Optimising central venous catheter placement by comparing cavoatrial junction position to chest X-ray landmarks: A cross-sectional study using CT chest reconstruction

INTRODUCTION

Central venous catheter (CVC) tip placement guided by chest X-ray (CXR) landmarks is currently prone to inconsistency and malpositioning. This study aims to better define the relationship between the cavoatrial junction (CAJ) and selected X-ray landmarks.

METHODS

Chest CTs of 100 patients were retrospectively assessed. CT images were converted to a 'virtual CXR' using a digital workstation, enabling simultaneous localisation of the CAJ and evaluation of CXR landmarks. Vertical distances between the CAJ and selected landmarks were measured for each patient. Measurements were assessed for correlation with age and compared between age groups and sexes.

RESULTS

The mean vertical distance of the following landmarks above the CAJ was found: the carina (46.2 mm), the intersection of the bronchus intermedius and the right heart border (7.6 mm) and the superior inflection of the right heart border (Sup-RHB) (13.0 mm). The maximum lateral bulge of the right heart border (Lat-RHB) was 18.4 mm below the CAJ. A new landmark: the mid-superior right heart border, defined as the mid-point between the Sup-RHB and Lat-RHB, was the closest to the CAJ, lying 2.6 mm below the CAJ.

CONCLUSION

We propose that the CVC tip can be placed at the mid-superior right heart border landmark.

The value of transthoracic echocardiography and chest X-ray in locating the tip of central venous catheter in dialysis patients: a comparative study with computed tomography imaging

To determine the tip position of the central venous catheter (CVC) in patients with dialysis, the guidelines recommend that it be determined using chest radiography (CXR) after catheterization, without fluoroscopy. However, some researchers have proposed that transthoracic echocardiography (TTE) can replace CXR, but this has not been widely adopted. This study aimed to determine which of the two aforementioned methods is more suitable for locating the tip position of the CVC. This prospective study included 160 patients who underwent hemodialysis at our hospital from March 2021 to December 2022. After inserting the CVC through the internal jugular vein, we used transthoracic echocardiography and CXR to determine the tip of the CVC and compared the results with those of computed tomography (CT). In the comparison between TTE and CXR for locating the CVC tip, we obtained three main findings. (1) TTE was associated with fewer misdiagnosed cases than CXR. (2) TTE provided higher sensitivity (similar sensitivity in position 2), specificity, positive/negative predictive values, and accuracy than CXR. (3) When comparing the receiver operating characteristic curves of TTE and CXR, the area under the curve (95% confidence interval) for the former was larger. Additionally, we made anatomical discoveries: the "hyperechoic triangle" recognized by TTE was equivalent to the entrance of the superior vena cava into the right atrium shown by transesophageal transthoracic echocardiography. TTE is more suitable than CXR as the first examination for CVC tip localization, as it improves diagnostic accuracy and reduces X-ray radiation damage.

Determination of the optimal length of insertion for central venous catheterization via axillary vein cannulation using preoperative chest X-ray- A prospective feasibility study

Background and Aims

Ensuring safe central venous catheter tip placement is important. Multiple techniques are available to estimate the length of catheter insertion for subclavian and internal jugular approaches. However, the methods to determine the length of insertion for the axillary route have not been validated. The purpose of this feasibility study was to evaluate a simple method for the calculation of catheter length to be inserted and assess whether it accurately predicts the correct tip placement.

Material and Methods

A total of 102 patients requiring preoperative central venous cannulation were evaluated, out of which 60 had successful axillary vein (AxV) cannulation. The length of insertion was calculated using the formula: (2/3* A + B) +Y (A: Clavicular length on chest radiograph [CXR], B: Vertical distance between the sternal head and carina on CXR, Y: Perpendicular distance from the skin to the AxV on ultrasound). A postoperative CXR was used to assess the accurate tip placement (2 cm above the carina to 0.5 cm below it). The primary outcome of the study was the rate of successful placement of the central venous catheter (CVC) in terms of the correct position of the tip of the catheter when the length of the catheter inserted was predicted by the formula described previously.

Results

Optimal placement was observed in 83.33% of the cases. A higher rate of accuracy was seen in the females (P value = 0.03) and shorter patients (P value = 0.01). A Bland-Altman plot depicted a high degree of agreement.

