Ultrasound-guided Central Line Research Articles

Comparison of Three Different Approaches to Ultrasound Guided Internal Jugular Vein Cannulation: A Randomised Clinical Study

Introduction: The standard approaches to ultrasound-guided central line insertion by Short Axis (SAX) and Long Axis (LAX) have limitations. The Medial Oblique Axis (M-OAX) approach allows visualisation of the length of the needle in real-time along with both the artery and vein. Aim: To compare the three approaches for ultrasound-guided right Internal Jugular Vein (IJV) cannulation with respect to ease of access and complications. Materials and Methods: A total of 171 patients scheduled to undergo right IJV cannulation were divided equally into three groups-SAX (Group-1), LAX (Group-2), and M-OAX (Group-3). They were compared with respect to first pass success, Venous Access Time (VAT), guide wire insertion time, catheterisation time, and complications. Continuous variables were compared with Analysis of Variance (ANOVA) test. Categorical variables were analysed using the Chi-square test. The p-value <0.05 was considered significant. Results: First pass success was 55 (96.49%), 53(92.98%), and 54 (94.74%) in groups 1, 2, and 3, respectively. The VAT, guidewire insertion time, and catheterisation time were significantly lesser in Groups 1 and 3 compared to 2 (p<0.001). Two cases of carotid artery puncture were noted in Group-2, though statistically not significant (p>0.05). Conclusion: The medial oblique approach to IJV cannulation combines the advantages of both LAX and SAX and is a safer alternative with easier and faster venous access.

The Frequency of POCUS in the Treatment of Sepsis in the Emergency Department: A Retrospective Cohort Study.

Background: Point of care ultrasound (POCUS) is ubiquitous in the modern emergency department (ED). POCUS can be helpful in the management of patients with sepsis in many ways including determining the cause of sepsis, assessing fluid status, guiding resuscitation, and performing procedures. However, the frequency and manner in which POCUS is incorporated into the care of septic patients in community emergency medicine remains unclear. Objective: To evaluate POCUS frequency and exam types used in the care of patients with sepsis in two community EDs in Southern California. Methods: We performed a retrospective analysis of 5,264 ED visits with a diagnosis of sepsis at two community emergency departments between January 2014 and December 2018. Patients 18 years or older who were diagnosed with sepsis and had either lactate ≥ 4 mmol, a documented mean arterial pressure (MAP) < 65 mmHg, or a systolic blood pressure (SBP) < 90 mmHg were included. Charts were reviewed to determine if POCUS was used during the ED evaluation. Primary outcomes were frequency of POCUS use in the cohort, change in POCUS use over the study period, and the types of exams performed. Results: POCUS was used in 21% of encounters meeting inclusion criteria and was positively correlated with ED arrival year (OR = 1.09; CI 1.04, 1.15; p=0.001). The most common POCUS exam was ultrasound-guided central line placement, with the next most common exams being cardiac, followed by inferior vena cava (IVC). Only the frequency of cardiac, IVC, lung and Focused Assessment with Sonography in Trauma (FAST) exams were found to increase significantly over the study period. Conclusions: Total POCUS use increased significantly in this cohort of septic patients over the study period due to more cardiac, IVC, lung and FAST exams being performed.

National Delphi Survey on Anesthesiology Resident Training in Perioperative Ultrasound

