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Pelagatti F, Pinelli F. Time to abandon chest X-rays in favor of intracavitary ECG or echocardiography for central venous access tip location: A case of a malpositioned CICC into the internal mammary vein. J Vasc Access 2023; 24:1513-1515. [PMID: 35229679 DOI: 10.1177/11297298221074751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023] Open
Abstract
Central vascular access devices (CVADs) correct tip location is of paramount importance to avoid malposition related complications. Despite recent guidelines recommend avoiding postprocedure radiograph in favor of alternative tip location technology, chest X-rays are still widely used in clinical practice as a CVADs tip location method. We present a clinical case of a central inserted central catheter (CICC) malposition in the right internal mammary vein, erroneously interpreted by chest X-rays as correctly placed, in a critically ill patient.
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Affiliation(s)
- Filippo Pelagatti
- School of Human Health Science, University of Florence, Florence, Tuscany, Italy
| | - Fulvio Pinelli
- Anesthesia and Intensive Care, University Hospital Careggi, Florence, Tuscany, Italy
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2
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Kamel T, Sauvage B, Lakhal K, Ottavy G, Janssen-Langenstein R, Jacquier M, Larrat C, Jacq G, Dauvergne JE, Maugars D, Labruyere M, Simeon V, Cugnart C, Girault C, Boulain T. The accuracy of intensive care nurses' interpretation of chest radiographs to recognise misplacement of endotracheal and nasogastric tubes after a single training session and comparison with residents' interpretation. Aust Crit Care 2023; 36:948-954. [PMID: 36872100 DOI: 10.1016/j.aucc.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 09/23/2022] [Accepted: 01/10/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Misplacements of endotracheal and nasogastric tubes are frequent encounters in critically ill patients. OBJECTIVES The purpose of this study was to assess the effectiveness of a single standardised training session on the ability of intensive care registered nurses (RNs) to recognise the misplacement of endotracheal and nasogastric tubes on bedside chest radiographs of patients in intensive care units (ICUs). METHODS In eight French ICUs, RNs received a 110-min standardised teaching on the position of endotracheal and nasogastric tubes on chest radiographs. Their knowledge was evaluated within the subsequent weeks. For 20 chest radiographs, each with an endotracheal and nasogastric tube, RNs had to indicate whether each tube was in the proper or incorrect position. Training success was defined as >90% for the lower bound of the 95% confidence interval (95% CI) of the mean correct response rate (CRR). Residents of the participating ICUs underwent the same evaluation (without prior specific training). RESULTS In total, 181 RNs were trained and evaluated and 110 residents were evaluated. The global mean CRR for RNs was 84.6% (95% CI: 83.3-85.9), significantly higher than for residents (81.4% [95% CI: 79.7-83.2]) (P < 0.0001). The mean CRR for RNs and residents was 95.9% (93.9-98.0) and 97.0% (94.7-99.3) for misplaced nasogastric tubes (P = 0.54), 86.8% (85.2-88.5) and 82.6% (79.4-85.7) (P = 0.07) for nasogastric tubes in the correct position, 86.6% (83.8-89.3) and 62.7% (57.9-67.5) for misplaced endotracheal tubes (P < 0.0001), and 79.1% (76.6-81.6) and 84.7% (82.1-87.2) for endotracheal tubes in the correct position (P = 0.01), respectively. CONCLUSIONS The ability of trained RNs to detect tube misplacement did not reach the predetermined arbitrary level, indicating training success. Their mean CRR was higher than that for residents and was considered satisfactory for detecting misplaced nasogastric tubes. This finding is encouraging but insufficient to ensure patient safety. Transferring responsibility for reading radiographs to detect the misplacement of endotracheal tubes to intensive care RNs will need a more advanced or more in-depth teaching method.
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Affiliation(s)
- Toufik Kamel
- Service de Médicine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, 14 Avenue de l'hôpital, 45100 Orléans, France; ED 393, Université de Paris, France.
| | - Brice Sauvage
- Service de Médicine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, 14 Avenue de l'hôpital, 45100 Orléans, France.
| | - Karim Lakhal
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, Nantes F-44093, France.
| | - Grégoire Ottavy
- Service de Médicine Intensive-Réanimation, CHU de Nantes, France.
| | | | - Marine Jacquier
- Service de Médecine Intensive et Réanimation CHU de Dijon, France.
| | - Charlotte Larrat
- Service de Médecine Intensive et Réanimation CHRU de Tours, France.
| | - Gwenaëlle Jacq
- Service de Réanimation Médico-chirurgicale, Centre Hospitalier de Versailles, France.
| | - Jérôme E Dauvergne
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, Nantes F-44093, France.
| | - Diane Maugars
- Service de Médicine Intensive-Réanimation, CHU de Nantes, France.
| | - Marie Labruyere
- Service de Médecine Intensive et Réanimation CHU de Dijon, France.
| | - Véronique Simeon
- Service de Médecine Intensive et Réanimation CHRU de Tours, France.
| | - Cécile Cugnart
- Rouen University Hospital, Medical Intensive Care Unit, F-76000 Rouen, France.
| | - Christophe Girault
- Normandie Univ, UNIROUEN, EA 3830, Rouen University Hospital, Medical Intensive Care Unit, F-76000 Rouen, France.
| | - Thierry Boulain
- Service de Médicine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, 14 Avenue de l'hôpital, 45100 Orléans, France.
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3
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Brown MS, Wong KP, Shrestha L, Wahi-Anwar M, Daly M, Foster G, Abtin F, Ruchalski KL, Goldin JG, Enzmann D. Automated Endotracheal Tube Placement Check Using Semantically Embedded Deep Neural Networks. Acad Radiol 2023; 30:412-420. [PMID: 35644754 DOI: 10.1016/j.acra.2022.04.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/07/2022] [Accepted: 04/22/2022] [Indexed: 01/25/2023]
Abstract
RATIONALE AND OBJECTIVES To develop artificial intelligence (AI) system that assists in checking endotracheal tube (ETT) placement on chest X-rays (CXRs) and evaluate whether it can move into clinical validation as a quality improvement tool. MATERIALS AND METHODS A retrospective data set including 2000 de-identified images from intensive care unit patients was split into 1488 for training and 512 for testing. AI was developed to automatically identify the ETT, trachea, and carina using semantically embedded neural networks that combine a declarative knowledge base with deep neural networks. To check the ETT tip placement, a "safe zone" was computed as the region inside the trachea and 3-7 cm above the carina. Two AI outputs were evaluated: (1) ETT overlay, (2) ETT misplacement alert messages. Clinically relevant performance metrics were compared against prespecified thresholds of >85% overlay accuracy and positive predictive value (PPV) > 30% and negative predictive value NPV > 95% for alerts to move into clinical validation. RESULTS An ETT was present in 285 of 512 test cases. The AI detected 95% (271/285) of ETTs, 233 (86%) of these with accurate tip localization. The system (correctly) did not generate an ETT overlay in 221/227 CXRs where the tube was absent for an overall overlay accuracy of 89% (454/512). The alert messages indicating that either the ETT was misplaced or not detected had a PPV of 83% (265/320) and NPV of 98% (188/192). CONCLUSION The chest X-ray AI met prespecified performance thresholds to move into clinical validation.