Conclusion

Use of the formula using a CXR and ultrasound allowed P successful placement of the CVC tip at the desired location in 83.33% of the cases.

Non-tunneled catheter tip depth position in urgent hemodialysis: a randomized controlled trial

BACKGROUND

The average accepted depth for non-tunneled catheters (NTC) insertion does not guarantee its correct position, so controversy exists. The aim of this study was to assess the effect of two NTC placement depths on the number of NTC complication episodes.

METHODS

We designed a triple blind, parallel group, randomized controlled trial in a single Hemodialysis Center in Mexico (Registry: ACTRN12619000774123). We included patients in urgent need of hemodialysis via internal right jugular vein NTC. The length of the NTC tip placement depth was randomized to second intercostal space (2ICS) or fourth intercostal space (4ICS), using physical landmarks. The primary outcome was to compare the composite number of NTC dysfunction, repositioning, and relocation episodes for 48 hours post-procedure.

RESULTS

One hundred and sixty-five patients were included, 86 and 79 patients to NTC placement in the 2ICS and 4ICS, respectively. All patients underwent intention-to-treat analysis. The incidence of the composite outcome was lower in the 2ICS group compared to the 4ICS group, 4 (4.6%) and 50 (63%) combined episodes, respectively (P<0.001). Compared to the 4ICS group, the 2ICS group presented a relative risk of 0.06 (CI: 0.02-0.21, P<0.001) and number needed to treat (NNT) of 2.1. No adverse events occurred, derived from the NTC placement.

CONCLUSIONS

NTC tip placement in the 2ICS compared to 4ICS decreases the incidence of the combined number of dysfunctions, repositioning and relocation episodes, with a NNT of 2 for its prevention.

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%).

Tunneled hemodialysis catheter insertion: Above, within, or below the right atrium-Where is the tip?

Background

One major challenge when inserting a tunneled, cuffed central venous catheter (CVC) for hemodialysis under fluoroscopy is to accurately place the catheter tip by assessing its position in relation to the cardiac silhouette to approximate the right atrium (RA).

Purpose

To investigate whether a weighted mean calculated from published results for two two-dimensional landmark reference distances may be useful in assessing CVC tip positions in relation to the RA.

Material and Methods

Central venous catheter tip positions attained under fluoroscopic imaging during insertion using the cardiac silhouette as approximation were retrospectively related to two reference distances (carina to cranial RA border and craniocaudal RA extent), which were used to group catheter tip locations above (1), within (2), or below (3) the RA (henceforth referred to as landmark technique approximation, LTA). The LTA-derived catheter tip locations were validated by correlation with postinterventional computed tomography (CT) datasets acquired shortly after implantation (if available).

Results

Based on LTA, 45 catheter tips (10.6%) were above, 179 (42.2%) within, and 200 (47.2%) below the RA. Postinterventional CT (n = 57; 13.4%) visualized 26.3% above, 66.7% within, and 7.0% below the RA.

Conclusion

The LTA reference distances appear to lead to a rather low categorization of the CVC tips, or the tips have been placed rather low in the study population. Validation using postinterventional CT indicated an underestimation of the RA in the LTA. Patient characteristics with a higher risk of false estimation through LTA have been defined.

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.

[Imaging in intensive care units]

Imaging is essential in the diagnosis and treatment of critically ill patients. Although bedside ultrasound and chest x‑rays are the major tools in the initial assessment, there are a variety of imaging options available to physicians in the intensive care unit such as computed tomography, magnetic resonance imaging, or nuclear medicine. Bedside diagnostic tools or radiology intervention procedures also play an important role in the management of critically ill patients. The choice of imaging modality is sometimes difficult and should be based on current recommendations or guidelines, available equipment, and the experience of the examiner. With the increasing importance of costs, the diagnostic and therapeutic benefits of the imaging process must be maximized in line with minimizing costs. The various indications, strengths, and weaknesses of the imaging modalities are summarized and the diagnostic findings using clinical examples are discussed. The focus of this article is on imaging of the thorax and the diagnostic imaging methods used in the intensive care unit.

