization in intensive care unit. The CVC tip placement was identified with ultrasound and then the finding was compared with postinsertion chest X-ray. Results In only 9 out of the 80 patients (11.3%) malposition was detected on ultrasound and was corrected immediately, whereas in remaining 71 patients (88.8%) no intervention was required. It was observed that all the patients had correct position of CVC tip on postprocedural chest X-ray. Accidental arterial cannulation occurred in two (2.5%) patients in whom right internal jugular vein was cannulated and in two (2.5%) patients who had arrhythmia. Conclusion Ultrasonography (USG) examination can be used as a diagnostic tool method for confirmation of CVC tip and identification of cannulation-related complications. Thus, we can say that USG might obviate the need for post-CVC insertion chest X-ray.

Routine chest X-ray following ultrasound-guided internal jugular vein catheterization in critically ill children: A prospective observational Study.

Recent studies in adults have shown that routine chest X-ray following ultrasound-guided central venous catheter insertion through the internal jugular vein is unnecessary due to a low rate of complications. To assess the usefulness of routine chest X-ray following ultrasound-guided central venous catheter insertion through the internal jugular veins in critically ill children. A prospective observational study was conducted at a pediatric intensive care unit of a tertiary, university-affiliated pediatric medical center. All children under the age of 18 who underwent ultrasound-guided central venous catheter insertion through the right or left internal jugular vein between May 2018 and November 2019 were evaluated for eligibility. Procedures were prospectively documented, and chest X-ray was screened for pneumothorax, hemothorax, central venous catheter tip position, and resultant corrective interventions. Of 105 central venous catheter insertion attempts, 99 central venous catheters (94.3%) were inserted. All were located within the venous system. None were diagnosed with pneumo/hemothorax on chest X-ray. Twenty (20.2%; 95% CI 12.8%-29.5%) were defined as malpositioned by strict criteria; however, only one (1%) was judged significantly misplaced by the clinical team leading to its repositioning. In this critically ill pediatric cohort, all central venous catheters inserted under ultrasound guidance could have been used with safety prior to acquiring chest X-ray. Overall chest X-ray impacted patient management in only 1% of cases. Our results do not support delaying urgent central venous catheter use pending chest X-ray completion in critically ill children.

A Novel Objective Approach Towards Physicians' Knowledge and Practice Patterns to Optimize Central Venous Catheter Placement: A Cross-sectional Study

Study objective: Central venous catheterization is an essential component of intensive care of critically ill patients, and proper positioning of the catheter is essential to prevent position-related complications. This study was conducted by using digital tape measurement to objectively assess clinician preferences for central venous catheter positioning based on specific position levels and landmarks on post-procedural chest radiographs. Design: A cross-sectional study using electronic questionnaire survey. Setting: Single academic teaching hospital participated in this study. Participants: The study enrolled 276 physicians from multiple clinical disciplines. Interventions: None. Measurements: A seven-level reference system labeled on a sample chest radiograph was used to identify the acceptable lower and upper limits and landmarks used to determine the optimal central venous catheter tip position as well as the pattern of clinical practices based on the specialty and level of experience of participants. Main results: Among the 276 respondents, the ratio of cumulative acceptance for the lower and upper catheter tip limit was 62% and 66.3% within a 4-cm range below or above the carina, respectively. Intensive care unit (ICU) physicians showed a greater tendency to choose a catheter tip 4 cm below and 6 cm above the carina (p = 0.004 and 0.002, respectively) as did experienced physicians (p = 0.007 and &lt; 0.001, respectively). The commonest reason for catheter tip withdrawal was arrhythmia (50% of cases). Physicians in the ICU and experienced physicians were more concerned about the risk of cardiac perforation than other respondents (p &lt; 0.001 and &lt; 0.001, respectively). The carina was the most commonly used landmark in 71.7% of all physicians, although 50% of radiologists also used other landmarks. Conclusions: The acceptable limit of the catheter tip is 4 cm above and below the carina (-4 to +4), as determined on chest radiography, without a need for tip adjustment.

Central venous catheter tip position on chest radiographs: a reply

Central venous catheter tip position on chest radiographs: a reply

Bedside Ultrasound in the Pediatric Intensive Care Unit: Newer Uses

To explore recent advancements in the use of point-of-care ultrasound in the pediatric intensive care unit or during the perioperative period. Ultrasound is useful for selecting an appropriate endotracheal tube size, predicting postextubation stridor, assessing vocal cord paralysis, performing ultrasound-guided lung recruitment, assessing circulatory volume status, performing transcranial Doppler for assessment of cerebral perfusion, assessing intracranial hypertension, assessing central venous catheter tip position, and performing arterial line cannulation. There has been rapid progress in the use of point-of-care ultrasound in pediatric critical care, which can revolutionize daily clinical practice. However, further studies are required to verify that some of these areas of clinical application are translatable and scalable to widespread adoption.

A checklist to improve the quality of central venous catheter tip positioning.

Central venous catheter insertion is a routine procedure performed by anaesthetists in the peri-operative setting. Upper body central venous catheters are usually placed such that their tip lies within the superior vena cava or at the cavo-atrial junction. Positioning the tip 'too low' in the right atrium has long been argued against on the basis that it increases the risk of perforation, leading to cardiac tamponade. Positioning the tip 'too high' in the brachiocephalic vein or above can also be problematic in that proximal migration can result in extravascular placement of the proximal lumen. Such an incident occurred at our hospital in 2016, resulting in extravasation of a vesicant medication causing tissue necrosis. We undertook a quality improvement project involving a standardised bundle of care and a peri-operative central venous catheter insertion checklist with the aim of reducing the risk of such an incident re-occurring. We conducted a three-month pre-intervention audit (n=84) in 2016 and a post-intervention audit (n=84) in 2017. Compared with the pre-intervention audit, the post-intervention audit coincided with a lower rate of central venous catheter tip malpositioning (5.6% vs. 9.2%); and a higher rate of 'optimal' central venous catheter tip position in the distal superior vena cava or cavo-atrial junction (45.1% vs. 29.2%). The central venous catheter insertion checklist also substantially improved documentation of sterility measures, insertion depth and post-insertional documentation of tip position on chest radiograph.