To establish agreement among nationwide experts through a Delphi process on the key components of perioperative ultrasound and the recommended minimum number of examinations that should be performed by a resident upon graduation. A prospective cross-sectional study. A survey on multiinstitutional academic medical centers. Anesthesiology residency program directors and/or experts in perioperative ultrasound. A list of components and examinations recommended for anesthesiology resident training in perioperative ultrasound was developed based on guidelines and 2 survey rounds among a steering committee of 10 experts. A questionnaire asking for a rating of each component on a 5-point Likert scale subsequently was sent to an expert panel of 120 anesthesiology residency program directors across the United States. An agreement of at least 70% of participants, rating a component as 4 or 5, was compulsory to list a component as essential for anesthesiology resident training in perioperative ultrasound. The nationwide survey's response rate was 62.5%, and agreement was reached after 2 Delphi rounds. The final list included 44 essential components for basic ultrasound physics and knobology, cardiac ultrasound, lung ultrasound, and ultrasound-guided vascular access. Agreement was not reached for abdominal ultrasound, gastric ultrasound, and ultrasound-guided airway assessment. Agreement for the recommended minimum number of examinations that should be performed by a resident upon graduation included 50 each for transthoracic and transesophageal echocardiography, and 20 each for lung ultrasound, ultrasound-guided central line, and ultrasound-guided arterial line placements. The recommendations outlined in this survey can be used to establish standardized training for perioperative ultrasound by anesthesiology residency programs.

Ultrasound-guided central line insertion: how much evidence is really needed?

Ultrasound-guided central line insertion: how much evidence is really needed?

EXPERIENTAL INTERPROFESSIONAL SIMULATION-BASED EDUCATION IMPROVES KNOWLEDGE, PERCIEVED PROFICIENCY AND VALUE IN COLLABORATIVE CRITICAL CARE

TOPIC: Education, Research, and Quality Improvement TYPE: Original Investigations PURPOSE: Interprofessional care teams are the pillars of intensive care units (ICUs) where severity of illness is high and care requires unique knowledge, skills and experience. Despite this model, programs rarely integrate different professions in training. ICU rotations present unique challenges, especially the rapid recognition of clinical deterioration. Many trainees are expected to have working knowledge of these without previously setting foot in an ICU. Simulation provides "hands-on" practice in a safe environment and also allows for the integration of teamwork into knowledge and skill training. Our study is important as it assesses the impact of this much needed interprofessional training in a novel but practical ICU simulation. We assessed the impact on knowledge, skills, comfort level with providing ICU care in a collaborative approach following participation in a simulation experience designed to educate and provide opportunities to lead, make decisions, and manage crises in critical patients. METHODS: This pilot study was designed as a mixed method study in a simulated environment where all participants took part in a three-hour immersive interprofessional learning. They completed a pre-survey followed by simulations meant to represent skills critical to the ICU setting in multi-disciplinary groups. Learners rotated through different stations such as the Ventilator knowledge hub where they received an overview of respiratory physiology, and ventilator mechanics. This was followed by a Ventilator simulation and using "VentiSim" software. They were also educated about the different oxygen delivery devices. They then partook in ultrasound-guided central line placement on a mannequin, cardiac rhythm recognition, and simulated Megacode using high fidelity simulators. A post survey was completed for assessment of knowledge, skills, and comfort level of participants. A three-tiered approach to debriefing was implemented for all participants. RESULTS: There were 74 participants of which 48% were medical residents, 19% nursing students, 16% medical students, 10% respiratory therapy students, 5% pharmacy trainees. Paired t-test was used to analyze the knowledge, and skills data which showed significant improvement with P-value < 0.0001(95% CI 1.16 to 2.20). Based on the Post-intervention survey, 99% agreed that it was worth their time to attend the session. 96% believed their ability to deliver patient care improved, 80% felt their anxiety reduced about rotating in ICU. During debriefing an overwhelming majority of learners commented how much they appreciated, “getting to interact with other professions”. There was strong feedback that we needed to conduct more workshops. CONCLUSIONS: Our novel ICU simulation workshop provided a statistically significant improvement in the knowledge base and understanding of common ICU procedures and concepts in a multidisciplinary team of healthcare trainees. It was evident during debriefing that participants appreciated the importance of an interprofessional, collaborative approach to critical care during their training. CLINICAL IMPLICATIONS: We will continue to refine our educational tool to bridge the gap in learning and collaboration. Although implementing such a detailed workshop was challenging, we feel it is essential for learning critical care skills in a safe environment and also to prioritize teamwork and communication in the ICU setting. DISCLOSURES: No relevant relationships by Nalini Kalanadhabhatta, source=Web Response No relevant relationships by Rajesh Kunadharaju, source=Web Response No relevant relationships by Archana Mishra, source=Web Response No relevant relationships by Alexander Pomakov, source=Web Response No relevant relationships by Raj Thapar, source=Web Response

