Ultrasound-guided Central Venous Catheterization Research Articles

Outcome-based simulation training for ultrasound-guided central venous catheter placement: clinical impact on preventing mechanical complications

BackgroundCentral venous catheter placement has been associated with mechanical complications, some of which can be life-threatening. Recent studies have shown that simulation-based education on ultrasound-guided central venous catheter placement improves puncture success rates; however, its effect on reducing mechanical complications remains unclear. This observational study examined how outcome-based simulation training for ultrasound-guided central venous catheter placement affects the incidence of mechanical complications in a clinical setting.MethodsThe Safe Central Venous Catheter Placement and Management Committee established a reporting system to monitor central venous catheter placement. In 2016, a skill assessment of ultrasound-guided central venous catheter placement was conducted. Outcome-based simulation training was introduced in 2017. Skills were evaluated using the skill assessment tool developed by the Japanese Society for Medical Simulation.ResultsAfter implementing skill assessment and outcome-based simulation training, the mechanical complication rate decreased from 2.2% in 2015 to 1.2% in 2023.ConclusionsA recent meta-analysis reported a 2.3% mechanical complication rate during ultrasound-guided central venous catheter placement. In comparison, the 1.2% complication rate at our institution is notably lower. This study suggests that outcome-based simulation training for ultrasound-guided central venous catheter placement may help reduce the incidence of mechanical complications in clinical settings.

The Study of Ultrasound-Guided Central Venous Catheterization in the Teaching of Anesthesia Residents

The Study of Ultrasound-Guided Central Venous Catheterization in the Teaching of Anesthesia Residents

One-hand guidewire introducer kit for ultrasound-guided central venous catheterization: a proof-of-concept study

Despite ultrasound guidance for central venous catheterization (CVC), the first-attempt success rate has remained around 52.6−62.1%. A significant reason is that the needle can sometimes be dislodged from the punctured vein during hand shifts. Here, a novel one-hand guidewire introducer (OGI) kit was developed to perform guidewire insertion in the central vein, eliminating hand shifts. To establish a protocol, the OGI kit was validated using a central line training phantom. A total of 48 randomized trials of guidewire insertion in the internal jugular vein in eight pigs were performed using either the conventional kit (group A) or the OGI kit (group B). All trials were technically successful with all eight pigs. First-attempt success rate (50% vs. 75%, p = 0.035) and global rating scale (12 (5−15) vs. 14 (8−15), p = 0.011) were significantly lower in group A than in group B. The number of needle redirections and guidewire insertions, time to guidewire insertion, and procedure-related complications were significantly higher in group A than in group B. Guidewire insertion using a novel OGI kit could be a promising approach for real-time ultrasound-guided CVC as it offers greater clinical usefulness.

Central Venous Catheterization in the ICU: A Comparison of Anatomical Landmark and Ultrasound-Guided Techniques

Introduction: Central venous catheterization (CVC) is frequently required in intensive care units (ICUs) for administering medications, fluids, and monitoring central venous pressure. However, CVC insertion can lead to complications such as arterial puncture, hematoma formation, and pneumothorax. Ultrasound guidance has been advocated to reduce these complications, but its effectiveness in the ICU setting remains debated. This study compared the complication rates of anatomical landmark-guided versus ultrasound-guided CVC insertion in ICU patients. Methods: A prospective cohort study was conducted in the ICU of a tertiary care hospital. Patients requiring CVC were divided into two groups: anatomical landmark-guided and ultrasound-guided insertion. The primary outcome was the incidence of complications, including arterial puncture, hematoma, and pneumothorax. Secondary outcomes included cannulation time and the number of cannulation attempts. Results: A total of 39 patients were included in the study. The incidence of complications was significantly lower in the ultrasound-guided group (2 complications) compared to the anatomical landmark group (7 complications) (p=0.017). The most common complication was arterial puncture, occurring in 7 patients in the anatomical landmark group and 2 patients in the ultrasound-guided group. Conclusion: Ultrasound guidance significantly reduces the risk of complications during CVC insertion in the ICU. This technique should be considered the standard of care for CVC insertion in this setting.

