Subclavian Central Venous Catheter Research Articles

Ultrasound-guided subclavian vein catheterisation with a needle guide (ELUSIVE): protocol for a randomised controlled study

IntroductionCentral venous catheters are indispensable in modern healthcare. Unfortunately, they are accompanied by minor as well as major complications, leading to increased morbidity, mortality and costs. Immediate insertion-related complications (mechanical...

Chlorhexidine gluconate-coated gel pad dressings for prevention of central venous catheter-related bloodstream infections in patients with hematologic diseases or autologous stem cell transplantation: A registry-based matched-pair analysis.

Chlorhexidine gluconate (CHG)-coated gel pad dressings for central venous catheter (CVC) may prevent CVC-related bloodstream infections (CRBSI). However, real-world data showing beneficial effects in patients with hematologic malignancies are scarce. In a matched-pair analysis with data from a multicenter CVC registry, non-tunneled jugular and subclavian vein CVC in adults with hematologic malignancies or germ cell tumors (including patients receiving autologous hematopoietic stem cell transplantation [ASCT]) with CHG were compared with non-CHG dressings. The primary endpoint was definite CRBSI rate within 14 days (dCRBSI14) of CVC insertion; secondary endpoints were combined rate of definite or probable CRBSI within 14 days (dpCRBSI14), overall (dpCRBSI), and CRBSI incidences of all estimates. In total, 2070 CVCs were assessed. There was no statistically significant difference in dCRBSI14 (2.3% vs. 3.5%) between patients with and without CHG gel dressings. Likewise, with regards to dpCRBSI14 (6.2% vs. 6.3%) and the overall dpCRBSI rate (9.2% vs. 10.5%), no significant difference was detected. Furthermore, dCRBSI14 incidence (2.0 vs. 3.2/1000 CVC days), dpCRBSI14 incidence (5.4 vs. 5.6/1000 CVC days), and overall CRBSI incidence (5.5 vs. 6.0/1000 CVC days) showed no significant differences. CRBSI rates were not reduced by the use of CHG gel dressings in patients with hematologic malignancies and/or ASCT.

Catheter Misplacement Following Subclavian Vein Catheterization Under Ultrasound Guidance: An Infrequent and Unusual Malposition

The most common malposition seen during subclavian vein cannulation is to the ipsilateral internal jugular vein. We report a case of unusual malposition of a subclavian central venous catheter, where it was found to be forming a “figure of U” in the ipsilateral subclavian vein. Although the catheterization was done under ultrasound guidance, we could not visualize the course of the guidewire due to a poor ultrasound window. This report highlights the fact that although ultrasound can facilitate identification of the vessels and prevent inadvertent arterial puncture, it seldom helps in the positioning of the guidewire tip and prevention of catheter malposition.

Surgical Removal of an Extravascular Knotted J-Tip Guidewire During Subclavian Central Venous Catheterization- A Case Report

Guidewire-related complications during central venous catheterization are relatively uncommon. However, they can still occur even with experienced physicians. This report presents a case of an extravascular knotted guidewire during central venous catheterization that required surgical removal. A 72-year-old male patient scheduled for cervical anterior interbody fusion surgery underwent left subclavian venous catheterization one day before the surgery. The J-tip guidewire was inserted through the introducer needle easily without any resistance. During the insertion of the catheter over the guidewire, the catheter did not advance more than 3 cm from the skin. The guidewire was kinked, which was further aggravated by attempts to remove it forcefully, leading to a knot formation that required surgical removal. The patient was discharged one week after the surgery without any additional complications. Safe removal of guidewires is of utmost importance, and preventive measures should be taken to reduce the risk of complications.

Impact of the insertion site of central venous catheters on central venous catheter-related bloodstream infections in patients with cancer: results from a large prospective registry.