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Affiliation(s)
- Matthew S Brown
- Department of Radiological Sciences, Center for Computer Vision and Imaging Biomarkers, David Geffen School of Medicine at UCLA, 924 Westwood Blvd., Suite 615, Los Angeles, CA 90024.
| | - Koon-Pong Wong
- Department of Radiological Sciences, Center for Computer Vision and Imaging Biomarkers, David Geffen School of Medicine at UCLA, 924 Westwood Blvd., Suite 615, Los Angeles, CA 90024
| | - Liza Shrestha
- Department of Radiological Sciences, Center for Computer Vision and Imaging Biomarkers, David Geffen School of Medicine at UCLA, 924 Westwood Blvd., Suite 615, Los Angeles, CA 90024
| | - Muhammad Wahi-Anwar
- Department of Radiological Sciences, Center for Computer Vision and Imaging Biomarkers, David Geffen School of Medicine at UCLA, 924 Westwood Blvd., Suite 615, Los Angeles, CA 90024
| | - Morgan Daly
- Department of Radiological Sciences, Center for Computer Vision and Imaging Biomarkers, David Geffen School of Medicine at UCLA, 924 Westwood Blvd., Suite 615, Los Angeles, CA 90024
| | - George Foster
- Department of Radiological Sciences, Center for Computer Vision and Imaging Biomarkers, David Geffen School of Medicine at UCLA, 924 Westwood Blvd., Suite 615, Los Angeles, CA 90024
| | - Fereidoun Abtin
- Department of Radiological Sciences, Center for Computer Vision and Imaging Biomarkers, David Geffen School of Medicine at UCLA, 924 Westwood Blvd., Suite 615, Los Angeles, CA 90024
| | - Kathleen L Ruchalski
- Department of Radiological Sciences, Center for Computer Vision and Imaging Biomarkers, David Geffen School of Medicine at UCLA, 924 Westwood Blvd., Suite 615, Los Angeles, CA 90024
| | - Jonathan G Goldin
- Department of Radiological Sciences, Center for Computer Vision and Imaging Biomarkers, David Geffen School of Medicine at UCLA, 924 Westwood Blvd., Suite 615, Los Angeles, CA 90024
| | - Dieter Enzmann
- Department of Radiological Sciences, Center for Computer Vision and Imaging Biomarkers, David Geffen School of Medicine at UCLA, 924 Westwood Blvd., Suite 615, Los Angeles, CA 90024
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Ablordeppey EA, Powell B, McKay V, Keating S, James A, Carpenter C, Kollef M, Griffey R. Protocol for DRAUP: a deimplementation programme to decrease routine chest radiographs after central venous catheter insertion. BMJ Open Qual 2021; 10:bmjoq-2020-001222. [PMID: 34663588 PMCID: PMC8524291 DOI: 10.1136/bmjoq-2020-001222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 10/02/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction Avoiding low value medical practices is an important focus in current healthcare utilisation. Despite advantages of point-of-care ultrasound (POCUS) over chest X-ray including improved workflow and timeliness of results, POCUS-guided central venous catheter (CVC) position confirmation has slow rate of adoption. This demonstrates a gap that is ripe for the development of an intervention. Methods The intervention is a deimplementation programme called DRAUP (deimplementation of routine chest radiographs after adoption of ultrasound-guided insertion and confirmation of central venous catheter protocol) that will be created to address one unnecessary imaging modality in the acute care environment. We propose a three-phase approach to changing low-value practices. In phase 1, we will be guided by the Consolidated Framework for Implementation Research framework to explore barriers and facilitators of POCUS for CVC confirmation in a single centre, large tertiary, academic hospital via focus groups. The qualitative methods will inform the development and adaptation of strategies that address identified determinants of change. In phase 2, the multifaceted strategies will be conceptualised using Morgan’s framework for understanding and reducing medical overuse. In phase 3, we will locally implement these strategies and assess them using Proctor’s outcomes (adoption, deadoption, fidelity and penetration) in an observational study to demonstrate proof of concept, gaining valuable insights on the programme. Secondary outcomes will include POCUS-guided CVC confirmation efficacy measured by time and effectiveness measured by sensitivity and specificity of POCUS confirmation after CVC insertion. With limited data available to inform interventions that use concurrent implementation and deimplementation strategies to substitute chest X-ray for POCUS using the DRAUP programme, we propose that this primary implementation and secondary effectiveness pilot study will provide novel data that will expand the knowledge of implementation approaches to replacing low value or unnecessary care in acute care environments. Ethics and dissemination Approval of the study by the Human Research Protection Office has been obtained. This work will be disseminated by publication of peer-reviewed manuscripts, presentation in abstract form at scientific meetings and data sharing with other investigators through academically established means. Trial registration number ClinicalTrials.gov Identifier, NCT04324762, registered on 27 March 2020.
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Affiliation(s)
- Enyo A Ablordeppey
- Department of Anesthesiology and Emergency Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Byron Powell
- Brown School at Washington University in St Louis, St Louis, Missouri, USA
| | - Virginia McKay
- Brown School at Washington University in St Louis, St Louis, Missouri, USA
| | - Shannon Keating
- Department of Anesthesiology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Aimee James
- Department of Surgery, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Christopher Carpenter
- Department of Emergency Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Marin Kollef
- Department of Internal Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Richard Griffey
- Department of Emergency Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
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5
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Baratella E, Marrocchio C, Bozzato AM, Roman-Pognuz E, Cova MA. Chest X-ray in intensive care unit patients: what there is to know about thoracic devices. DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY (ANKARA, TURKEY) 2021; 27:633-638. [PMID: 34559048 DOI: 10.5152/dir.2021.20497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Critically ill patients admitted to the intensive care unit require continuous monitoring of vital functions as well as mechanical and pharmacological support, provided through different devices. Chest radiographs play a fundamental role in monitoring the conditions of these patients and assessing the intensive-care devices after their insertion; therefore, the radiologist needs to know their normal appearance and their correct position and should be aware of the possible complications that may occur after their placement. This pictorial review illustrates the radiographic appearance of non-cardiological devices commonly used in clinical practice (central venous catheters, tunneled catheters, Swan-Ganz catheters, chest tubes, endotracheal tubes, and nasogastric tubes), their correct position and the most common complications that may occur after their placement.