Wire-in-needle versus conventional syringe-on-needle technique for ultrasound-guided central venous catheter insertion in the internal jugular vein: the WIN randomized trial.

There are different techniques for ultrasound-guided central venous catheter (CVC) insertion. When using the conventional syringe-on-needle technique, the syringe needs to be removed from the needle after venous puncture to pass the guidewire through the needle into the vein. When, alternatively, using the wire-in-needle technique, the needle is preloaded with the guidewire, and the guidewire-after venous puncture-is advanced into the vein under real-time ultrasound guidance. We tested the hypothesis that the wire-in-needle technique reduces the time to successful guidewire insertion in the internal jugular vein compared with the syringe-on-needle technique in adults. We randomized 250 patients to the wire-in-needle or syringe-on-needle technique. Our primary endpoint was the time to successful guidewire insertion in the internal jugular vein. Two hundred and thirty eight patients were analyzed. The median (25th percentile, 75th percentile) time to successful guidewire insertion was 22 (16, 38) s in patients assigned to the wire-in-needle technique and 25 (19, 34) s in patients assigned to the syringe-on-needle technique (estimated location shift: 2s; 95%-confidence-interval: - 1 to 5s, p = 0.165). CVC insertion was successful on the first attempt in 103/116 patients (89%) assigned to the wire-in-needle technique and in 113/122 patients (93%) assigned to the syringe-on-needle technique. CVC insertion-related complications occurred in 8/116 patients (7%) assigned to the wire-in-needle technique and 19/122 patients (16%) assigned to the syringe-on-needle technique. The wire-in-needle technique-compared with the syringe-on-needle technique-did not reduce the time to successful guidewire insertion in the internal jugular vein. Clinicians can consider either technique for ultrasound-guided CVC insertion in adults.

Systematic review of ultrasound-guided central venous catheter placement-related complications in neonates and infants aged

Although ultrasound can be considered an assistant method, successful placement of a central venous catheter (CVC) in infants is still challenging. The incidence of CVC placement-related complications is still high. Therefore, this systematic review aimed to synthesize evidence to assess the effects of ultrasound-guided CVC placement on adverse outcomes in infants and neonates aged <12 months. PubMed, Ovid, EMBASE, and the Cochrane Library were searched to identify potentially relevant studies. The main outcome was the incidence of adverse events, which included inadvertent arterial puncture, hematoma, pneumothorax and hemothorax, catheter kinking, threading, and malpositioning problems, venous thrombosis, catheter-related infection, phlebitis, and cardiac tamponade. Eleven studies involving 2097 patients were included in the final analysis. The odds of inadvertent arterial puncture, and catheter kinking, threading, and malpositioning problems were lower in the ultrasound group than in the control group. No significant difference was detected in the incidence of hematoma or venous thrombosis between the control and ultrasound groups. Other complications, such as pneumothorax, hemothorax, phlebitis, and cardiac tamponade, rarely occurred. Ultrasound-guided CVC placement can improve the safety of punctures in neonates and infants. CVC punctures should be guided in real-time by ultrasound.

Augmented reality visualization for ultrasound-guided interventions: a pilot randomized crossover trial to assess trainee performance and cognitive load

