Central venous access

Assessment of the Tip Position of Central Venous Catheters Inserted Using Peres' Height Formula

OBJECTIVES

The tip of a central venous catheter (CVC) should be positioned in the proximity of the cavo-atrial junction (CAJ) where the lower third of the superior vena cava (SVC) and the upper right atrium (RA) are located to prevent life-threatening complications. This study aimed to determine the accuracy of Peres' height formula in predicting the correct insertion depth of CVC.  Methods: A total of 332 patients were enrolled in this prospective observational study. All CVCs were inserted using Peres' formula. The 'correct' tip position of CVC was the placement of the CVC tip 1 cm above and 1 cm below the carina in CXR. Rates of correct placements for each side and site of catheter insertions, gender, and body mass index (BMI) differences were evaluated.

RESULTS

The correct placement rate of all catheters was 74.4%. There were statistically significant correlations between the correct placement of right-sided jugular and subclavian catheters (p<0.001) and left-sided jugular and subclavian catheters (p=0.014). There was a statistically significant difference in male patients (p=0.047). Higher BMI resulted in a lower rate of correct placement with no statistically significant difference (p=0.457).

CONCLUSIONS

Peres' formula can be easily used to determine the correct position of CVC tips with a success rate in the Turkish population. However, practitioners should be aware of the low accuracy rate of Peres' formula in female patients (68.5%) and patients with BMI over 35 kg/m² (62.5%).

Chest radiography for simplified evaluation of central venous catheter tip positioning for safe and accurate haemodynamic monitoring: a retrospective observational study

OBJECTIVES

The tip-to-carina (TC) distance on a simple chest X-ray (CXR) has proven value in the determination of correct central venous catheter (CVC) positioning. However, previous studies have mostly focused on preventing the atrial insertion of the CVC tip, and not on appropriate positioning for accurate haemodynamic monitoring. We aimed to assess whether the TC distance could detect the passage of the CVC tip into the superior vena cava (SVC) and the right atrium (RA), and to accordingly suggest cut-off reference values for these two aspects.

DESIGN

Retrospective observational cohort study.

SETTING

Single urban tertiary level academic hospital.

PARTICIPANTS

479 patients who underwent CXR and chest CT scan after the insertion of a CVC with a 24-hour interval during the study period.

INTERVENTION

The TC distance was measured on CXR, and the position of the CVC tip was assessed on the chest CT images. The TC distance was described as a negative or positive number if the CVC tip was above or below the carina, respectively. Receiver-operating characteristics curve analyses were conducted to ascertain the TC distance to detect SVC entrance and RA insertion of CVC tip.

RESULTS

The TC distance could significantly detect both SVC entrance and RA insertion (p<0.001 for both; area under curve 0.987 and 0.965, respectively), with a reference range of -6.69 to 15.61 mm.

CONCLUSION

The TC distance in CXR is a simple and precise method to confirm not only the safe placement of the CVC tip but also its optimal positioning for accurate haemodynamic monitoring.

Agitated saline bubble-enhanced ultrasound for the positioning of cuffed, tunneled dialysis catheters in patients with end-stage renal disease

BACKGROUND

In patients with end-stage renal disease, the use of cuffed, tunneled dialysis catheters for hemodialysis has become integral to treatment plans. Fluoroscopy is a widely accepted method for the insertion and positioning of cuffed dialysis catheters, because it is easy to use, accurate and reliable, and has a relatively low incidence of complications. The purpose of our study was to evaluate the feasibility of tunneled hemodialysis catheter placement without the use of fluoroscopy but with a dynamic ultrasound-imaging-based guided technique.

METHODS

From January 2015 to December 2017, we performed an observational prospective cohort study of 56 patients with end-stage renal disease who required tunneled dialysis catheter placement.

RESULTS

The overall success rate for ultrasound-guided central access was 100%, with a mean number of 1.16 (±0.4) attempts per patient. There were no incidences of guide wire coiling/kinking, carotid puncture, pneumothorax, or catheter malfunction. Catheter flow during dialysis was 286 (±38) mL/min. The total number of catheter days was 7451, with a mean of 133 days and a range of 46-322 days. Life table analysis revealed primary patency rates of 100%, 96%, and 53% at 30, 60, and 120 days, respectively.

CONCLUSION

Dynamic ultrasound-based visualization of microbubbles in the right atrium is a highly accurate method to detect percutaneous implantation of large-lumen, tunneled, central venous catheters without the need for fluoroscopic guidance technology. Future research should further develop and confirm these initial findings.

Radiological Central Vein Treatment in Vascular Access

In the last decades, the percutaneous interventional approach for the treatment of central venous obstructions (CVO) has become increasingly popular as the treatment of first choice because of its minimal invasiveness and reported success rates. CVOs are caused by a diverse spectrum of diseases which can be broadly categorized into two principal eliciting genera, either benign or malignant obstructions. The large group of benign venous obstructions includes the increasing number of end-stage renal disease patients with vascular access related complications. Due to the invasiveness and complexity of thoracic surgery for benign CVOs, the less invasive percutaneous interventional therapy can generally be considered the preferred treatment option. Initially, the radiological intervention consisted of balloon angioplasty alone, subsequently additional stent placement was applied. This was advocated as either primary placement or secondary in cases of elastic recoil or residual stenosis after percutaneous transluminal angioplasty (PTA). The efficacy of angioplasty of CVO in patients with vascular accesses, either with or without stenting, has been addressed by various studies. Overall, reports indicate an initial technical and clinical success rate above 95% and satisfactory patency rates. However, systematic follow-up and frequent re-interventions are necessary to maintain vascular patency to achieve long-term success.