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Affiliation(s)
- Elisa Baratella
- Department of Radiology, University of Trieste, Trieste, Italy
| | - Cristina Marrocchio
- Department of Medicine, Surgery and Health Science, University of Trieste, Trieste, Italy
| | | | - Erik Roman-Pognuz
- Department of Anesthesia and Intensive Care, Azienda Sanitaria Universitaria integrata di Trieste ASUGI, Trieste, Italy
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Laroia AT, Donnelly EF, Henry TS, Berry MF, Boiselle PM, Colletti PM, Kuzniewski CT, Maldonado F, Olsen KM, Raptis CA, Shim K, Wu CC, Kanne JP. ACR Appropriateness Criteria® Intensive Care Unit Patients. J Am Coll Radiol 2021; 18:S62-S72. [PMID: 33958119 DOI: 10.1016/j.jacr.2021.01.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/18/2021] [Indexed: 02/07/2023]
Abstract
Chest radiography is the most frequent and primary imaging modality in the intensive care unit (ICU), given its portability, rapid image acquisition, and availability of immediate information on the bedside preview. Due to the severity of underlying disease and frequent need of placement of monitoring devices, ICU patients are very likely to develop complications related to underlying disease process and interventions. Portable chest radiography in the ICU is an essential tool to monitor the disease process and the complications from interventions; however, it is subject to overuse especially in stable patients. Restricting the use of chest radiographs in the ICU to only when indicated has not been shown to cause harm. The emerging role of bedside point-of-care lung ultrasound performed by the clinicians is noted in the recent literature. The bedside lung ultrasound appears promising but needs cautious evaluation in the future to determine its role in ICU patients. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Edwin F Donnelly
- Panel Chair, Vanderbilt University Medical Center, Nashville, Tennessee. Chief, Division of Thoracic Radiology, Department of Radiology, Ohio State University Wexner Medical Center
| | - Travis S Henry
- Panel Vice-Chair, University of California San Francisco, San Francisco, California
| | - Mark F Berry
- Stanford University Medical Center, Stanford, California, The Society of Thoracic Surgeons
| | - Phillip M Boiselle
- Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida
| | | | | | - Fabien Maldonado
- Vanderbilt University Medical Center, Nashville, Tennessee, American College of Chest Physicians
| | | | | | - Kyungran Shim
- John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois, American College of Physicians
| | - Carol C Wu
- University of Texas MD Anderson Cancer Center, Houston, Texas, Chair of Thoracic Use Case Panel of ACR DSI, Deputy Chair ad interim, Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center
| | - Jeffrey P Kanne
- Specialty Chair, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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7
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Current Practices in Central Venous Catheter Position Confirmation by Point of Care Ultrasound: A Survey of Early Adopters. Shock 2020; 51:613-618. [PMID: 30052580 DOI: 10.1097/shk.0000000000001218] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE Although routine chest radiographs (CXR) to verify correct central venous catheter (CVC) position and exclude pneumothorax are commonly performed, emerging evidence suggests that this practice can be replaced by point of care ultrasound (POCUS). POCUS is advantageous over CXR because it avoids radiation while verifying correct placement and lack of pneumothorax without delay. We hypothesize that a knowledge translation gap exists in this area. We aim to describe the current clinical practice regarding POCUS alone for CVC position confirmation and pneumothorax exclusion as compared with chest radiography. METHODS We used a modified Dillman technique to conduct a brief web-based survey to Critical Care Medicine and Emergency Medicine physicians (targeted group of early adopters) evaluating the current practice related to CVC position confirmation and PTX exclusion via CXR or POCUS. RESULTS Of 200 post-training clinicians contacted, 136 (68%) responded to the survey. For routine CVC confirmation and PTX evaluation, 50.7% of Critical Care Medicine physicians and 65.4% of Emergency Medicine physicians reported using CXR alone while 49.3% and 33.1% respectively reported using CXR and ultrasound together. Though 84.6% of clinicians use ultrasound for CVC insertion "most of the time" or "always," none use ultrasound alone for CVC position confirmation, and only 1% has used ultrasound alone for PTX exclusion. CONCLUSIONS Though data support its utility and advantages for POCUS as a sole modality for CVC position confirmation and PTX evaluation, POCUS is rarely used for this indication. We identified several perceived barriers toward widespread utilization suggesting areas for dissemination and implementation strategy development that will benefit patient care practices.
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8
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Misplacement of Tracheostomy Tube in the Right Main Bronchus: a Rare Complication. Case Rep Surg 2020. [DOI: 10.1155/2020/3597901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
A 38-year-old woman known case of metastatic squamous cell carcinoma of the cervical esophagus due to increasing dyspnea and stridor attributed to the pressure effect of the primary mass was scheduled for tracheostomy, which ended up in the right main bronchus. This rare complication occurred using a tracheostomy tube number 7.5 via a vertical tracheotomy over 4th and 5th tracheal rings. The misplacement was confirmed by chest X-ray and fiberoptic bronchoscopy, and the tracheostomy tube was successfully repositioned in a nonoperative approach.
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9
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Raptis DA, Neal K, Bhalla S. Imaging Approach to Misplaced Central Venous Catheters. Radiol Clin North Am 2019; 58:105-117. [PMID: 31731895 DOI: 10.1016/j.rcl.2019.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Central venous catheters (CVCs) are commonly used in patients in a variety of clinical settings, including the intensive care unit, general ward, and outpatient settings. After placement, the radiologist is frequently requested to evaluate the location of CVCs and deem them suitable for use. An understanding of the ideal location of catheter tips as well as the approach to identifying malpositioned catheter tips is essential to prevent improper use, recognize and/or prevent further injury, and direct potential lifesaving care. An approach to CVC placement based on tip location can be helpful in localization and guiding management.
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Affiliation(s)
- Demetrios A Raptis
- Mallinckrodt Institute of Radiology, 216 South Kingshighway Boulevard, St Louis, MO 63110, USA.
| | - Kevin Neal
- Mallinckrodt Institute of Radiology, 216 South Kingshighway Boulevard, St Louis, MO 63110, USA
| | - Sanjeev Bhalla
- Mallinckrodt Institute of Radiology, 216 South Kingshighway Boulevard, St Louis, MO 63110, USA
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10
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Kim HY, Kim EJ, Shin CS, Kim J. Shallow nasal RAE tube depth after head and neck surgery: association with preoperative and intraoperative factors. J Anesth 2019; 33:118-124. [PMID: 30603829 DOI: 10.1007/s00540-018-2595-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 11/30/2018] [Indexed: 11/24/2022]
Abstract
PURPOSE To evaluate risk factors associated with improper postoperative nasal Ring-Adair-Elwyn (RAE) tube depth. METHODS We retrospectively enrolled 133 adult patients who were admitted to the intensive care unit (ICU) with the nasal RAE tube after head and neck surgery. Postoperative chest radiography was performed to confirm nasal RAE tube depth immediately after the patient was admitted to the ICU. Proper tube depth was defined as the tube tip between 2 and 7 cm above the carina. The patients were divided into the proper-depth group (78 patients) and the improper-depth group (55 patients). Patients' characteristics were collected. The risk factors for improper postoperative tube depth were assessed using logistic regression analysis. MAIN RESULTS All patients who showed improper tube depth had a shallow tube depth (the tube tip > 7 cm above the carina). Multivariable analysis revealed that tall stature [odds ratio (OR) 1.16; 95% confidence interval (CI) 1.08-1.25; P < 0.001], prolonged anesthesia duration (OR 1.16; 95% CI 1.02-1.32; P = 0.026), and right-sided surgical field as compared to the left (OR 0.36; 95% CI 0.14-0.93; P = 0.034) or median field (OR 0.25; 95% CI 0.07-0.85; P = 0.027) were risk factors associated with postoperative shallow tube depth. CONCLUSIONS Tall stature, prolonged anesthesia duration, and right-sided surgical field were independent risk factors for postoperative shallow nasal RAE tube depth.