Overall, insertion of central venous catheter (CVC) into femoral veins (FV) has been shown to be associated with a higher risk of infection compared with subclavian and internal jugular (IJV/SCV) CVC, but no data are available on the impact of the FV insertion site on the CVC-related bloodstream infections (CRBSI) risk in patients with cancer. The objective of the study is to compare CRBSI rates and incidences of FV with those of internal jugular and subclavian vein (IJV/SCV CVC) as observed in the prospective SECRECY registry. SECRECY is an ongoing observational, prospective, clinical CRBSI registry active in six departments of hematology/oncology in Germany. Each case of FV CVC was matched at a ratio of 1:1 to a case with IJV/SCV CVC. The propensity score was estimated using a multivariable logistic regression model adjusting for age, sex, cancer type, and duration of indwelling catheter. Of 4268 CVCs included in this analysis, 52 (1.2%) were inserted into the FV and 4216 (98.8%) into the IJV/SCV. 52 cases of FV CVC were matched with 52 IJV/SCV CVC. There was no significant difference in the CRBSI rate (3.8% vs. 9.6%), the CRBSI incidence (5.7 vs. 14.2/1000 CVC days), and the median CVC time (5.5 vs. 5days) between the FV and the IJV/SCV group. Based on this data, inserting FV CVCs in patients with cancer does, at least in the short-term, not appear to be associated with an increased risk of CRBSI as compared to IJV/SCV CVC.

Subclavian Catheterization Procedure Performed by In-plane Technique Guided by Ultrasonography

Objective: Central venous catheterization (CVC) is one of the most commonly performed interventional procedures in intensive care unit (ICU) patients. According to guidelines, it is recommended as the first choice because it is better tolerated by patients, and the infection rate is lower compared to other areas of CVC placement.. However, complications such as pneumothorax, arterial puncture, nerve injury and bleeding may be relatively higher. For these reasons, it has become increasingly common to perform subclavian CVC applications with ultrasonography (USG) to minimize the risks in recent years. Our study aimed to evaluate 53 patients who underwent subclavian CVC with the in-plane technique accompanied by USG. Method: In this study, the system records of 53 patients with CVC indication, who were hospitalized in the ICU between January 1, 2020, and April 1, 2021, were reviewed retrospectively and subclavian CVC procedures performed using the USG-guided in-plane technique were analyzed. Results: A total of 53 patients (25 women (47.2%), 28 men (52.8%)) with CVC indication followed in the ICU underwent subclavian CVC with the in-plane technique under USG guidance. The mean age of the patients was 69.98±11.29 years. The mean BMI of the patients was found to be 26,10 kg/m2. Of the 53 patients evaluated, 28 had chronic obstructive pulmonary disease (COPD), 5 had lung malignant neoplasm, 16 had pneumonia, 2 had acute renal failure, and 2 required ICU follow-up after cardiopulmonary resuscitation.. Catheter malposition and other complications were not observed in any of the patients. Conclusion: Subclavian catheterization applied with an in-plane technique guided by USG is a method that experienced practitioners can safely apply.

Simulation-based Mastery Learning Improves Critical Care Skills of Advanced Practice Providers.