The Direct and Indirect Costs of Ultrasound-Guided Peripherally Inserted Central Catheter Repositioning at a Large Academic Medical Center

Background: To assess the technical success of ultrasound (US)-guided peripherally inserted central catheter (PICC) placement at a large academic medical center and evaluate the direct and indirect costs associated with malpositioned catheters.

Methods: This retrospective chart review consisted of 250 consecutive inpatients and 150 consecutive outpatients (N = 400, aged 58 ± 17 years, 225 men and 175women) who underwent US-guided PICC placement at a single center. Repositioning rates were compared between high-complexity (inpatient) and low-complexity (outpatient) groups using a χ2 test and phi coefficient. Initial and final catheter tip position was assessed by radiography. Direct costs of repositioning were estimated using Medicare reimbursement rates. Indirect costs, including additional staff time, imaging, and delays in treatment, were assessed via a survey of PICC nurses and chart reviews.

Results: Initial PICC placement resulted in an optimal tip position in 34% of patients and an optimal or acceptable position in 84% of patients. Repositioning rates were significantly higher for inpatients with a low to moderate association between inpatient PICC placement and the need for repositioning (χ2 = 9.603, P = .002; σ = 0.155, P = .002). In total, 77 catheters required repositioning, costing on average an additional $186.03 and 50 minutes of staff time per catheter as well as delaying catheter use in 23 patients for at least 24 hours.

Conclusions: PICC malpositioning is a significant source of inefficiency, especially for inpatient services, that should be addressed to reduce expenditures and maximize patients' perceptions of quality health care.

Central Venous Catheter Intravascular Malpositioning: Causes, Prevention, Diagnosis, and Correction

Despite the level of skill of the operator and the use of ultrasound guidance, central venous catheter (CVC) placement can result in CVC malpositioning, an unintended placement of the catheter tip in an inadequate vessel. CVC malpositioning is not a complication of central line insertion; however, undiagnosed CVC malpositioning can be associated with significant morbidity and mortality. The objectives of this review were to describe factors associated with intravascular malpositioning of CVCs inserted via the neck and chest and to offer ways of preventing, identifying, and correcting such malpositioning. A literature search of PubMed, Cochrane Library, and MD Consult was performed in June 2014. By searching for “Central line malposition” and then for “Central venous catheters intravascular malposition,” we found 178 articles written in English. Of those, we found that 39 were relevant to our objectives and included them in our review. According to those articles, intravascular CVC malpositioning is associated with the presence of congenital and acquired anatomical variants, catheter insertion in left thoracic venous system, inappropriate bevel orientation upon needle insertion, and patient’s body habitus variants. Although plain chest radiography is the standard imaging modality for confirming catheter tip location, signs and symptoms of CVC malpositioning even in presence of normal or inconclusive conventional radiography findings should prompt the use of additional diagnostic methods to confirm or rule out CVC malpositioning. With very few exceptions, the recommendation in cases of intravascular CVC malpositioning is to remove and relocate the catheter. Knowing the mechanisms of CVC malpositioning and how to prevent, identify, and correct CVC malpositioning could decrease harm to patients with this condition.

Chemo-port insertion: A cause of vocal cord palsy

We describe extremely rare cases of vocal cord palsy following surgical insertion of a chemo port. Our cohort consisted of patients with cancer who developed hoarseness immediately after central venous line placement for the administration of chemotherapy, with vocal cord palsy confirmed with flexible laryngoscopy. Given the timing, central venous line placement appears to be the most likely cause.

Comparison between radiation exposure levels using an image intensifier and a flat-panel detector-based system in image-guided central venous catheter placement in children weighing less than 10 kg

BACKGROUND

Ultrasound-guided central venous puncture and fluoroscopic guidance during central venous catheter (CVC) positioning optimizes technical success and lowers the complication rates in children, and is therefore considered standard practice.

OBJECTIVE

The purpose of this study was to compare the radiation exposure levels recorded during CVC placement in children weighing less than 10 kg in procedures performed using an image intensifier-based angiographic system (IIDS) to those performed in a flat-panel detector-based interventional suite (FPDS).

MATERIALS AND METHODS

A retrospective review of 96 image-guided CVC placements, between January 2008 and October 2013, in 49 children weighing less than 10 kg was performed. Mean age was 8.2 ± 4.4 months (range: 1-22 months). Mean weight was 7.1 ± 2.7 kg (range: 2.5-9.8 kg). The procedures were classified into two categories: non-tunneled and tunneled CVC placement.