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Affiliation(s)
- Ha Yeon Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - Eung Jin Kim
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Cheung Soo Shin
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Jeongmin Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
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11
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Cohen A, Tan L, Fargo R, Anholm JD, Gasho C, Yaqub K, Chopra S, Hansen J, Huang C, Moretta D, Washburn D, Bryant Nguyen H. A multi-center evaluation of a disposable catheter to aid in correct positioning of the endotracheal tube after intubation in critically ill patients. J Crit Care 2018; 48:222-227. [PMID: 30243202 DOI: 10.1016/j.jcrc.2018.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 09/04/2018] [Accepted: 09/04/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To demonstrate that use of a minimally invasive catheter reduces endotracheal tube (ETT) malposition rate after intubation. MATERIALS AND METHODS This study is a multi-center, prospective observational cohort of intubated patients in the medical intensive care unit. The catheter was inserted into the ETT immediately after intubation. The ETT was adjusted accordingly based on qualitative color markers on the catheter. A confirmatory chest radiograph was obtained to determine the ETT position. Malposition of the ETT was defined by the distal ETT not being within 2-5 cm above the carina. RESULTS Sixty-nine patients were enrolled, age 56.2 ± 19.5 years, body mass index 31.0 ± 13.8 kg/m2. The catheter prompted repositioning of the ETT in 39 (56.5%) patients. Using the catheter, the rate of malposition decreased to 7.2%, with the distal ETT position at 3.7 ± 1.2 cm above the carina. Without the catheter, the ETT malposition rate would have been 39.1%. The time for catheter use and chest radiograph completion at our institutions was 1.7 ± 1.5 and 44.4 ± 36.4 min, respectively. CONCLUSIONS With use of an ETT positioning catheter after intubation, the ETT malposition rate was reduced by 82%. This catheter-based system was safe, and its use may perhaps decrease the need for the post-intubation chest radiograph.
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Affiliation(s)
- Avi Cohen
- Division of Pulmonary, Critical Care, Hyperbaric and Sleep Medicine, Department of Medicine, School of Medicine, Loma Linda University, Loma Linda, CA 92354, USA; Loma Linda University Medical Center, Loma Linda University Health, Loma Linda, CA 92354, USA
| | - Laren Tan
- Division of Pulmonary, Critical Care, Hyperbaric and Sleep Medicine, Department of Medicine, School of Medicine, Loma Linda University, Loma Linda, CA 92354, USA
| | - Ramiz Fargo
- Division of Pulmonary, Critical Care, Hyperbaric and Sleep Medicine, Department of Medicine, School of Medicine, Loma Linda University, Loma Linda, CA 92354, USA; Division of Pulmonary and Critical Care Medicine, Riverside University Healthcare System, Moreno Valley, CA 92555, USA
| | - James D Anholm
- Division of Pulmonary, Critical Care, Hyperbaric and Sleep Medicine, Department of Medicine, School of Medicine, Loma Linda University, Loma Linda, CA 92354, USA; Pulmonary and Critical Care Section, Medical Service, VA Loma Linda Healthcare System, Loma Linda, CA 92357, USA
| | - Chris Gasho
- Division of Pulmonary, Critical Care, Hyperbaric and Sleep Medicine, Department of Medicine, School of Medicine, Loma Linda University, Loma Linda, CA 92354, USA; Loma Linda University Medical Center, Loma Linda University Health, Loma Linda, CA 92354, USA
| | - Kashif Yaqub
- Division of Pulmonary, Critical Care, Hyperbaric and Sleep Medicine, Department of Medicine, School of Medicine, Loma Linda University, Loma Linda, CA 92354, USA; Loma Linda University Medical Center, Loma Linda University Health, Loma Linda, CA 92354, USA
| | - Sahil Chopra
- Division of Pulmonary, Critical Care, Hyperbaric and Sleep Medicine, Department of Medicine, School of Medicine, Loma Linda University, Loma Linda, CA 92354, USA; Loma Linda University Medical Center, Loma Linda University Health, Loma Linda, CA 92354, USA
| | - Jennifer Hansen
- Division of Pulmonary, Critical Care, Hyperbaric and Sleep Medicine, Department of Medicine, School of Medicine, Loma Linda University, Loma Linda, CA 92354, USA; Loma Linda University Medical Center, Loma Linda University Health, Loma Linda, CA 92354, USA
| | - Cynthia Huang
- Division of Pulmonary, Critical Care, Hyperbaric and Sleep Medicine, Department of Medicine, School of Medicine, Loma Linda University, Loma Linda, CA 92354, USA; Loma Linda University Medical Center, Loma Linda University Health, Loma Linda, CA 92354, USA
| | - Dafne Moretta
- Division of Pulmonary, Critical Care, Hyperbaric and Sleep Medicine, Department of Medicine, School of Medicine, Loma Linda University, Loma Linda, CA 92354, USA; Division of Pulmonary and Critical Care Medicine, Riverside University Healthcare System, Moreno Valley, CA 92555, USA
| | - Destry Washburn
- Division of Pulmonary, Critical Care, Hyperbaric and Sleep Medicine, Department of Medicine, School of Medicine, Loma Linda University, Loma Linda, CA 92354, USA; Division of Pulmonary and Critical Care Medicine, Riverside University Healthcare System, Moreno Valley, CA 92555, USA
| | - H Bryant Nguyen
- Division of Pulmonary, Critical Care, Hyperbaric and Sleep Medicine, Department of Medicine, School of Medicine, Loma Linda University, Loma Linda, CA 92354, USA.