Advanced practice providers (APPs) are essential members of intensive care unit (ICU) interprofessional teams and are expected to be competent in performing procedures. There are no published criteria for establishing when APPs can independently perform procedures. Simulation-based mastery learning (SBML) is an effective strategy for improving critical care skills but has not been applied to practicing ICU APPs. The purpose of this study was to evaluate if an SBML curriculum could improve the critical care skills and procedural self-confidence of ICU APPs. We performed a pretest-posttest study of central venous catheter (CVC) insertion, thoracentesis, and mechanical ventilation (MV) management skills among ICU APPs who participated in an SBML course at an academic hospital. For each skill, APPs underwent baseline skills assessments (pretests) on a simulator using previously published checklists, followed by didactic sessions and deliberate practice with individualized feedback. Within 2 weeks, participants were required to meet or exceed previously established minimum passing standards (MPS) on simulated skills assessments (posttests) using the same checklists. Further deliberate practice was provided for those unable to meet the MPS until they retested and met this standard. We compared pretest to posttest skills checklist scores and procedural confidence. All 12 eligible ICU APPs participated in internal jugular CVC, subclavian CVC, and MV training. Five APPs participated in thoracentesis training. At baseline, no APPs met the MPS on all skills. At training completion, all APPs achieved the mastery standard. Internal jugular CVC pretest performance improved from a mean of 67.2% (standard deviation [SD], 28.8%) items correct to 97.1% (SD, 3.8%) at posttest (P = 0.005). Subclavian CVC pretest performance improved from 29.2% (SD, 32.7%) items correct to 93.1% (SD 3.9%) at posttest (P < 0.001). Thoracentesis pretest skill improved from 63.9% (SD, 30.6%) items correct to 99.2% (SD, 1.7%) at posttest (P = 0.054). Pretest MV skills improved from 54.8% (SD, 19.7%) items correct to 92.3% (SD, 5.0%) at posttest (P < 0.001). APP procedural confidence improved for each skill from pre to posttest. SBML is effective for training APPs to perform ICU skills. Relying on traditional educational methods does not reliably ensure that APPs are adequately prepared to perform skills such as CVC insertion, thoracentesis, and MV management.

Effectiveness of Ultrasonography Guided Subclavian Catheterization

Background: Central venous catheterization (CVC) insertion is a common invasive procedure performed in critical care patients. Although this procedure is considered to providebetter patient comfort and a lower risk of infection compared to other methods, it has a higher risk of complications such as pneumothorax, arterial puncture, nerve injury, and bleeding. Ultrasonography (USG)-guided subclavian catheterization hasrecently become a popular technique. In this study, we retrospectively analyzed 50 patients who underwent infraclavicular subclavian catheterization with the out-of-plane technique under USG guidance. Materials and Methods: The retrospective study included50 patients who underwent subclavian CVC insertion via the out-of-plane technique under USG guidance in our intensive care unit (ICU)between March and December 2020. Results: The 50 patients comprised 27 (54%) men and 23 (46%) women with a mean age of 72.8±11.8 years. In all patients, subclavian CVC insertion was successfully performed under USG guidance via the out-of-plane technique. Mean procedural time was 220.90±60.20 sec. Only one complication (pneumothorax) developed in one patient, who underwent tube thoracostomy. The procedure was completed in a single session in 27 (54%), two sessions in 22 (44%), and three sessions in 1 (2%) patient. No catheter malposition was observed in any patient. Conclusion: USG-guided subclavian catheterization isa safetechnique to be performed by experienced practitioners.

Central Subclavian Catheterization in Newborns: Single-Center Experience

AbstractOur main aim of this article was to show that central venous catheter (CVC) can be an easy-to-use, less-complicated catheter application such as peripherally inserted central catheter and umbilical catheter placement in the neonatal intensive care unit. We here described our experience with subclavian vein catheterization. Neonates who had venous access through subclavian central catheterization were assessed retrospectively. Data such as gestational age, age at the time of catheter insertion, birth weight, and gender were collected. In addition, problems related to catheterization during hospitalization were documented. This study comprised 40 newborns, 22 male and 18 female, with a mean gestational week of 29.57 ± 3.80 weeks and a mean gestational weight of 2067.50 ± 545.97 g. Due to occlusion, catheters were switched in five cases twice and in three cases once, totaling 53 catheterizations on 40 newborns. None of our patients had pneumothorax or hemothorax. On the postoperative 8th and 21st days, the catheter was withdrawn due to catheter infection in two (5%) patients, and catheter cultures revealed coagulase negative Staphylococcus aureus in both cases. Even in preterm infants, subclavian central venous catheterization is a safe and straightforward technique of gaining venous access in expert hands in the neonatal intensive care unit.

An enigmatic complication after an uncomplicated insertion of a right subclavian central venous catheter.

An enigmatic complication after an uncomplicated insertion of a right subclavian central venous catheter.