BackgroundAugmented reality (AR) technology involving head-mounted displays (HMD) represents a significant innovation in medical education, particularly for training in guided invasive procedures. Novice physicians often face challenges in simultaneously identifying anatomical landmarks and performing procedures when learning point-of-care ultrasound (POCUS). Our primary objective was to determine the effectiveness of AR in enhancing physician training for ultrasound-guided interventions using AR visual overlays. The secondary objective was to compare cognitive load between traditional ultrasound training settings and AR-assisted training settings.MethodsThis randomized crossover study, conducted from 2021 to 2022, compared performance and cognitive load of trainees attempting accurate central venous catheter (CVC) placement using an AR-HMD to display ultrasound images (AR-US), compared with standard ultrasound without visual overlay (S-US). We enrolled 47 trainees, including 22 final-year undergraduate medical students and 25 postgraduate physicians (years 1–4) from three hospitals in Taiwan. All participants had basic training in US-guided CVC placement but lacked AR-US experience. Performance and cognitive load were assessed using time measurements and NASA Task Load Index (NASA-TLX), covering the dimensions of Mental-, Physical- and Temporal Demand, and Performance, Effort and Frustration.ResultsWe found AR technology reduced the time required for critical steps in CVC placement, while minimizing users’ neck strain. Female and junior trainees using AR-US identified anatomy and localized veins faster than those using S-US. Using AR-US, female trainees significantly outperformed males in anatomical identification [mean difference (MD): -10.79 s (95% CI: -2.37 to -19.21)]. The NASA-TLX cognitive load assessment showed mental workload trending lower in all dimensions except performance while using AR-US, compared to S-US. Similarly, junior trainees’ effort- and frustration scores were lower [MD: -2.73 (95% CI: -5.04 to -0.41) and -2.41 (95% CI: -4.51 to -0.31), respectively], as were female trainees’ effort scores [MD: -3.07 (95% CI: -6.10 to -0.03)] when using AR-US, compared to S-US, whereby these differences were statistically significant.ConclusionsAR technology helped improve trainee performance and reduced cognitive load during ultrasound-guided CVC placement. These findings support the application of AR technology to enhance physician training in ultrasound-guided interventional procedures, suggesting that AR-HMDs could be a valuable tool in medical education.Trial registrationThe trial was registered with Clinicaltrials.gov on 20/09/2023 as a clinical trial, under the identifier NCT 06055400.

Comparing the Complications in Central Venous Catheterization by Ultrasound Guidance vs Anatomical Landmark Technique in Critical Ill ICU Patients

Objective: To compare the complication rates during central venous catheterization using ultrasound guidance versus the anatomical landmark technique in critical ill ICU patients. Methodology: A prospective comparative study was conducted in intensive care unit (ICU) of Farooq Teaching Hospital, Rawalpindi from December 2023 to June 2024. Total 127 critically ill ICU patients with acute surgical or medical conditions requiring central venous catheterization (CVC), such as hypotension, dehydration, or required blood resuscitation, where periphery approach was not feasible, underwent CVC insertion. Patients were randomly divided into two groups: one group underwent ultrasound-guided CVC insertion, while the other group used anatomical landmark technique. The rate of complications was measured between the groups. Results: Mean age of the patients was 46.5±11.2 years. The mean time from skin puncture to blood flashback was 104±172 sec in ultrasound group compared to 401±587 sec in landmark group. Among 127 patients, 61 underwent catheterization using ultrasound guidance, while 66 underwent catheterization using the anatomical landmark technique. The complication rates between the two groups were compared. The complications experienced by patients included multiple attempts (&gt;1 puncture), pneumothorax, improper cannulation, hematoma, arterial punctures, incisional bleeding, and ecchymosis. In ultrasound group, 11.5% of patients experienced complications, compared to 28.8% in anatomical landmark group (p = 0.016). Conclusion: Ultrasound-guided central venous catheterization was associated with fewer complications and a higher success rate (correct placement of the CVC), making it easier to perform. This procedure simplicity is linked to enhanced safety and patient comfort.

Critical care ultrasound among Tunisian intensive care residents: A Cross-sectional Survey.