A Comparison of the external anatomical landmark and the radiological landmark for obtaining the optimal depth of a right internal jugular venous catheter in pediatric cardiac patients

BACKGROUND

The external anatomical landmark and the radiological landmark have been introduced to provide estimation of the depth of right internal jugular venous catheter during insertion.

AIMS

This study aimed to compare the accuracy, agreement, and reliability of the external anatomical landmark and the radiological landmark, confirmation being by transesophageal echocardiography.

METHODS

This prospective observational study was conducted in children ages 1-15 years. The catheter was placed at the superior vena cava and the right atrium junction guided by transesophageal echocardiography. The catheter depth derived from the transesophageal echocardiography, the external anatomical landmark, and the radiological landmark was recorded. The optimal zone of the catheter tip was 5 mm below and 10 mm above the superior vena cava and the right atrium junction. Accuracy was assessed by the difference between the transesophageal echocardiography and the external anatomical landmark or the radiological landmark. Agreement with Bland-Altman plots and correlation were tested.

RESULTS

Eighty participants, median age of 3 years, were enrolled. The median (IQR) differences between the depth of the transesophageal echocardiography and the external anatomical landmark or the radiological landmark were 0.30 (0, 0.70) and 0.10 (-0.20, 0.90) cm, respectively. Bland-Altman plots demonstrated good agreement between the depths. The catheter tips were located in the optimal zone more frequently with the external anatomical landmark than the radiological landmark (94.7% vs 64.5%). The external anatomical landmark showed a stronger correlation to transesophageal echocardiography than the radiological landmark (r = .95 vs .83).

CONCLUSION

Both the external anatomical landmark and the radiological landmark enabled accurate estimation of the central venous catheter depth close to the superior vena cava and the right atrium junction. The external anatomical landmark is of more potential use than the radiological landmark in clinical practice.

Clinical Survey of Decreased Blood Flow Rate in Continuous Renal Replacement Therapy: A Retrospective Observational Study

Background

Continuous renal replacement therapy (CRRT) is an essential procedure for patients with acute kidney injury in intensive care. It is important to maintain an adequate blood flow rate during CRRT. Several previous studies have reported the relationships between blood flow rate and filter lifespan, or circuit life, in CRRT. Here, we aim at elucidating the incidence and factors associated with a decreased blood flow rate in CRRT.

Methods

This is a retrospective observational study. From January 2014 to June 2017, 119 patients who underwent CRRT in the intensive care unit were enrolled. The definition of a decreased blood flow rate included situations in which the medical staff needed to decrease the blood flow volume. We statistically analyzed the association of the decreased blood flow rate with patients' clinical characteristics.

Results

Of 119 patients, 52 required a decreased blood flow rate during CRRT. Almost half of the cases occurred within one day of starting CRRT. None of the clinical factors (age, sex, height, sequential organ failure assessment (SOFA) score, catheter position, systemic infection, albumin, hemoglobin, and activating coagulation time) were significantly associated with decreased blood flow rate.

Conclusions

A decreased blood flow rate often occurs during CRRT. Clinical factors significantly associated with the occurrence of the decreased blood flow rate were not detected in the current study. Further investigation regarding the occurrence of a decreased blood flow is warranted.

Pediatric central venous catheterization: The Role of the Aortic Valve in Defining the Superior Vena Cava-Right Atrium Junction

The aortic valve (AV) has been used as a surrogate marker for the superior vena cava-right atrium (SVC-RA) junction during the placement of central venous catheters. There is a paucity of evidence to determine whether this is a consistent finding in children. Eighty-seven computed tomography scans of the thorax acquired at local children's hospitals from April 2010 to September 2011 were retrospectively collected. The distance between the SVC-RA junction and the AV was measured by dual consensus. The cranio-caudal level of the junction and the AV were referenced to the costal cartilages (CCs) and anterior intercostal spaces (ICSs). The results confirmed that the SVC-RA junction has a variable relationship to the AV. The junction was on average 3.1 mm superior to the AV. This distance increased with age. In the <1-year-old age group, the junction was on average 1.3 mm superior to the AV (range: -6 to 11 mm). In the 1-2 years old age group: 3.5 mm (range: -8 to 15 mm). In the 3-6 years old: 3.8 mm (range: -9 to 13 mm). In the >7 years old age group: 4 mm (range: -11 to 16 mm). The surface anatomy of the SVC-RA junction was variable, ranging from the second ICS to sixth CC. The SVC-RA junction has a predictable relationship to the AV, and this can be used as an adjunct marker for accurate placement of central venous catheters except in the smallest neonates. Clin. Anat. 32:778-782, 2019. © 2019 Wiley Periodicals, Inc.