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Diagnostic Accuracy of Central Venous Catheter Confirmation by Bedside Ultrasound Versus Chest Radiography in Critically Ill Patients: A Systematic Review and Meta-Analysis. Crit Care Med 2017; 45:715-724. [PMID: 27922877 DOI: 10.1097/ccm.0000000000002188] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE We performed a systematic review and meta-analysis to examine the accuracy of bedside ultrasound for confirmation of central venous catheter position and exclusion of pneumothorax compared with chest radiography. DATA SOURCES PubMed, Embase, Cochrane Central Register of Controlled Trials, reference lists, conference proceedings and ClinicalTrials.gov. STUDY SELECTION Articles and abstracts describing the diagnostic accuracy of bedside ultrasound compared with chest radiography for confirmation of central venous catheters in sufficient detail to reconstruct 2 × 2 contingency tables were reviewed. Primary outcomes included the accuracy of confirming catheter positioning and detecting a pneumothorax. Secondary outcomes included feasibility, interrater reliability, and efficiency to complete bedside ultrasound confirmation of central venous catheter position. DATA EXTRACTION Investigators abstracted study details including research design and sonographic imaging technique to detect catheter malposition and procedure-related pneumothorax. Diagnostic accuracy measures included pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio. DATA SYNTHESIS Fifteen studies with 1,553 central venous catheter placements were identified with a pooled sensitivity and specificity of catheter malposition by ultrasound of 0.82 (0.77-0.86) and 0.98 (0.97-0.99), respectively. The pooled positive and negative likelihood ratios of catheter malposition by ultrasound were 31.12 (14.72-65.78) and 0.25 (0.13-0.47). The sensitivity and specificity of ultrasound for pneumothorax detection was nearly 100% in the participating studies. Bedside ultrasound reduced mean central venous catheter confirmation time by 58.3 minutes. Risk of bias and clinical heterogeneity in the studies were high. CONCLUSIONS Bedside ultrasound is faster than radiography at identifying pneumothorax after central venous catheter insertion. When a central venous catheter malposition exists, bedside ultrasound will identify four out of every five earlier than chest radiography.
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Diagnostic Accuracy of Central Venous Catheter Confirmation by Bedside Ultrasound Versus Chest Radiography in Critically Ill Patients: A Systematic Review and Meta-Analysis. Crit Care Med 2016. [PMID: 27922877 DOI: 10.1097/ccm.0000000000002188.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We performed a systematic review and meta-analysis to examine the accuracy of bedside ultrasound for confirmation of central venous catheter position and exclusion of pneumothorax compared with chest radiography. DATA SOURCES PubMed, Embase, Cochrane Central Register of Controlled Trials, reference lists, conference proceedings and ClinicalTrials.gov. STUDY SELECTION Articles and abstracts describing the diagnostic accuracy of bedside ultrasound compared with chest radiography for confirmation of central venous catheters in sufficient detail to reconstruct 2 × 2 contingency tables were reviewed. Primary outcomes included the accuracy of confirming catheter positioning and detecting a pneumothorax. Secondary outcomes included feasibility, interrater reliability, and efficiency to complete bedside ultrasound confirmation of central venous catheter position. DATA EXTRACTION Investigators abstracted study details including research design and sonographic imaging technique to detect catheter malposition and procedure-related pneumothorax. Diagnostic accuracy measures included pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio. DATA SYNTHESIS Fifteen studies with 1,553 central venous catheter placements were identified with a pooled sensitivity and specificity of catheter malposition by ultrasound of 0.82 (0.77-0.86) and 0.98 (0.97-0.99), respectively. The pooled positive and negative likelihood ratios of catheter malposition by ultrasound were 31.12 (14.72-65.78) and 0.25 (0.13-0.47). The sensitivity and specificity of ultrasound for pneumothorax detection was nearly 100% in the participating studies. Bedside ultrasound reduced mean central venous catheter confirmation time by 58.3 minutes. Risk of bias and clinical heterogeneity in the studies were high. CONCLUSIONS Bedside ultrasound is faster than radiography at identifying pneumothorax after central venous catheter insertion. When a central venous catheter malposition exists, bedside ultrasound will identify four out of every five earlier than chest radiography.
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Madan R, Peavy LD, Crudup B, Hunsaker A. Reporting of Malposition of Lines and Tubes on Portable Radiographs Using Alert Notification of Critical Results. Curr Probl Diagn Radiol 2016; 46:181-185. [PMID: 27842903 DOI: 10.1067/j.cpradiol.2016.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 09/18/2016] [Accepted: 09/19/2016] [Indexed: 11/22/2022]
Abstract
Line malposition may result in significant iatrogenic complications. Awareness of the most common types of line malposition and the frequency of significant line-related complications is an important reminder to the radiologist to look carefully at all lines, especially the devices that are most commonly subject to malposition. Alert Notification of Critical Results (ANCR) are computer-generated pages or e-mails created by the radiologist to inform referring clinicians of significant radiologic findings. The alert is logged on the computer and all data are saved for future review. The primary purpose of the ANCR is to ensure that radiologists and clinicians have an effective and well-documented method of communication regarding significant imaging findings. A secondary purpose of ANCR data is the ability to review clinical practice. We have used the ANCR data to identify the frequency and types of line malpositions in the intensive care unit.
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Affiliation(s)
- Rachna Madan
- Division of Thoracic Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - LaTia D Peavy
- Masters Student, Department of Biological Sciences, Mississippi College, Clinton, MS
| | - Breland Crudup
- Student, Division of Natural Science, Tougaloo College, Tougaloo, MS
| | - Andetta Hunsaker
- Division of Thoracic Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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15
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Abstract
Portable chest radiography is a fundamental and frequently utilized examination in the critically ill patient population. The chest radiograph often represents a timely investigation of new or rapidly evolving clinical findings and an evaluation of proper positioning of support tubes and catheters. Thoughtful consideration of the use of this simple yet valuable resource is crucial as medical cost containment becomes even more mandatory. This review addresses the role of chest radiography in the intensive care unit on the basis of the existing literature and as formed by a consensus of an expert panel on thoracic imaging through the American College of Radiology. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Forouzannia SK, Sarvi A, Sarebanhassanabadi M, Nafisi-Moghadam R. Elimination of routine chest radiographs following off-pump coronary artery bypass surgery: A randomized controlled trial study. Adv Biomed Res 2015; 4:236. [PMID: 26682202 PMCID: PMC4673704 DOI: 10.4103/2277-9175.167966] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 09/09/2014] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Post cardiac surgery routine chest radiographs (CXRs), ordered without any clinical and laboratory indications, is a standard obligatory practice in many cardiothoracic centers. Routine CXRs incur cost, manpower, and radiation. The objective of this study is to assess early outcome in off-pump coronary artery bypass (OPCAB) patients with postoperative routine versus clinically indicated CXR protocols. MATERIALS AND METHODS This study is a randomized clinical trial conducted on 231 OPCAB candidates in Afshar Cardiac Center, Yazd, Iran. Patients were categorized into two groups. All 118 patients in group A had routine postoperative CXRs. The 113 patients in group B were selectively exposed to CXR only on clinical indications. All patients were postoperatively followed up for 30 days. Data gathered from both groups were statistically analyzed. RESULTS Routine postoperative CXRs obtained in 118 OPCAB group A candidates showed abnormal findings in 20 patients that did not require new intervention. One month follow-up of these patients showed no complications. In 113 OPCAB candidates of group B, 7 on-demand CXRs were obtained on clinical evaluation that required added intervention. In a 1-month follow-up of this group, five patients presented with symptomatic complaints. On re-examination, none needed readmission, intervention, or paraclinical evaluation. No complications were observed due to CXR elimination. CONCLUSION The study suggests that postoperative CXR selected on clinical grounds in place of routine CXR does not change early postoperative outcome of OPCAB procedure.