Critical Care ultrasound (CCUS) is more and more used in Tunisian critical care units. An objective assessment of this training has not yet been performed. To assess the theoretical and practical knowledge about CCUS among Intensive Care Unit (ICU) residents. This is a cross-sectional study conducted during the period from January to June 2021. Data were collected using a French language questionnaire distributed on the day of the selection of the residents' posts for the next training period (at the end of June 2021). Out of 75 residents, 37 accepted to answer to the survey (Participation rate =49 %). The majority were female (66.4%). The mean age was 29±12.36 years. Only 5.4% of participants (n=2) had previously received training concerning echocardiography and only 8.1% of the participants have received dedicated training for lung ultrasound (LU). Among the participants, 80.1% of residents (n=30) had never performed a transthoracic echocardiography (TTE). Competence in performing echocardiography was self-assessed quite good and bad by 5.4% and 43.2% of responders respectively. Most of the residents (86%) did not insert before ultrasound-guided central venous catheters. Views known by the participants using TTE were mainly parasternal long axis section (56.8%) and apical 4/5 chambers section (52.8%). All participants (100%) thought that teaching CCU is a necessary part of the training of intensivists. Our study highlighted the lack of training of Tunisian ICU residents regarding CCUS learning. Therefore, it is crucial to integrate such learning and training into their training programs.

Massive Haemo Thorax Following Ultrasound-Guided Central Venous Catheterization in an Anaesthetized Patient: A Case Report

Central venous catheterization is a commonly performed procedure in operation theatre. After the advent of ultrasound (US) guided central venous catheterization (CVC), the incidence of life-threatening complications has reduced significantly and are rare. We present a case of haemothorax in a young patient after US guided, which was inserted at the end of surgery under anaesthesia. The operator had some technical difficulty while inserting the CVC. The Haemothorax was diagnosed post-operatively in the ward after was missed clinically by radiological investigation. It was treated by inserting a 36 Fr chest drain on the second post-operative day which was removed on the seventh postoperative day and the patient was discharged to home.

The Effect of Ultrasound-guided Central Venous Catheterization on Complications and Success Rate in Critically Ill Children: A Multicenter Study

Objective: The aims of this study were to compare the results of ultrasound (US) guidance and the landmark (LM) technique for central venous catheter (CVC) placement in pediatric intensive care units (PICUs) as performed by clinicians. Material and Methods: The patients were divided into two groups according to the technique used: an LM group (459 patients) and a US-guided group (200 patients). We evaluated the success rate, the number of attempts, and the complication rates based on each patient’s age and weight. Results: The time required for the successful placement of the CVC was significantly different between the two groups: 10.9±10.8 min in the LM group and 8.1±7.6 min in the US-guided group (p=0.012). Additionally, the average number of attempts for successful catheterization was 1.8±0.8 in the US-guided group; and 2.5 ± 1.4 in the LM group (p=0.024). A total of 115 (17.3%) complications were noted: 24 (3.6%) in the US-guided group and 91 (13.7%) in the LM group (p=0.014). The frequency of complications decreased as the age and weight of the patients increased. When the inserted catheters used by ultrasound were evaluated, 59.5% of them were placed by clinicians who had ultrasound training while 40.5% were inserted by clinicians who did not have ultrasound training. There was no significant difference in the complication rate, number of punctures, and success rates between the ultrasound-trained and untrained clinicians (p=0.476). Conclusion: This is the largest multicenter study comparing the US-guided vs. LM technique for CVC placement in children. We believe that the US-guided CVC procedure is more safe and takes less time than the LM technique. Also, point-of-care ultrasound is useful, beneficial, and easily available for pediatric intensivists.

A Simple and Safe Method for Checking the Position of Central Venous Catheters-A New and Reliable Threshold for Right Atrial Swirl Sign in Microbubbles Tests.