Ultrasound in pediatric surgery; intraoperative applications of the growing technology

BackgroundUltrasonography is increasingly used in pediatric surgery. Intraoperatively, ultrasonography can be used to confirm the preoperative diagnosis, guide the surgical approach, and enhance decision-making. We aimed to report our experience with intraoperative ultrasonography in different neonatal and pediatric procedures. So, a retrospective study was designed. It included all pediatric patients who had intraoperative ultrasound between January 2018 and October 2020 in a single center.ResultsWe used intraoperative ultrasonography in 208 pediatric patients for various types of surgery. The authors compared ultrasound-guided central line insertion (n = 139) to the landmark method (n = 153). The number of trials was significantly lower in the ultrasound-guided method (P < 0.001). Conversion to cut-down was significantly lower with the ultrasound-guided technique (4 (2.8%) vs. 13 (8.5%); P = 0.047) and insertion-related complications were lower with ultrasound (0 vs 13 (8.5%); P < 0.001). We used ultrasound-guided sclerotherapy for cystic hygroma in 15 patients. Nine patients had successful treatment with a single injection (60%).ConclusionThe application of intraoperative ultrasound in pediatric patients is increasing in our institution. The technique is safe and could effectively reduce central line insertion complications and enhance cystic hygroma sclerotherapy’s success with a single injection. Ultrasonography should be an essential part of residents’ and fellows’ training in pediatric surgery.

Ultrasound guidance for Port-A-Cath insertion in children; a comparative study.

BackgroundGaining vascular access in children is challenging. Ultrasound-guided central line insertion in adults became the standard of care; however, its role in children is not clear. Our objective was to evaluate the ultrasound-guided Port-A-Cath or totally implanted long-term venous access device insertion in pediatric patients compared to the traditional approach.MethodsThis single-institution retrospective cohort study included 169 children who had port-A-catheters between May 2016 and Oct 2019. The patients were divided into two groups; group A included patients who had Port-A-Cath insertion using the landmark method (n = 117), and Group B included patients who had ultrasound-guided Port-A-Cath insertion (n = 52). Preoperative, operative, and postoperative data were collected and compared between the two groups. The study outcomes were operative time and catheter insertion-related complications.ResultsThere was no significant difference in age or gender between both groups (P = .33 and .71, respectively). Eleven cases in group A and two cases in group B were converted to cut down technique because of difficulty in inserting the guidewire. There was no difference in the indication of the need for the port-A-Cath between both groups. The mean operative time for group A was 47 min and for group B was 41.7 min (P < .042). Two patients had intraoperative bleeding and hemothorax and required blood transfusion and chest tube insertion in group A. No statistically significant difference was found in the reported complications between the groups. However, the insertion-related complications were higher in group A (P = .053). No procedure-related mortality was reported.ConclusionsUltrasound-guided insertion of Port-A-Cath is an effective and safe technique with a reduction of failure rate. It should be considered the standard technique for Port-A-Cath insertion in the pediatric population.