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Affiliation(s)
| | - Ali Sarvi
- Department of Medicine, Islamic Azad University, Yazd Branch, Yazd, Iran
| | | | - Reza Nafisi-Moghadam
- Department of Radiology, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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Gupta PK, Gupta K, Jain M, Garg T. Postprocedural chest radiograph: Impact on the management in critical care unit. Anesth Essays Res 2015; 8:139-44. [PMID: 25886216 PMCID: PMC4173625 DOI: 10.4103/0259-1162.134481] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Postprocedural chest radiograph is done to illustrate the position of endotracheal tubes (ETTs), nasogastric and drainage tubes, indwelling catheters, and intravascular lines or any other lifesaving devices to confirm their position. These devices are intended to save life, but may be life-threatening if in the wrong place. The incidence of malposition and complications ranges from 3% to 14%, respectively. The portable chest radiograph is of tremendous value, inexpensive and can be obtained quickly at the patient's bedside in any location of the hospital. A systemic literature search was performed in PubMed and the Cochranre library by setting up the search using either single text word or combinations. Those studies were also included where the chest radiograph was compared with other imaging modalities. Its clinical efficacy, cost-effectiveness and practicality allow anesthesiologist to evaluate the post-procedural position and complications of ETT, indwelling catheters, and multi lumen intravascular lines. Knowledge of the radiological features of commonly used devices is of utmost importance.
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Affiliation(s)
- Prashant K Gupta
- Department of Radio-Diagnosis, Imaging and Interventional Radiology, N.S.C.B. Subharti Medical College, Swami Vivekananda Subharti University, Subhartipuram, Meerut, Uttar Pradesh, India
| | - Kumkum Gupta
- Department of Anaesthesiology and Critical Care, N.S.C.B. Subharti Medical College, Swami Vivekananda Subharti University, Subhartipuram, Meerut, Uttar Pradesh, India
| | - Manish Jain
- Department of Anaesthesiology and Critical Care, N.S.C.B. Subharti Medical College, Swami Vivekananda Subharti University, Subhartipuram, Meerut, Uttar Pradesh, India
| | - Tanuj Garg
- Department of Radio-Diagnosis, Imaging and Interventional Radiology, N.S.C.B. Subharti Medical College, Swami Vivekananda Subharti University, Subhartipuram, Meerut, Uttar Pradesh, India
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The role of early postmortem CT in the evaluation of support-line misplacement in patients with severe trauma. AJR Am J Roentgenol 2015; 204:3-7. [PMID: 25539229 DOI: 10.2214/ajr.14.12796] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to retrospectively assess the role of early postmortem CT in evaluating support-line misplacement to improve future treatment in the trauma setting. MATERIALS AND METHODS We included all postmortem CT examinations that were performed for trauma patients within the 1st hour after declaration of death in our tertiary medical center between August 1, 2008, and August 31, 2013. Correct placement of the following support lines was evaluated: endotracheal tubes (ETTs), chest drains, central venous catheters (CVCs), and nasogastric tubes (NGTs). Prehospital resuscitation efforts were started in all cases. RESULTS Early postmortem CT was performed on average 22 minutes after declaration of death in 25 consecutive patients with severe trauma. Overall, 14 subjects (56%) had suboptimal or misplaced support lines. Of ETTs inserted into 18 trauma victims; three (17%) were mislaid in the right main bronchus and five (28%) were near or at the level of the carina. Of chest drains inserted into 13 subjects, 10 were suboptimally positioned (77%). Of CVCs inserted into eight subjects (seven femoral and one brachiocephalic), one femoral CVC (13%) was malpositioned in the soft tissues of the pelvis. Of NGTs inserted in five trauma victims, one was folded within the pharynx. CONCLUSION Early postmortem CT for patients who have experienced severe poly-trauma can be of important educational value to radiologists and the trauma teams, providing immediate feedback regarding the location of the support lines and possibly contributing to improved training and command of the learning curve by medical staff.
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Needleless closed system does not reduce central venous catheter-related bloodstream infection: a retrospective study. Int Surg 2014; 98:88-93. [PMID: 23438283 DOI: 10.9738/cc132.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The needleless closed system (NCS) has been disseminated in several clinical fields to prevent central venous catheter-related bloodstream infection (CVC-RBSI), in place of the conventional Luer cap system (LCS). The purpose of this study is to examine whether NCS is really superior to conventional LCS for prevention of CVC-RBSI. Between May 2002 and December 2008, 1767 patients received CVC in our department. The time interval from insertion to development of CVC-RBSI was compared retrospectively between selected patients who were treated using the conventional LCS (group 1, n = 89, before June 2006) and the NCS (group 2, n = 406, June 2006 and after). Kaplan-Meier analysis revealed no significant difference in the time interval from insertion to development of CVC-RBSI between the two groups. NCS does not reduce CVC-RBSI in adult colorectal cancer patients who undergo CVC insertion.
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McKay WP, Klonarakis J, Pelivanov V, O'Brien JM, Plewes C. Tracheal palpation to assess endotracheal tube depth: an exploratory study. Can J Anaesth 2013; 61:229-34. [PMID: 24259250 DOI: 10.1007/s12630-013-0079-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 11/04/2013] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Correct placement of the endotracheal tube (ETT) occurs when the distal tip is in mid-trachea. This study compares two techniques used to place the ETT at the correct depth during intubation: tracheal palpation vs placement at a fixed depth at the patient's teeth. METHODS With approval of the Research Ethics Board, we recruited American Society of Anesthesiologists physical status I-II patients scheduled for elective surgery with tracheal intubation. Clinicians performing the tracheal intubations were asked to "advance the tube slowly once the tip is through the cords". An investigator palpated the patient's trachea with three fingers spread over the trachea from the larynx to the sternal notch. When the ETT tip was felt in the sternal notch, the ETT was immobilized and its position was determined by fibreoptic bronchoscopy. The position of the ETT tip was compared with our hospital standard, which is a depth at the incisors or gums of 23 cm for men and 21 cm for women. The primary outcome was the incidence of correct placement. Correct placement of the ETT was defined as a tip > 2.5 cm from the carina and > 3.5 cm below the vocal cords. RESULTS Movement of the ETT tip was readily palpable in 77 of 92 patients studied, and bronchoscopy was performed in 85 patients. Placement by tracheal palpation resulted in more correct placements (71 [77%]; 95% confidence interval [CI] 74 to 81) than hospital standard depth at the incisors or gums (57 [61%]; 95% CI 58 to 66) (P = 0.037). The mean (SD) placement of the ETT tip in palpable subjects was 4.1 (1.7) cm above the carina, 1.9 cm (1.5-2.3 cm) below the ideal mid-tracheal position. CONCLUSION Tracheal palpation requires no special equipment, takes only a few seconds to perform, and may improve ETT placement at the correct depth. Further studies are warranted.