AIR IN THE BRAIN: AIR EMBOLISM ASSOCIATED WITH AN OUTPATIENT LINE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cerebral air embolisms are a rare and potentially fatal phenomenon associated with central venous catheter (CVC) insertions, especially in patients with an underlying cardiac defect. We present a case of a 64 year old male with a patent foramen ovale who suffered severe complications from a massive air embolism while accessing a tunneled CVC. CASE PRESENTATION: 64-year-old male with a history of prostate adenocarcinoma, pulmonary embolism on anticoagulation, and multiple myeloma was originally admitted to the hospital to undergo a stem cell transplant. A tunneled right subclavian CVC which was placed 14 days prior was accessed for routine labwork before transplant. There was some difficulty reported while accessing the catheter this time similar to previous documentation. Immediately following this attempt to access the catheter, the patient was noted to develop acute loss of consciousness and was found unresponsive. On exam, he was noted to have asymmetric pupils, without any response to noxious stimuli. He was emergently intubated for airway protection. A CT Head showed multiple areas bilateral sulcal hypoattenuation concerning for air embolism along with areas of evolving infarct. (Figure 1) which was further confirmed by magnetic resonance imaging (MRI). Echocardiogram showed evidence of right to left shunting from a patent foramen ovale. Patient was transferred to a facility with a hyperbaric oxygen (HBO) chamber. During his initial HBO therapy which occurred about 12 hrs from the time of the event, the patient was noted to have persistent myoclonic seizures, deemed to be clinical myoclonic status. This warranted aborting the HBO therapy for appropriate medical management of his seizure activity. EEG performed noted severe cerebral dysfunction without any active epileptiform activity. A repeat MRI showed severe hypoxic injury and edema involving both cerebral hemispheres diffusely, the thalami and right caudate nucleus (Figure 2). Given the poor neurological status and irreversible neurological injury, the patient passed comfortably in the presence of family. DISCUSSION: We present a case of paradoxical embolism associated with a patent foramen ovale while accessing a CVC, that unfortunately resulted in cerebral air embolism and severe hypoxic brain injury. Supportive literature for such severe cases has shown benefit from HBO. However, the delay that results from transport to HBO treatment centers, as in our patient, remains a barrier for time sensitive efforts to prevent poor outcomes associated with cerebral air embolism CONCLUSIONS: Education and strong emphasis must be provided to health care providers to prevent air embolism while caring for or insertion of CVCs. If an air embolism occurred, high index of suspicion is essential for timely identification of cerebral air embolism which are associated with poor outcomes. REFERENCE #1: Gordy S, Rowell S. Vascular air embolism. Int J Crit Illn Inj Sci. 2013;3(1):73-76. doi:10.4103/2229-5151.109428 REFERENCE #2: Patel AR, Patel AR, Singh S, Singh S, Khawaja I. Central Line Catheters and Associated Complications: A Review. Cureus. 2019;11(5):e4717. Published 2019 May 22. doi:10.7759/cureus.4717 REFERENCE #3: Hinkle DA, Raizen DM, McGarvey ML, Liu GT. Cerebral air embolism complicating cardiac ablation procedures. Neurology. 2001 Mar 27;56(6):792-4. doi: 10.1212/wnl.56.6.792. PMID: 11274320. DISCLOSURES: No relevant relationships by Ashley Graziano, source=Web Response No relevant relationships by Aaron Haag, source=Web Response No relevant relationships by Swathi Sangli, source=Web Response

The value of real-time ultrasound-guidance for definite placement of a right supraclavicular subclavian central venous catheter.