P002: Minimum archiving requirements for emergency medicine point-of-care ultrasound: a modified Delphi-derived national consensus

Introduction: Point-of-care ultrasound (POCUS) has become standard practice in emergency departments ranging from remote rural hospitals to well-resourced academic centres. To facilitate quality assurance, the Canadian Association of Emergency Physicians (CAEP) recommends image archiving. Due in part to poor infrastructure and lack of a national standard, however, archiving remains uncommon. Our objective was to establish a minimum standard archiving protocol for the core emergency department POCUS indications. Methods: Itemization of potential archiving standards was created through an extensive literature review. An online, three-round, modified Delphi survey was conducted with the thirteen POCUS experts on the national CAEP Emergency Ultrasound Committee tasked with representing diverse practice locations and experiences. Participants were surveyed to determine the images or clips, measurements, mode, and number of views that should comprise the minimum standard for archiving. Consensus was pre-defined as 80%. Results: All thirteen experts participated fully in the three rounds. In establishing minimum image archiving standards for emergency department POCUS, complete consensus was achieved for first trimester pregnancy, hydronephrosis, cardiac activity versus standstill, lower extremity deep venous thrombosis, and ultrasound-guided central line placement. Consensus was achieved for the majority of statements regarding abdominal aortic aneurysm, extended focused assessment with sonography in trauma, pericardial effusion, left and right ventricular function, thoracic B-line assessment, cholelithiasis and cholecystitis scans. In total, consensus was reached for 58 of 69 statements (84.1%). This included agreement on 41 of 43 statements (95.3%) describing mandatory images for archiving in the above indications. Conclusion: Our modified Delphi-derived consensus represents the first national standard archiving requirements for emergency department POCUS. Depending on the clinical context, additional images may be required beyond this minimum standard to support a diagnosis.

Ultrasound guided central line insertion in neonates: Pain score results from a prospective study.

Central lines can be placed through different techniques, either peripherally or centrally. Although they have the same aim, decision to use one of these modalities depends on the patient outcomes. The aim is to compare pain scores between ultrasound-guided central line insertion and peripherally inserted catheter in neonates in a prospective randomized single center study. A randomized controlled trial was conducted in neonates requiring central venous access for any of the following reasons: total parenteral nutrition (TPN), antibiotics treatment for at least 7 days and having poor or difficult venous access. The study compared pain difference, in neonates, that were randomized between peripherally and ultra-sound guided centrally placed central lines using the validated pain score N - PASS. 61 neonates were enrolled in the study. US-guided CICC was associated with less pain as reported by the statistically significant lower pain score difference (p-value <0.001) than the standard PICC. Additionally, the US-guided CICC had a higher rate of successful first attempt (p = 0.012), lower overall number of attempts (p < 0.001), and shorter procedure duration (p < 0.001) as compared to standard PICC. US-guided CICC is a less painful technique than PICC line insertion associated with higher rate of successful first attempt, lower overall number of attempts and shorter procedure duration.

Teaching neurological disorders with ultrasound: A novel workshop for medical students.

INTRODUCTION:The goal of this study was to assess if a neurological disorder ultrasound workshop for the first-year medical students significantly enhanced the students' ability to retain and apply concepts related to neuroanatomy and neurophysiology.MATERIALS AND METHODS:We performed a prospective study to evaluate student performance before and after an optional ultrasound workshop. Data were collected through a within-population pretest–posttest design. Purposive sampling was used to recruit first-year medical students for this study. The six stations were transcranial doppler ultrasound, ocular ultrasound, ultrasound-guided external ventricular drain placement, high-intensity focused ultrasound for brain lesions, carotid artery scan with ultrasound, and ultrasound-guided central line placement. We used a pre–post workshop survey to identify opinions and perceptions about ultrasound and a pre–post workshop test to assess knowledge about neuroanatomy, neurophysiology, and related ultrasound topics.RESULTS:Twenty-two 22 first-year medical students consented to participate in this study. The Wilcoxon signed-rank test showed a statistically significant difference in pre- and posttest scores, suggesting that participants demonstrated higher levels of medical knowledge related to neurological physiology, anatomy, and ultrasound after participating in the workshop. The analysis of the pre–post survey showed participants attributed greater value to ultrasound as a useful tool for their future medical practice after participation in the event (Z = −2.45, P = 0.014).CONCLUSIONS:There is value in integrating experiences with ultrasound into the neurological disorder block of medical school. Future studies, with a larger sample size, are needed to further explore the efficacy of this workshop in enhancing knowledge retention.