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Affiliation(s)
- William P McKay
- Department of Anesthesia, RUH, University of Saskatchewan, 103 Hospital Dr., Saskatoon, SK, S7N 0W8, Canada,
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22
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Amorosa JK, Bramwit MP, Mohammed TLH, Reddy GP, Brown K, Dyer DS, Ginsburg ME, Heitkamp DE, Jeudy J, Kirsch J, MacMahon H, Ravenel JG, Saleh AG, Shah RD. ACR appropriateness criteria routine chest radiographs in intensive care unit patients. J Am Coll Radiol 2013; 10:170-4. [PMID: 23571057 DOI: 10.1016/j.jacr.2012.11.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 11/21/2012] [Indexed: 11/27/2022]
Abstract
Daily routine chest radiographs in the intensive care unit (ICU) have been a tradition for many years. Anecdotal reports of misplacement of life support items, acute lung processes, and extra pulmonary air collections in a small number of patients served as a justification for routine chest radiographs in the ICU. Having analyzed this practice, the ACR Appropriateness Criteria Expert Panel on Thoracic Imaging has made the following recommendations: • When monitoring a stable patient or a patient on mechanical ventilation in the ICU, a portable chest radiograph is appropriate for clinical indications only. • It is appropriate to obtain a chest radiograph after placement of an endotracheal tube, central venous line, Swan-Ganz catheter, nasogastric tube, feeding tube, or chest tube. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. The strongest data contributing to these recommendations were derived from a meta-analysis of 8 trials comprising 7,078 ICU patients by Oba and Zaza [1].
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Affiliation(s)
- Judith K Amorosa
- Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA.
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Repositioning endotracheal tubes in the intensive care unit: depth changes poorly correlate with postrepositioning radiographic location. J Trauma Acute Care Surg 2013; 75:146-9. [PMID: 23940860 DOI: 10.1097/ta.0b013e31829849cd] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Suboptimal positioning of endotracheal tubes (ETs) is often identified on routine chest radiographs prompting adjustment. The accuracy of ET adjustments based on tube measurement markings at the incisors has not been reported. METHODS We performed a 1-year prospective observational study of all surgical intensive care unit patients requiring repositioning of their ET based on chest x-ray (CXR) study. The ET was repositioned by a respiratory therapist using tube markings at the incisors, and follow-up CXR images were obtained within 2 hours. ET tube locations were compared with the planned intervention. Mean, median, interquartile range (IQR) and [chi]2 results are reported. RESULTS Fifty-five patients met inclusion criteria and had a complete set of data (80% male). ET advancement was the most commonly required intervention (80%). For advancement, the median starting position was 7.10 cm (IQR, 2.20 cm) from the carina, with a median planned advancement of 2.00 cm. The actual advancement was a median of 1.15 cm, achieving 57.5% of the goal. Patients requiring ET withdrawal were more likely female (8 of 11, p < 0.001). For the withdrawal group, the median starting position was 0.70 cm (IQR, 1.05 cm) from the carina with a planned median withdrawal of 2.00 cm (IQR, 0.75 cm). The actual withdrawal was a median of 1.00 cm, achieving 50.0% of the goal. Overall, the mean difference between the planned and actual intervention was 1.55 cm (95% confidence interval, 1.16-1.95 cm) differing by a mean of 40% from the planned intervention (95% confidence interval, 29.0-51.0%). There was no correlation between the original location or the planned intervention and the accuracy of the intervention. In three cases, the ET moved opposite of the planned intervention. CONCLUSION ET repositioning based on measurement at the incisors is inaccurate and the magnitude of the intervention does not correlate with the degree of error. Repositioning of ETs based on measurements at the incisors should be abandoned, or follow-up CXR images should be obtained.
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Zanobetti M, Coppa A, Bulletti F, Piazza S, Nazerian P, Conti A, Innocenti F, Ponchietti S, Bigiarini S, Guzzo A, Poggioni C, Taglia BD, Mariannini Y, Pini R. Verification of correct central venous catheter placement in the emergency department: comparison between ultrasonography and chest radiography. Intern Emerg Med 2013; 8:173-80. [PMID: 23242559 DOI: 10.1007/s11739-012-0885-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 11/21/2012] [Indexed: 12/22/2022]
Abstract
In 210 consecutive patients undergoing emergency central venous catheterization, we studied whether an ultrasonography examination performed at the bedside by an emergency physician can be an alternative method to chest X-ray study to verify the correct central venous catheter placement, and to identify mechanical complications. A prospective, blinded, observational study was performed, from January 2009 to December 2011, in the emergency department of a university-affiliated teaching hospital. Ultrasonography interpretation was completed during image acquisition; ultrasound scan was performed in 5 ± 3 min, whereas the time interval between chest radiograph request and its final interpretation was 65 ± 74 min p < 0.0001. We found a high concordance between the two diagnostic modalities in the identification of catheter position (Kappa = 82 %, p < 0.0001), and their ability to identify a possible wrong position showed a high correlation (Pearson's r = 0.76 %, p < 0.0001) with a sensitivity of 94 %, a specificity of 89 % for ultrasonography. Regarding the mechanical complications, three iatrogenic pneumothoraces occurred, all were correctly identified by ultrasonography and confirmed by chest radiography (sensitivity 100 %). Our study showed a high correlation between these two modalities to identify possible malpositioning of a catheter resulting from cannulation of central veins, and its complications. The less time required to perform ultrasonography allows earlier use of the catheter for the administration of acute therapies that can be life-saving for the critically ill patients.
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Affiliation(s)
- Maurizio Zanobetti
- Intensive Observation Unit, Careggi University Hospital, Florence, Italy.
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Tobler WD, Mella JR, Ng J, Selvam A, Burke PA, Agarwal S. Chest X-ray after tracheostomy is not necessary unless clinically indicated. World J Surg 2012; 36:266-9. [PMID: 22167261 DOI: 10.1007/s00268-011-1380-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND Chest radiography is routinely used post-tracheostomy to evaluate for complications. Often, the chest X-ray findings do not change clinical management. The present study was conducted to evaluate the utility of post-tracheostomy X-rays. METHOD This retrospective review of 255 patients was performed at a single-center, university, level I trauma center. All patients underwent tracheostomy and were evaluated for postprocedure complications. RESULTS Of the 255 patients, 95.7% had no change in postprocedure chest X-ray findings. New significant chest X-ray findings were found in 4.3% of patients, including subcutaneous emphysema, pneumothorax, and new significant consolidation. Only three of these patients required change in clinical management, and all changes were based on clinical presentation alone. CONCLUSIONS Routine chest X-ray following tracheostomy fails to provide additional information beyond clinical examination. Therefore radiographic examination should be performed only after technically difficult procedures or if the patient experiences clinical deterioration. Significant cost savings and minimization of radiation exposure can be achieved when chest radiography after tracheostomy is performed exclusively for clinical indications.