Central venous catheters (CVC) are widely used in critically ill patients and in those undergoing major surgery. Significant adverse events, such as pneumothorax and hemothorax, can be caused by needle insertion during CVC insertion. CVC misplacement is less often described, yet equally important, as it can lead to deleterious complications.Here, we describe a case in which misplacement of a guidewire following infraclavicular puncture of the right axillary vein was detected by continuous ultrasound employing the right supraclavicular fossa view. Utilizing this ultrasound view, the insertion approach to the vessel was changed and correct CVC placement could be achieved.While ultrasound guidance is widely accepted for vessel puncture, this case demonstrates the value of continuous ultrasound guidance for the entire process of CVC insertion: vessel puncture, correct guidewire advancement, catheter placement, and exclusion of complications such as pneumothorax. It also shows that there should be a high index of suspicion for guidewire misplacement, even after successful venipuncture.In conclusion, ultrasound protocols covering the complete CVC insertion process should be implemented into current clinical practice.

Re-expansion pulmonary edema after thoracentesis for iatrogenic pneumothorax and severe subcutaneous emphysema.

Subclavian central venous catheterization can cause severe complications, including tension pneumothorax, subcutaneous emphysema, and pneumomediastinum. Re‐expansion pulmonary edema after thoracentesis is a life‐threatening complication.

Iatrogenous puncture of the aortic arch closed with ProGlide.

An 89-year-old woman was referred to our hospital owing to syncope caused by an atrioventricular conduction disease. She presented with a past medical history of hypertension, dyslipidemia, and depression. A temporary balloon-tipped pacemaker electrode was inserted in the emergency department through the right jugular vein. Jugular catheter placement is a routine procedure. Several authors recommend the use of ultrasound guidance to avoid complications, such as arterial injury. Saugle et al1Saugle B. Scheeren T.W.L. Teboul J.L. Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice.Crit Care. 2017; 21: 225Crossref PubMed Scopus (135) Google Scholar reviewed the literature and described six steps to perform ultrasound-guided jugular catheter placement: identify the anatomy of the insertion site and localize the vessels, confirm the patency of the jugular vein with a compression test, use real-time ultrasound guidance for puncture of the vein, confirm needle position in the vein, confirm the wire position, and confirm the catheter position in the vein. In our case, a percutaneous echocardiography-guided puncture of the jugular vein was made; however, once the 6F sheath was placed inside, an arterial flow was obtained from the sheath; therefore, the on-call cardiologist considered it to be placed in the carotid artery. Upon examination, an abnormally oblique position of the sheath was observed in the patient's neck (A). Doppler ultrasound examination revealed no contact between the sheath and the supra-aortic trunks. Arteriography was performed through the sheath, revealing an introducer placed in the aortic arch (B and C/Cover). After a multidisciplinary consensus, owing to the patient's age and the difficulty of open sheath withdrawal, a percutaneous artery closure device was used. Under general anesthesia and controlled hypotension, the 6F sheath was removed and the aortic arch was closed with a ProGlide (Abbott Laboratories, Chicago, Ill). A computed tomography scan after the procedure revealed a hematoma at the superior mediastinum close to supra-aortic trunks without signs of bleeding (D). The patient was admitted to the coronary unit with strict control of the blood pressure. After 48 hours, a permanent pacemaker was inserted. One week later, the patient was discharged home. The patient provided consent for the publication of her case details and imaging. Inadvertent arterial puncture during central venous catheter placement is a well-known complication.2Bowdle A. Vascular complications of central venous catheter placement: evidence-based methods for prevention and treatment.J Cardiothorac Vasc Anesth. 2014; 28: 358-368Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar In the majority of cases of misplaced jugular catheters, the carotid artery is punctured. Accidental aortic arch puncture is a rare complication and its treatment includes open surgery with median sternotomy.3Sellem M.I. Al-Hashemy A.A. Al-Naemi A. Ectopic intra-aortic insertion of a subclavian central venous catheter: case report and review of the literature.J Thorac Cardiovasc Surg. 2004; 127: 1515-1516Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Since the advent of percutaneous closures, some authors have described their use in the management of accidental artery puncture.4Pikwer A. Acosta S. Kölbel T. Malina M. Sonesson B. Akeson J. Management of inadvertent arterial catheterisation associated with central venous access procedures.Eur J Vasc Endovasc Surg. 2009; 38: 707-714Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar We found one case in the literature where an aortic arch puncture was treated with a percutaneous closure. In this case, the puncture of the aorta was done during subclavian catheter placement and they used Angio-Seal Vascular Closure Device (St Jude Medical, Saint Paul, Minn).5Leijdekkers V.J. Go H.L.S. Legemate D.A. Reekers J.A. The use of percutaneous closure device for closure of an accidental puncture of the aortic arch; a simple solution for a difficult problem.Eur J Vasc Endovasc Surg. 2006; 32: 94-96Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar In our case, there was no option for open repair owing to patients comorbidities. We preferred to use a suture-mediated closure system (ProGlide) because we have experience using this system in peripheral arteries. This case highlights that complications may occur and, even though there is no indication for the use of the ProGlide system in aortic puncture, we have to be able to individualize the treatment plan for this patients without other available options. The authors thank Dr Bernat Lloret Villas for his expertise and assistance with patient management.