Ultrasound Guidance for Central Venous Access: Current Evidence and Clinical Recommendations

Ultrasound-guided central line placement has been shown to decrease the number of needle puncture attempts, complication, and failure rates. In order to obtain successful central access, it is important to have adequate cognitive knowledge, workflow understanding, and manual dexterity to safely execute this invasive procedure. The operator should also be familiar with the anatomical variations, equipment operations, and potential complications and their prevention. In this article, we present a detailed review of ultrasound-guided central venous access. It includes a description of anatomy, operative technique, equipment operation, and techniques for specific situations. We describe the use of ultrasound guidance to avoid and identify various complications associated with this procedure. We have also reviewed recent recommendations and guidelines for the use of ultrasound for central venous access and the current evidence pertaining to the recommendations for the expected level of training, methodology, and metrics for establishing competency.

Perceptions of Faculty and Students of Point-of-Care Ultrasound Utilization in Medical Education

Objective: To study the perceptions of Medical College of Georgia residency directors and clerkship directors, and students on the utilization of point-of-care ultrasound (POCUS) in medical education and clinical practice. Methods: An online, anonymous survey was distributed to clerkship and residency directors and undergraduate medical education (UME) students. Participants were asked to indicate their level of experience and agreement for teaching specific POCUS applications. Results: The response rate was 40.13% among UME students (N = 274), 100% among residency directors (N = 17), and 100% among core clerkship directors (N = 9). Majority of residency and clerkship directors agreed to include most of the proposed POCUS applications except for pediatric bladder catheterization (35%) and inferior vena cava to evaluate the presence of hypovolemia (46%). There was no more than 12% disagreement to include any application among both cohorts of responders. Within medical students, the most desired application to learn was ultrasound-guided central line placement (58% strongly agreed; 33% agreed) followed by ultrasound-guided peripheral venous access (88% strongly agreed or agreed), and assessment for presence of pericardial and pleural effusion, abdominal / pelvic fluid collections, and cholelithiasis. Conclusions: This survey documents the desired learning and teaching applications for the POCUS curriculum content. Results will be useful for documentation and as a supplement to the development of a national ultrasound education curriculum.

Evaluation of a Low-Cost, High-Fidelity Animal Model to Train Graduate Advanced Practice Nursing Students in the Performance of Ultrasound-Guided Central Line Catheter Insertion

Ultrasound-guided central venous catheter insertion (UGCVC) is a commonly performed procedure taught through simulation. The aims of the study were to examine the utilization of an animal model and compare it with two currently used Blue Phantom central line models to determine whether an animal model provides good or better simulated conditions for the performance of UGCVC insertion. Using a randomized cross-over study, 46 advanced practice nursing students were assessed using a task-specific performance tool in their performance of UGCVC insertion on both the animal model and the Blue Phantom models. The number of insertion attempts and time to performance was recorded. A preprocedure survey was used to ascertain their presimulation workshop experience, followed by a postprocedure survey. A cost comparison was completed as a secondary outcome. A comparison was conducted on the performance scores and the postsurvey results between the animal model and the Blue Phantom models. The number of venous access attempts was not significantly different when comparing the three models. A cost comparison showed the total cost of each animal model was US $15.66 as compared with the approximate cost for the Blue Phantom IJ model of US $1500.00 and the Gen I model of US $2700.00. Current Blue Phantom models lack the ability to fully perform all the necessary steps critical to the performance of UGCVC insertion. At a total cost of US $15.66 per model, this study showed that training with an alternative economical model was comparable with more expensive mannequin simulators. The results of this study may serve to guide clinicians and educators who are seeking alternative simulation models to provide skill acquisition.