The "rapid atrial swirl sign" for assessing central venous catheters: Performance by medical residents after limited training.

RationaleCentral venous catheter (CVC) placement is a standard procedure in critical care. Ultrasound guidance during placement is recommended by current guidelines, but there is no consensus on the best method for evaluating the correct CVC tip position. Recently, the “rapid atrial swirl sign” (RASS) has been investigated in a limited number of studies.ObjectivesWe performed a prospective diagnostic accuracy study of focused echocardiography for the evaluation of CVC tip position in our medical ICU and IMC units.MethodsWe performed a prospective diagnostic accuracy study in 100 patients admitted to the Intensive Care Unit and Intermediate Care Unit at our center. The first 10 subjects were assessed by one staff physician investigator (reference cohort), the remaining 90 patients by different residents (test cohort). All patients received a post-procedural chest radiograph (CXR) as gold standard. CVC placement was assessed with focused echocardiography performed by residents after a short training session. A rapid opacification of the right atrium (RASS) after injection of 10 mL of normal saline was regarded as “positive”, flush after more than two seconds was defined as “delayed”, no flush was a “negative” test result.Measurements and main resultsOverall sensitivity of the RASS was 100% (95% CI 73.54–100%), specificity was 94.32% (CI 87.24–98.13%). Positive and negative predictive values were 70.59% (CI 44.04–89.09%) and 100% (CI 95.65–100%), respectively. Median time for echocardiographic testing was 5 minutes (1–28) in the whole cohort, CXRs were available after 49.5 minutes (13–254). Interrater agreement of the RASS was 0.77 (Cohen’s kappa), Measurement of CVC tip position was not different between two observers. Test characteristics were similar among differently experienced residents.ConclusionsPresence of the RASS by focused echocardiography showed excellent sensitivity and specificity and was equally performed by residents after minimal training. In patients with a positive RASS, routine CXR can be safely omitted, reducing time, costs and radiation exposure. A negative RASS should lead to a search for misplaced catheters.Clinical trial registrationThe study was registered with www.clinicaltrials.gov (NCT02661607).

Central venous catheterization for acute trauma resuscitation: Tip position analysis using routine emergency computed tomography.

Central venous catheter insertion for acute trauma resuscitation may be associated with mechanical complications, but studies on the exact central venous catheter tip positions are not available. The goal of the study was to analyze central venous catheter tip positions using routine emergency computed tomography. Consecutive acute multiple trauma patients requiring large-bore thoracocervical central venous catheters in the resuscitation room of a university hospital were enrolled retrospectively from 2010 to 2015. Patients who received a routine emergency chest computed tomography were analyzed regarding central venous catheter tip position. The central venous catheter tip position was defined as correct if the catheter tip was placed less than 1 cm inside the right atrium relative to the cavoatrial junction, and the simultaneous angle of the central venous catheter tip compared with the lateral border of the superior vena cava was below 40°. During the 6-year study period, 97 patients were analyzed for the central venous catheter tip position in computed tomography. Malpositions were observed in 29 patients (29.9%). Patients with malpositioned central venous catheters presented with a higher rate of shock (systolic blood pressure <90 mmHg) at admission (58.6% vs 33.8%, p = 0.023) and a higher mean injury severity score (38.5 ± 15.7 vs 31.6 ± 11.8, p = 0.041) compared with patients with correctly positioned central venous catheter tips. Logistic regression revealed injury severity score as a significant predictor for central venous catheter malposition (odds ratio = 1.039, 95% confidence interval = 1.005-1.074, p = 0.024). Multiple trauma patients who underwent emergency central venous catheter placement by experienced anesthetists presented with considerable tip malposition in computed tomography, which was significantly associated with a higher injury severity.

Electrocardiography-controlled central venous catheter tip positioning in patients with atrial fibrillation.

A significant increase of the p-wave of a real-time intracavitary electrocardiography is a reliable and safe method to confirm the central venous catheter tip position close to the atrium. However, conflicting data about the feasibility of electrocardiography exist in patients with atrial fibrillation. An observational prospective case-control cohort study was set up to study the feasibility and accuracy of the electrocardiography-controlled central venous catheter tip placement in 13 patients with atrial fibrillation versus 10 patients with sinus rhythm scheduled for elective surgery. Each intervention was crosschecked with ultrasound-guided positioning via right supraclavicular fossa view and chest radiography. Ultrasound-guided supraclavicular venipuncture of the right subclavian vein and guidewire advancement were performed. A B-mode view of the superior vena cava and the right pulmonary artery was obtained to visualize the J-tip of the guidewire. The central venous catheter was advanced over the guidewire and the electrocardiography was derived from the J-tip of the guidewire protruding from the central venous catheter tip. Electrocardiography was read for increased p- and atrial fibrillation waves, respectively, and insertion depth was compared with the ultrasound method. Electrocardiography indicated significantly increasing fibrillation and p-waves, respectively, in all patients and ultrasound-guided central venous catheter positioning confirmed a tip position within the lower third of the superior vena cava. Electrocardiography-guided central venous catheter tip positioning is a feasible real-time method for patients with atrial fibrillation. Combined with ultrasound, the electrocardiography-controlled central venous catheter placement may eliminate the need for postinterventional radiation exposure.

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.