Comparing the conventional 15 cm and the C-length approaches for central venous catheter placement

Introduction: The present guidelines recommend placing the catheter tip in the superior vena cava (SVC) above the pericardial cephalic reflection. The aim of this study was to compare the accuracy of two different approaches in locating the tip of the Central venous catheter (CVC) at the suggested vascular zone. Methods: This was an interventional study on two hundred patients undergoing Coronary artery bypass surgery (CABG) operation who required a central venous cannulation. They were randomly assigned into two groups. In the first group catheter placement was applied through using the conventional 15 cm method. In the second group a C-length method was applied for measuring the depth of catheter tip placement from the preoperative chest radiographs. For statistical analysis Chi-square test and T-test were used. Results: In the first group (15 cm) 100% of the patients had their catheters placed below the C-line (Carina line) and the average distance between the catheter tip and the C-line was +4.22±2.10 cm. In the second (C-Length) group 52% of the catheters were below C-line with an average distance of +0.77±0.5 cm. There was a meaningful difference between the two groups in respect to the catheter location depth and zone of placement (P<0.001). Conclusion: The C-Length approach in comparison to the conventional 15 cm approach resulted in a considerable higher number of catheters above the recommended C-line, thus it can provide a more reliable and safe mode for CVC placement in the SVC.

Peripherally inserted central catheter with intracavitary electrocardiogram guidance: Malposition risk factors and indications for post-procedural control

Objectives:

To confirm the feasibility of intracavitary electrocardiogram guidance to verify tip’s position during insertion of peripherally inserted central catheter and to identify clinical factors or intracavitary electrocardiogram patterns associated with aberrant tip’s position.

Methods:

A prospective study was conducted in our university hospital after authorization of the ethics committee. All patients addressed for peripherally inserted central catheter insertion were included and received the insertion using intracavitary electrocardiogram and electromagnetic guidance. Side of insertion and three electrocardiogram factors were collected: visualization of P-wave at baseline (sinusal rhythm), acquisition of the maximal P-wave and the negative deflection. All patients had a systematic post-procedural chest X-ray. One of the investigators assessed all chest X-ray, blinded to the results of intracavitary electrocardiogram, and confirmed whether the tip’s position on chest X-ray matched with the intracavitary electrocardiogram information or if the tip was malpositioned on chest X-ray (mismatch with intracavitary electrocardiogram or aberrant position). Factors associated with malposition were described.

Results:

From January 2015 to April 2015, 330 patients were eligible, 5 had an uninterpretable chest X-ray, and 14 were non-sinusal at baseline. Our main analysis population included 311 patients. We observed a mismatch between intracavitary electrocardiogram and chest X-ray estimate of the tip’s position in 3 cases (1%) and an aberrant tip’s position occurred in 3 cases (1%). Incidence of malposition was higher in the group of patients with non-sinusal rhythm (14%) and when the catheter was inserted on the left side (7%).

Conclusion:

This study confirmed the feasibility of intracavitary electrocardiogram for peripherally inserted central catheter positioning and the limits of chest X-ray. Insertion on left side may represent risk factor for aberrant position but our study lacked power to establish a statistical link.

Ultrasound-guided central venous tip confirmation via right external jugular vein using a right supraclavicular fossa view

Introduction:

Ultrasound-guided central venous catheter tip confirmation has a potential to precisely locate the central venous catheter, preventing its misplacement, using real-time guidance. This observational study sought to determine the accuracy of central venous catheter tip positioning via the external jugular vein via a supraclavicular fossa view under ultrasound guidance.

Methods:

In total, 77 patients scheduled for central venous catheter insertion via the right external jugular vein were enrolled. The depth of central venous catheter insertion was determined by advancing the tip of the guidewire to the junction of the superior vena cava and right pulmonary artery, using a right supraclavicular fossa view ultrasound method. We determined the reference insertion depth to the carina using a postoperative chest x-ray photograph method. We then compared insertion depths obtained by the ultrasound and x-ray photograph methods and body-height formula.