Quantitative Analysis of Needle Navigation under Ultrasound Guidance in s Simulated Central Venous Line Procedure

Complications in ultrasound-guided central line insertions are associated with the expertise level of the operator. However, a lack of standards for teaching, training and evaluation of ultrasound guidance results in various levels of competency during training. To address such shortcomings, there has been a paradigm shift in medical education toward competency-based training, promoting the use of simulators and quantitative skills assessment. It is therefore necessary to develop reliable quantitative metrics to establish standards for the attainment and maintenance of competence. This work identifies such a metric for simulated central line procedures. The distance between the needle tip and ultrasound image plane was quantified as a metric of efficacy in ultrasound guidance implementation. In a simulated procedure, performed by experienced physicians, this distance was significantly greater in unsuccessful procedures (p = 0.04). The use of this metric has the potential to enhance the teaching, training and skills assessment of ultrasound-guided central line insertions.

Routine chest X-ray is unnecessary after ultrasound-guided central venous line placement in the operating room

BackgroundCentral venous catheters (CVC) can be useful for perioperative monitoring and insertion has low complication rates. However, routine post insertion chest X-rays have become standard of care and contribute to health care costs with limited impact on patient management. Methods200 patient charts who underwent pancreaticoduodenectomy with central line placement and early line removal were reviewed for clinical complications related to central line placement as well as radiographic evidence of malpositioning. A cost analysis was performed to estimate savings if CXR had not been performed across routine surgical procedures requiring central access. ResultsIn 200 central line placements for Whipple procedures, 198 lines were placed in the right internal jugular and 2 were placed in the subclavian. No cases of pneumothorax or hemothorax were identified and 30 (15.3%) of CVCs were improperly positioned. Only 1 (0.5%) of these was deemed clinically significant and repositioned after the CXR was performed. ConclusionRoutine CXR consumes valuable time and resources (≅$155,000 annually) and rarely affects management. Selection should be guided by clinical factors.

The Impact of Deployment on the Practice of the Military Internist: A Needs Assessment for Post-Deployment Refresher Training.

U.S. Army internists serve in a variety of provider roles during deployment, many of which vary from the traditional responsibilities of a general internist or internal medicine subspecialist. There is significant interest in defining specific clinical and procedural skills in which Army internists may require refresher training after deployment, but information to quantify and clarify these needs is lacking. An online, anonymous survey was created to assess Army internists' experience and comfort level with specialty-specific problems and procedures before and after deployment. This survey was distributed via the Army Central Simulation Committee to all U.S. Army internists eligible for deployment. The survey was available online from January 11, 2012, to March 9, 2012. Ninety-seven of all 115 (84%) U.S. Army internists eligible for deployment responded. The reported comfort level with core clinical problems in general internal medicine before and after deployment did not change, with the exception of decreased comfort with the performance of advanced cardiac life support (87% versus 76% comfortable, p = 0.035), evaluation and management of anemia (92% versus 83% comfortable, p = 0.039), and comfort with preoperative risk stratification and mitigation (81% versus 65% comfortable, p = 0.017). Providers' reported comfort level performing core internal medicine procedures decreased, including significant decreases with lumbar puncture (p < 0.001), arterial line placement (p = 0.02), ultrasound-guided central line placement (p = 0.01), ultrasound-guided thoracentesis (p = 0.004), and arthrocentesis (p = 0.01). Despite a reported deceased comfort with certain core clinical problems and procedural skills, only 10 of 68 (13%) respondents reported being offered refresher skills training following deployment. Although Army internists' comfort with core general internal medicine clinical problems remains largely unaffected by deployment, confidence in core internal medicine procedures suffers because of limited opportunities to practice these skills in the deployed setting. Skills training and assessment in procedures required for individual provider practice should be a primary focus of reintegration after deployment.