Background: Central venous catheters (CVCs) are indispensable tools in intensive care and emergency medicine. CVC malpositions still occur frequently and can cause various complications leading to increased patient mortality. A microbubbles test (MBT) can be used to confirm correct CVC positioning. However, there is serious doubt regarding whether the currently applied threshold of a 2 s push-to-bubbles time (PTB time) for rapid atrial swirl sign (RASS) in an MBT is reliable and accurate. The aim of the present study was to prove the quality of a new threshold: 1 s. Methods: Consecutive patients who were admitted to the intensive care unit (ICU) in a German neurological specialist hospital from 1 March 2021 to 20 July 2022 were enrolled. After ultrasound-guided CVC insertion, an MBT was performed, PTB time was measured, and RASS was interpreted. Additionally, a chest X-ray (CXR) was requested to check CVC position. Results: A total of 102 CVCs (98% jugular and 2% subclavian) were inserted in 102 patients (38% female and 62% male; median age: 66 years). Negative RASS (PTB time > 1 s) was observed in 2 out of 102 patients, resulting in an echocardiographic malposition rate of 2.0%. CXR confirmed the echocardiographic results. After correcting CVC position in the initially malpositioned CVCs, the PTB time was <1 s (positive RASS). The MBT protocol took about 0.5 min on average, while the CXR results were all available within 30 min. Sensitivity, specificity, and positive and negative predictive value were each 100% for the detection of CVC malpositions via an MBT using a threshold of 1 s compared to CXR. Conclusions: A new threshold of a 1 s PTB time for RASS in an MBT could detect CVC malpositions with excellent quality compared to CXR. Since the MBT was fast and safe and could be performed at the bedside, we propose that an MBT with the new and reliable threshold of 1 s should be routinely used in patient care.

Central venous catheter tip positioning using ultrasound in pediatric patients-A prospective observational study.

In children, central venous catheter (CVC) placement is usually performed under ultrasound guidance for optimal visualization of vessels and reduction of puncture-related complications. Nevertheless, in many cases, additional radiographic examinations are performed to check the position of the catheter tip. The primary objective of this observational feasibility study was to determine the number of ultrasound-guided central venous catheter tips that can be identified in a subsequent position check using ultrasonography. Furthermore, we investigated the optimal ultrasound window, time expenditure, and success rate concerning puncture attempts and side effects. In addition, we compared the calculated and real insertion depths and analyzed the position of the catheter tip on postoperative radiographs with the tracheal bifurcation as a traditional landmark. Ninety children with congenital heart defects who required a central venous line for cardiac surgery were included in this single-center study. After the insertion of the catheter, the optimal position of its tip was controlled using one of four predefined ultrasound windows. A chest radiograph was obtained postoperatively in accordance with hospital standards to check the catheter tip position determined by ultrasonography. The children had a median (IQR) age of 11.5 (4.0, 58.8) months and a mean (SD) BMI of 15.3 (2.91) kg/m2 Ultrasound visualization of the catheter tip was successful in 86/90 (95.6%) children (95% confidence interval [CI]: 91.3%, 99.8%). Postoperative radiographic examination showed that the catheter tip was in the desired position in 94.4% (95% CI: 89.7%, 99.2%) of the cases. None of the children needed the catheter tip position being corrected based on chest radiography. Additional radiation exposure after the placement of central venous catheters can be avoided with the correct interpretation of standardized ultrasound windows, especially in vulnerable children with cardiac disease.

Ultrasound-guided central venous catheterization around the neck: Systematic review and network meta-analysis

BackgroundUltrasound-guided central venous catheterization (CVC) has become the standard of care. However, providers use a variety of approaches, encompassing the internal jugular vein (IJV), supraclavicular subclavian vein (SupraSCV), infraclavicular subclavian vein (InfraSCV), proximal axillary vein (ProxiAV), distal axillary vein (DistalAV), and femoral vein. ObjectiveThis review aimed to compare the first-pass success rate and arterial puncture rate for different approaches to ultrasound-guided CVC above the diaphragm. MethodsIn May 2023, Embase, MEDLINE, CENTRAL, ClinicalTrials.gov, and World Health Organization International Clinical Trials Platform were searched for randomized controlled trials (RCTs) comparing the 5 CVC approaches. The Confidence in Network Meta-Analysis tool was used to assess confidence. Thirteen RCTs (4418 participants and 13 comparisons) were included in this review. ResultsThe SupraSCV approach likely increased the proportion of first-attempt successes compared to the other 4 approaches. The SupraSCV first-attempt success demonstrated risk ratios (RRs) > 1.21 with a lower 95% confidence interval (CI) exceeding 1. Compared to the IJV, the SupraSCV approach likely increased the first-attempt success proportion (RR 1.22; 95% confidence interval [CI] 1.06–1.40, moderate confidence), whereas the DistalAV approach reduced it (RR 0.72; 95% CI 0.59–0.87, high confidence). Artery puncture had little to no difference across all approaches (low to high confidence). ConclusionConsidering first-attempt success and mechanical complications, the SupraSCV may emerge as the preferred approach, while DistalAV might be the least preferable approach. Nevertheless, head-to-head studies comparing the approaches with the greatest first attempt success should be undertaken.