RESULTS

Thirty-five procedures were performed with the IIDS (21 non-tunneled CVC, 14 tunneled CVC); 61 procedures were performed with the FPDS (47 non-tunneled CVC, 14 tunneled CVC). For non-tunneled CVC, mean DAP was 113.5 ± 126.7 cGy cm(2) with the IIDS and 15.9 ± 44.6 cGy · cm(2) with the FPDS (P < 0.001). For tunneled CVC, mean DAP was 84.6 ± 81.2 cGy · cm(2) with the IIDS and 37.1 ± 33.5 cGy cm(2) with the FPDS (P = 0.02).

CONCLUSION

The use of flat-panel angiographic equipment reduces radiation exposure in small children undergoing image-guided CVC placement.

Real-time multimodal axillary vein imaging enhances the safety and efficacy of axillary vein catheterization in neurosurgical intensive care patients

BACKGROUND

Controversy exists regarding the increased safety profile when ultrasound is used for central venous catheters inserted in the subclavian or axillary vein. The critically ill neurosurgical patient presents unique considerations for the optimal central line approach.

METHODS

This report is a retrospective chart review of 6 neurosurgical intensive care patients in whom an ultrasound-guided, transpectoral, axillary vein catheterization was attempted. A sterile technique was observed. The anatomy was confirmed using combined transverse, longitudinal, and Doppler flow images. The needle tip was advanced into the axillary vein under real-time ultrasound using an in-plane technique. The central venous catheter was inserted using the Seldinger technique. A chest radiograph was obtained after each line.

RESULTS

Five of the 6 central lines were inserted easily, without complications. The sixth central line was inserted without complications but more proximally because of difficulty in visualizing the axillary vein on account of the patient's morbid obesity and severe hypovolemia.

CONCLUSIONS

This series illustrates new and useful aspects of ultrasound use in transpectoral axillary vein catheterization: it requires minimal additional training; it combines the real time, in-plane technique with transverse, longitudinal, and Doppler color flow images; and it is used safely in the critically ill neurosurgical patient. The data on infraclavicular central venous catheters indicate decreased line sepsis, arterial punctures, and venous thrombosis while improving nursing care and patient comfort. This technique's potential for decreasing the risk of pneumothorax may make it a reasonable option for many critically ill patients in whom other central venous catheter approaches may not be ideal.

Central venous access device-related infections in patients with haemophilia

AIMS

Fully implantable central venous access devices (CVADs) can offer long-term reliable venous access to facilitate regular factor replacement therapy in haemophilia. However, CVAD-related infection remains a major deterrent to the optimal use of CVAD in this population. This report represents the first review of CVAD use in haemophilia in Australia and aims to examine the rate of complications including CVAD-related infections.

METHODS

A retrospective review of medical records was conducted of all haemophilic patients with fully implantable CVADs at the Royal Children's Hospital (RCH), Melbourne, between 1 June 1992 and 30 June 2009. CVAD-related bloodstream infection was defined based on the guidelines from the Centre of Disease Control and Victoria National Nosocomial Infection Surveillance. To further enhance identification of CVAD-related infection in this study, a third criterion of 'suspected infection' was added by the authors.

RESULTS

Eighty-one CVADs in 56 patients were managed at the RCH during this time period resulting in a combined study period of 94 756 CVAD days. Median age at first CVAD insertion = 2.16 years (range 0.66 to 13.98 years). CVADs were inserted predominantly due to difficult venous access and prophylaxis initiation (70.4%). Median life-span of a CVAD was 1227 days, equivalent to 3.36 years (n = 50; range 0.22 to 9.44 years). Fifty-seven CVAD-related infections occurred in 37 CVADs (46.3%) in 29 patients (51.8%). Overall incidence of confirmed CVAD-related bloodstream infection = 0.42 per 1000 CVAD days (95% confidence interval (CI): 0.31 to 0.58 per 1000 CVAD days) and indicate better performance compared with the published benchmark of 0.66 per 1000 CVAD days (0.44 to 0.97 per 1000 CVAD days). The incidence of both confirmed (criteria 1, 2) and suspected (criterion 3) CVAD-related infection is 0.60 per 1000 CVAD days (95% CI: 0.46 to 0.78), which is comparable to the international benchmark. The majority of CVAD-related infections (73.7%) were successfully treated with intravenous antimicrobials without necessitating CVAD removal. Klebsiella pneumoniae was the most common organism found in positive blood cultures.

CONCLUSION

CVAD-related infection in this Australian population was comparable to rates described in the medical literature. Ongoing surveillance for infection rates is important to provide an up-to-date assessment of risks associated with CVAD use in this population.

Central venous catheters in premature babies: radiological evaluation, malpositioning and complications

Central venous catheters are important in the care for prematurely born children in the neonatal intensive care unit. The purpose of this pictorial essay is to illustrate correct positioning, malpositioning and possible complications of such devices.

Central venous catheter tip malposition

Central venous catheters are commonly utilised to gain vascular access for varied clinical indications. Successful central venous catheter placement requires not only technical expertise, but also awareness of the potential complications. This article reviews the major procedural and post-procedural complications resulting from central venous catheter tip malposition.