Ultrasound-guided central venous catheterization - "Syringe-Free" approach

Central venous catheterization of the internal jugular vein is a commonly performed invasive procedure associated with a significant morbidity and even mortality. Ultrasound-guided methods have shown to improve significantly the success of the technique and are recommended by various scientific societies, including the American Society of Anesthesiologists. The aim of this report is to describe an innovative ultrasound-guided central line placement of the internal jugular vein. The authors describe an innovative ultrasound-guided central line placement of the internal jugular vein based on an oblique approach - the "Syringe-Free" approach. This technique allows immediate progression of the guide wire in the venous lumen, while maintaining a real-time continuous ultrasound image. The described method adds to the traditional oblique technique the possibility of achieving a continuous real-time ultrasound-guided venipuncture and a guide wire insertion that does not need removing the probe from the puncture field, while having a single operator performing the whole procedure.

Ultrasound-guided central line placement: is a gelatine phantom a good and affordable alternative?

Ultrasound-guided central line placement: is a gelatine phantom a good and affordable alternative?

Expert Evaluation of a Chicken Tissue-based Model for Teaching Ultrasound-guided Central Venous Catheter Insertion

Ultrasound-guided central venous catheterization (CVC) is a commonly performed procedure which carries significant risks for complications. Current models used for simulation-based teaching are expensive and may not replicate tissue feel and ultrasound qualities of human tissues. We aimed to evaluate a tissue model composed of chicken breast and balloons and compare it to a commercially available mannequin. Forty attending physicians from four departments with extensive CVC experience were enrolled. Participants completed an ultrasound-guided central line placement utilizing both models during a hands-on workshop. Following CVC placement on each model, participants completed a survey to assess their experience with that particular model. 40 attending physicians (12 (30%) anesthesia, 11 (28%) emergency medicine, 11 (28%) internal medicine, and 6 (15%) surgery) participated in the study. The chicken model was rated significantly higher than the mannequin model with regard to ultrasound quality (p=0.02) and tissue feel (p=0.002). In a direct comparison, participants rated the chicken model more highly than the mannequin in all categories except similarity to the human anatomy. Overall the chicken model was preferred to the mannequin, (mean score 44.5; standard deviation 26.0). The mannequin was rated higher with regard to similarity to human anatomy (mean score 52.8; standard deviation 25.7). The comparison between key features (ultrasound characteristics, similarity to human anatomy and teaching trainees) of the models did not vary significantly by area of practice, with the exception of ease of use (p=0.045). In this prospective study of experienced clinicians we found that a novel tissue model for ultrasound-guided CVC placement was rated more highly compared to a commercially available mannequin task trainer.

Brachiocephalic vein for percutaneous ultrasound-guided central line positioning in children: A 20-month preliminary experience with 109 procedures.

Ultrasound-guided (USG) cannulation of the brachiocephalic vein (BCV) is gaining worldwide consensus for central venous access in children. This study reports a 20-month experience with this approach in children. All patients who underwent percutaneous USG central venous catheter (CVC) positioning in the BCV between August 2013 and March 2015 have been included. Devices inserted during this period were open-ended, either single or double-lumen tunneled CVC. Our series was divided into three consecutive study periods in order to determine the relative incidence of repositioning and complications. During the study period, a total of 95 patients underwent 109 CVC insertions in the BCV. The median length of CVC duration was 230 days for a total of 23,212 catheter days. No major intraoperative complications occurred. Overall rate of CVC-related postoperative complications requiring repositioning or precocious removal was 0.90 per 1,000 catheter days and involved 21 CVC (19%, 95% confidence interval 13-28). These included 18 dislodgments, two infections, and one malfunction. Double-lumen CVCs represented the only significant risk factor for complications (52% complications-three per 1,000 catheter days). USG supraclavicular cannulation of the BCV represents a safe approach for central line placement in children. It proved to be versatile, as it can be used in premature infants as well as in adolescents. Provided it is adopted by operators experienced in USG cannulation, we strongly suggest to resort to this approach as a first-line choice in children undergoing tunnelled central line placement for long-lasting therapy.