Ultrasound-Guided Central Venous Catheterization of the Internal Jugular Vein in Cardiovascular Surgery

Ultrasound-Guided Central Venous Catheterization of the Internal Jugular Vein in Cardiovascular Surgery

Single-plane versus real-time biplane approaches for ultrasound-guided central venous catheterization in critical care patients: a randomized controlled trial

BackgroundCritical care patients often require central venous cannulation (CVC). We hypothesized that real-time biplane ultrasound-guided CVC would improve first-puncture success rate and reduce mechanical complications. The purpose of this study was to compare the success rate and safety of single-plane and real-time biplane approaches for ultrasound-guided CVC.MethodsFrom October 2022 to March 2023, 256 participants with critical illness requiring CVC were randomized to either the single-plane (n = 128) or biplane (n = 128) ultrasound-guided cannulation groups. The success rate, number of punctures, procedure duration, incidence of catheterization-related complications, and confidence score of operators were documented.ResultsThe central vein was successfully cannulated in all 256 participants (163 [64%] man and 93 [36%] women; mean age 69 ± 19 [range 13–104 years]), including 182 and 74 who underwent internal jugular vein cannulation (IJVC) and femoral vein cannulation (FVC), respectively. The incidence of successful puncture on the first attempt was higher in the biplane group than that in the single-plane group (91.6% vs. 74.7%; relative risk (RR), 1.226; 95% confidence interval (CI), 1.069–1.405; P = 0.002 for the IJVC and 90.9% vs. 68.3%; RR, 1.331; 95% CI, 1.053–1.684; P = 0.019 for the FVC). The biplane group was also associated with a higher first-puncture single-pass catheterization success rate (87.4% vs. 69.0% and 90.9% vs. 68.3%), fewer undesired punctures (1[1–1(1–2)] vs. 1[1–2(1–4)] and 1[1–1(1–3)] vs. 1[1–2(1–4)]), shorter cannulation time (205 s [162–283 (66–1,526)] vs. 311 s [243–401 (136–1,223)] and 228 s [193–306 (66–1,669)] vs. 340 s [246–499 (130–944)]), and fewer immediate complications (10.5% vs. 28.7% and 9.1% vs. 34.1%) for both IJVC and FVC (all P < 0.05).ConclusionReal-time biplane imaging of ultrasound-guided CVCs offers advantages over the single-plane approach for critically ill patients.Trial registration: This prospective RCT was registered at Chinese Clinical Trial Registry (ChiCTR2200064843). Registered 19 October 2022.

Catheter Guided Central Venous Ultrasound in Pediatric Patients: Experience in A Hospital of Second Level in Mexico