Ultrasound-guided central venous catheter insertion in pediatric patients

In pediatric patients, central venous catheterization (CVC) is necessary for administration of fluids, drugs, high concentration electrolytes, vasopressors or inotropic drugs, transfusion, intravenous nutrition, and dialysis. Using an anatomical landmark for the CVC insertion may have a low success rate in children due to the positional variation between the deep vein and the landmarks, the small size of body and blood vessels, low insertion frequency, and operator skill. In order to improve the success rate, ultrasound guided CVC insertion is recommended in critically ill children. It is also expected to reduce mechanical complications, which are more common with subclavian CVC insertion. However, the association between the insertion site and the infection or thrombosis is unclear. Since thrombosis is relatively common, further studies are needed on the association between the incidence rate and insertion sites. Key Words: Central Venous Catheters; Infections; Pediatrics; Thrombosis; Ultrasonography

P1687 When the easiest answer is the right one

Abstract A 42 year-old woman presented with moderate exertion dyspnea within the past months. She was hypertensive, with end stage-chronic kidney disease (CKD) on hemodialysis for 8 years, initially by arteriovenous fistula and then by central venous catheter. She associated thrombosis of both common femoral veins. Clinical examination revealed mild leg edema, hepatomegaly, III/VI systolic murmur, left brachiocephalic arteriovenous fistula with aneurismal dilation and subclavian central venous catheter. Resting ECG showed atrial flutter with variable block and biventricular hypertrophy. Lab studies highlighted mild anemia, glomerular filtration rate (MDRD) 13.5 ml/min/1.73m2, hyperhomocysteinemia. Transthoracic echocardiography revealed left ventricle (LV) with normal diameters and mild concentric hypertrophy, mild systolic LV dysfunction and diastolic dysfunction (Fig A), dilation of both atria, mild mitral regurgitation, dilated RV with moderate global dysfunction, moderate tricuspid regurgitation and secondary pulmonary hypertension (PH) with estimated systolic pulmonary artery pressure of 79 mmHg (Fig C), moderate pulmonary regurgitation, moderate dilatation of pulmonary artery. Vascular Doppler ultrasonography showed thrombosis of the arteriovenous fistula and of right jugular vein. To confirm PH, right heart catheterization was necessary. The intervention could not be realized on femoral approach due to thrombosis of both common femoral veins. We considered the jugular approach, but weighing the risks/benefits balance, with one functional jugular vein, we decided not going for it, as the jugular approach was the only vascular approach for dialysis. We performed left catheterization right after a dialysis session and an LV end-diastolic pressure of 13 mmHg was measured. The possible causes of PH considered in this case were the CKD by itself, a pulmonary thromboembolic component in a patient with hyperhomocisteinemia and thrombosis of both femoral veins and a left heart component given the borderline value of LV end-diastolic pressure. The patient received treatment with beta-blockers, blockers of the renin-angiotenins-aldosterone system, calcium channel blockers and oral anticoagulation. She was evaluated after two months describing improvement of symptoms. The resting ECG showed sinus rhythm and the echocardiography revealed improved parameters of LV diastolic function (Fig B), with reduction of systolic pulmonary artery pressure (Fig D) and improvement of right heart parameters. PH is a frequent complication in patients with CKD on hemodialysis. Possible mechanism of its development include RV overload with increased pulmonary flow or creating a fistula with an increased flow through arteriovenous shunt. Thromboembolic complications and hyperhomocysteinemia are other frequent findings in these patients. Despite all the above, the left heart involvement with LV diastolic dysfunction remains a common and amendable cause of PH in this setting. Abstract P1687 Figure.

Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine.

Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine.

A Comparison of Approaches for Mastery Learning Standard Setting.

Defensible minimum passing standards (MPSs) must be used to evaluate learner performance outcomes in health professions education. In this study, the authors compared the results of traditional Angoff and Hofstee standard-setting exercises with the Mastery Angoff and Patient-Safety approaches for central venous catheter (CVC) insertion skills examinations. The authors also evaluated how these standards affected the historical performance of residents who participated in a simulation-based mastery learning (SBML) curriculum for CVC insertion skills. In April and May 2015, 12 physicians with expertise in CVC insertion set MPSs for previously published internal jugular (IJ) and subclavian (SC) CVC insertion checklists using Angoff, Hofstee, Mastery Angoff, and Patient-Safety approaches. The resulting MPSs were compared using historical performance of internal medicine and emergency medicine residents who participated in CVC insertion SBML. The MPSs were set as follows: Angoff: IJ 91% checklist items correct, SC 90%. Hofstee: IJ 88%, SC 90%. Mastery Angoff: IJ 98%, SC 98%. Patient-Safety: IJ 98%, SC 98%. Based on the historical performance of 143 residents assessed on IJ and SC insertion, applying the 98% MPS would result in additional practice and retesting of 55/123 residents (45%) who had previously passed the IJ examination and 36/130 residents (28%) who had passed the SC examination using the Angoff and Hofstee MPSs. The Mastery Angoff and Patient-Safety standard-setting approaches resulted in higher CVC insertion SBML MPSs compared with traditional standard-setting methods. Further study should assess the impact of these more rigorous standards on patient outcomes.

Evaluation of a central venous catheter tip placement for superior vena cava-subclavian central venous catheterization using a premeasured length: A retrospective study.

Subclavian central venous catheterization is a common procedure for which misplacement of the central venous catheter (CVC) is a frequent complication that can potentially be fatal. The carina is located in the mid-zone of the superior vena cava (SVC) and is considered a reliable landmark for CVC placement in chest radiographs. The C-length, defined as the distance from the edge of the right transverse process of the first thoracic spine to the carina, can be measured in posteroanterior chest radiographs using a picture archiving and communication system. To evaluate the placement of the tip of the CVC in subclavian central venous catheterizations using the C-length, we reviewed the medical records and chest radiographs of 122 adult patients in whom CVC catheterization was performed (from January 2012 to December 2014) via the right subclavian vein using the C-length. The tips of all subclavian CVCs were placed in the SVC using the C-length. No subclavian CVC entered the right atrium. Tip placement was not affected by demographic characteristics such as age, sex, height, weight, and body mass index. The evidence indicates that the C-length on chest radiographs can be used to determine the available insertion length and place the right subclavian CVC tip into the SVC.

Successful Detachable Coil Embolization of Iatrogenic Superior Vena Cava Penetration by Central Venous Catheter: A Case Report

: Iatrogenic injuries of the superior vena cava (SVC) are infrequent but could bring severe complications. Perforation of the SVC may result in massive hemorrhage and hemodynamic instability. We report the case of a 58-year-old female with a right hemothorax after left subclavian central venous catheter (CVC) placement. Penetration of the SVC can be managed by coil embolization through left subclavian CVC. As a result, this injury was successfully managed. To our knowledge, this is the first report of management of SVC penetration using coil embolization.