Results:

In total, 62 patients were able to advance the guidewire and underwent ultrasound-guided central venous catheter insertion. In four patients, we corrected for misplaced guidewires. According to Bland–Altman plots, the insertion depth was 0.88 cm shorter for the ultrasound method (95% limits of agreement, −1.66 to 3.41 cm) and 0.90 cm shorter for the formulaic method (95% limits of agreement, −2.77 to 4.56 cm), compared with the x-ray photograph method. The x-ray photograph method had significantly positive correlations with the ultrasound (r = 0.73) and formulaic methods (r = 0.27).

Conclusion:

A right supraclavicular fossa view improves the accuracy of central venous catheter tip positioning and prevents central venous catheter misplacement via the right external jugular vein.

Is Routine Chest X-Ray After Ultrasound-Guided Central Venous Catheter Insertion Choosing Wisely?: A Population-Based Retrospective Study of 6,875 Patients

BACKGROUND

A routine chest radiograph (CXR) is recommended as a screening test after central venous catheter (CVC) insertion. The goal of this study was to assess the value of a routine postprocedural CXR in the era of ultrasound-guided CVC insertion.

METHODS

This population-based retrospective cohort study was performed to review the records of all adult patients who had a CVC inserted in the operating room in a tertiary institution between July 1, 2008, and December 31, 2015. We determined the incidence of pneumothorax and catheter misplacement after ultrasound-guided CVC insertion. A logistic regression analysis was performed to examine the potential risk factors associated with these complications, and a cost analysis was conducted to evaluate the economic impact.

RESULTS

Of 18,274 patients who had a CVC inserted, 6,875 patients were included. The overall incidence of pneumothorax and catheter misplacement was 0.33% (95% CI, 0.22-0.5) (23 patients) and 1.91% (95% CI, 1.61-2.26) (131 patients), respectively. The site of catheterization was the major determinant of pneumothorax and catheter misplacement; left subclavian vein catheterization was the site at a higher risk for pneumothorax (OR, 6.69 [95% CI, 2.45-18.28]; P < .001), and catheterization sites other than the right internal jugular vein were at a higher risk for catheter misplacement. Expenditures on routine postprocedural CXR were US $105,000 to $183,000 per year at our institution.

CONCLUSIONS

This study found that pneumothorax and catheter misplacement after ultrasound-guided CVC insertion were rare, and the costs of a postprocedural CXR were exceedingly high. We concluded that a routine postprocedural CXR is unnecessary and not a wise choice in our setting.

The Ultrasound-Only Central Venous Catheter Placement and Confirmation Procedure

The placement of a central venous catheter remains an important intervention in the care of critically ill patients in the emergency department. We propose an ultrasound-first protocol for 3 aspects of central venous catheter placement above the diaphragm: dynamic procedural guidance, evaluation for pneumothorax, and confirmation of the catheter tip location.

The carina is approximately 1-2 cm above the pericardial reflection among Chinese patients

BACKGROUND

Central venous catheters (CVCs) and central venous pressure (CVP) monitor is essential in fluid resuscitation and management for critically ill patients. Accuracy of the CVP is mainly dependent on the proper position of the catheter tip. Although the X-ray visible carina was generally recommended as the alternative of pericardial reflection (PR) to guide the placement of CVCs, few data was available with respect to the distance between the carina and PR among Chinese patients. The purpose of this study was to explore the topographic relationship between the trachea carina and PR among Chinese patients by using computed tomography (CT) images.

METHODS

CT images of 172 patients who underwent CT pulmonary angiogram or CT angiogram for aorta from January 1, 2013 to November 30, 2013 were retrospectively reviewed. Distances between upper margin of the right clavicular notch, trachea carina, PR and atriocaval junction (ACJ) were calculated using the table positions on axial images.

RESULTS

The mean length of extrapericardial superior vena cava (SVC) was 2.5 cm. For all patients, the PR was lower than the carina by average 1.6 cm.

CONCLUSIONS

Given the PR was average 1.6 cm lower than the carina among Chinese patients, placing the CVCs tip approximate 1.6 cm lower the carina among Chinese patients would be more likely to result in a satisfactory placement.