Objective: To compare the number of attempts, procedure time and complications in pediatric patients at the Dr. Jesús Gilberto Gómez Maza hospital in two groups with an indication for the installation of a central venous catheter (CVC). Methodology: Randomized clinical trial at the Hospital Dr. Jesús Gilberto Gómez Maza, from southeastern Mexico; in the Pediatrics service, which includes pediatric emergency room, pediatric intensive care unit, pediatric hospitalization and operating room for all pediatric patients aged 1 month to 15 years with 11 months hospitalized during the period January 1, 2017 to December 31 of 2018 that required the installation of a CVC with a blind technique versus the ultrasound-guided technique. Results: A total of 585 patients with indication for CVC installation were included, with distribution of 248 women (42.4%) and 337 men (57.6%), the highest frequency being in the pediatric emergency service, with 388 patients (66.3%), followed by pediatrics with 94 (16.1%). In 471 patients a central and femoral insertion catheter was used (80.5%) and in 114, a peripheral insertion central catheter was used (19.5%). Of the 585 patients, in 448 in cases, the CVC was installed with a blind technique (76.6%) and 137 guided by ultrasound (23.4%) Complications (hematoma, hemorrhage, hemothorax, hydrothorax, catheter material failure, misplacing, multipuncture, arterial puncture, stenosed vein and Venodisection) observed with the blind technique, 107 (23.8%) were recorded and with the ultrasound-guided technique, 9 (6.5%). Of the 137 patients with ultrasound-guided CVC, 92 the procedure time took between 10 to 20 minutes ( 67.1%), and with blind technique, 326 (72.7%) the ti me of hard procedure between 21 and 60 minutes. Regarding the number of punctures, it was observed that the proportions were similar, in the sense that the majority received 1 to 2 punctures for the ultrasound-guided technique (91%), and the blind technique (88.1%). Conclusions: The insertion of the ultrasound-guided central venous catheter in pediatric patients is an effective and safe technique, with which complications and time during the procedure are significantly reduced.

Comparative study of internal jugular, supraclavicular, and infraclavicular approaches for ultrasound-guided central venous catheterization

Comparative study of internal jugular, supraclavicular, and infraclavicular approaches for ultrasound-guided central venous catheterization

Platelet Transfusion before CVC Placement in Patients with Thrombocytopenia

BackgroundTransfusion guidelines regarding platelet-count thresholds before the placement of a central venous catheter (CVC) offer conflicting recommendations because of a lack of good-quality evidence. The routine use of ultrasound guidance has decreased CVC-related bleeding complications.MethodsIn a multicenter, randomized, controlled, noninferiority trial, we randomly assigned patients with severe thrombocytopenia (platelet count, 10,000 to 50,000 per cubic millimeter) who were being treated on the hematology ward or in the intensive care unit to receive either one unit of prophylactic platelet transfusion or no platelet transfusion before ultrasound-guided CVC placement. The primary outcome was catheter-related bleeding of grade 2 to 4; a key secondary outcome was grade 3 or 4 bleeding. The noninferiority margin was an upper boundary of the 90% confidence interval of 3.5 for the relative risk.ResultsWe included 373 episodes of CVC placement involving 338 patients in the per-protocol primary analysis. Catheter-related bleeding of grade 2 to 4 occurred in 9 of 188 patients (4.8%) in the transfusion group and in 22 of 185 patients (11.9%) in the no-transfusion group (relative risk, 2.45; 90% confidence interval [CI], 1.27 to 4.70). Catheter-related bleeding of grade 3 or 4 occurred in 4 of 188 patients (2.1%) in the transfusion group and in 9 of 185 patients (4.9%) in the no-transfusion group (relative risk, 2.43; 95% CI, 0.75 to 7.93). A total of 15 adverse events were observed; of these events, 13 (all grade 3 catheter-related bleeding [4 in the transfusion group and 9 in the no-transfusion group]) were categorized as serious. The net savings of withholding prophylactic platelet transfusion before CVC placement was $410 per catheter placement.ConclusionsThe withholding of prophylactic platelet transfusion before CVC placement in patients with a platelet count of 10,000 to 50,000 per cubic millimeter did not meet the predefined margin for noninferiority and resulted in more CVC-related bleeding events than prophylactic platelet transfusion. (Funded by ZonMw; PACER Dutch Trial Register number, NL5534.)

A creative approach to central venous access in a Kenyan intensive care unit

As healthcare systems in resource-constrained environments advance, implementation of novel services and technologies bring both opportunities for advancing patient care along with new challenges to the existing infrastructure. One example of this is the need for additional consumable goods when facilities add services such as dedicated critical care and hemodialysis. The addition of these services in the authors’ hospital led to an increased need for central venous access. In this paper, the authors describe equipment substitutions that were made to facilitate ultrasound-guided central venous catheter placement while attempting to reduce financial and logistical needs to perform the procedure safely and effectively.