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Affiliation(s)
- William D Tobler
- Department of Surgery, Boston University School of Medicine, c/o Lana Ketlere, 88 East Newton Street, C515, Boston, MA 02118, USA.
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Chest radiography in the ICU: Part 1, Evaluation of airway, enteric, and pleural tubes. AJR Am J Roentgenol 2012; 198:563-71. [PMID: 22357994 DOI: 10.2214/ajr.10.7226] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE In this pictorial essay, we discuss and illustrate normal and aberrant positioning of nonvascular support and monitoring devices frequently used in critically ill patients, including endotracheal and tracheostomy tubes, chest tubes, and nasogastric and nasoenteric tubes, as well as their inherent complications. CONCLUSION The radiographic evaluation of the support and monitoring devices used in patients in the ICU is important because the potentially serious complications arising from their introduction and use are often not clinically apparent. Familiarity with normal and abnormal radiographic findings is critical for the detection of these complications.
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Efrati S, Deutsch I, Gurman GM. Endotracheal tube cuff-small important part of a big issue. J Clin Monit Comput 2012; 26:53-60. [DOI: 10.1007/s10877-011-9333-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2011] [Accepted: 12/21/2011] [Indexed: 11/24/2022]
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Ioos V, Galbois A, Chalumeau-Lemoine L, Guidet B, Maury E, Hejblum G. An integrated approach for prescribing fewer chest x-rays in the ICU. Ann Intensive Care 2011; 1:4. [PMID: 21906323 PMCID: PMC3159900 DOI: 10.1186/2110-5820-1-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Accepted: 03/21/2011] [Indexed: 11/10/2022] Open
Abstract
Chest x-rays (CXRs) are the main imaging tool in intensive care units (ICUs). CXRs also are associated with concerns inherent to their use, considering both healthcare organization and patient perspectives. In recent years, several studies have focussed on the feasibility of lowering the number of bedside CXRs performed in the ICU. Such a decrease may result from two independent and complementary processes: a raw reduction of CXRs due to the elimination of unnecessary investigations, and replacement of the CXR by an alternative technique. The goal of this review is to outline emblematic examples corresponding to these two processes. The first part of the review concerns the accumulation of evidence-based data for abandoning daily routine CXRs in mechanically ventilated patients and adopting an on-demand prescription strategy. The second part of the review addresses the use of alternative techniques to CXRs. This part begins with the presentation of ultrasonography or capnography combined with epigastric auscultation for ensuring the correct position of enteral feeding tubes. Ultrasonography is then also presented as an alternative to CXR for diagnosing and monitoring pneumothoraces, as well as a valuable post-procedural technique after central venous catheter insertion. The combination of the emblematic examples presented in this review supports an integrated global approach for decreasing the number of CXRs ordered in the ICU.
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Affiliation(s)
- Vincent Ioos
- UPMC Univ Paris 06, UMR_S 707, Paris F-75012, France.
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Chalumeau-Lemoine L, Ioos V, Galbois A, Maury E, Hejblum G, Guidet B. Peut-on réduire le nombre de radiographies de thorax en réanimation ? MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-010-0001-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ishizuka M, Nagata H, Takagi K, Kubota K. Right internal jugular vein is recommended for central venous catheterization. J INVEST SURG 2010; 23:110-4. [PMID: 20497014 DOI: 10.3109/08941930903469342] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The internal jugular vein (IJV) is one of the recommended sites for safe insertion of a central venous catheter (CVC). Although CVC insertion via the IJV has a lower risk of severe complications such as pneumothorax and arterial bleeding than insertion via the subclavian vein, few reports have provided concrete evidence for the safety of a right-sided approach. PURPOSE To examine whether a right-sided approach, rather than a left-sided one is superior for CVC insertion via the IJV. METHODS A retrospective study was performed to compare the right IJV with the left in terms of characteristics such as vertical and horizontal diameters, depth from the skin, and the relationship between the IJV and the common carotid artery (CCA) using the same computed tomography axial slice. RESULTS From April 2006 to September 2008, 100 patients (50 male and 50 female) who underwent CVC insertion via the IJV before surgery for colorectal cancer were enrolled. Vertical and horizontal diameters of the right IJV were significantly larger than those of the left IJV [right: left (cm), 1.51 +/- 0.41 vs 1.13 +/- 0.34, p <.0001, 1.54 +/- 0.36 vs 1.08 +/- 0.33, p <.0001], respectively. The right IJV runs more superficially than the left IJV [right: left (cm), 1.74 +/- 0.60 vs 1.87 +/- 0.56, p <.0001]. CONCLUSIONS Because the right IJV has a much wider diameter and runs more superficially than the left IJV, a right-sided approach is more acceptable than a left-sided one for CVC insertion via the IJV.
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Affiliation(s)
- Mitsuru Ishizuka
- Department of Gastroenterological Surgery, Dokkyo Medical University, Mibu, Tochigi, Japan.
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Pikwer A, Bååth L, Perstoft I, Davidson B, Akeson J. Routine chest X-ray is not required after a low-risk central venous cannulation. Acta Anaesthesiol Scand 2009; 53:1145-52. [PMID: 19422354 DOI: 10.1111/j.1399-6576.2009.01980.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Knowledge of the radiographic catheter tip position after central venous cannulation is normally not required for short-term catheter use. Detection of a possible iatrogenic pneumothorax may nevertheless justify routine post-procedure chest X-ray. Our aim was to design a clinical decision rule to select patients for radiographic evaluation after central venous cannulation. METHODS A total of 2230 catheterizations performed using external jugular, internal jugular or subclavian venous approaches during a 4-year period were included consecutively. Information on patient data and corresponding procedures was recorded prospectively. A post-procedure chest X-ray was obtained after each cannulation. RESULTS Thirteen cases (0.58%) of cannulation-associated pneumothorax were identified. The risk of pneumothorax after a technically difficult (1.8%) or subclavian (1.6%) cannulation was significantly higher than after cannulation not considered as difficult (0.37%) or performed using other routes (0.33%). Clinical signs of pneumothorax within 8 h of cannulation were found in all seven patients with pneumothorax requiring specific treatment. A new clinical decision rule for radiographic evaluation after central venous cannulation based on the results of the present study shows that 48% of the post-procedure chest X-rays performed in our patients were clinically redundant. CONCLUSION Clinical symptoms were reported in all patients with pneumothorax requiring specific treatment. Approximately half of the post-procedure chest X-ray controls could be avoided using the proposed clinical decision rule to select patients for radiographic evaluation after central venous cannulation. A large prospective multi-centre study should be carried out to further evaluate this decision rule.
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Affiliation(s)
- A Pikwer
- Department of Anaesthesiology and Intensive Care Medicine, Malmö University Hospital, Lund University, Malmö, Sweden.
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Geisser W, Maybauer DM, Wolff H, Pfenninger E, Maybauer MO. Radiological validation of tracheal tube insertion depth in out-of-hospital and in-hospital emergency patients. Anaesthesia 2009; 64:973-7. [DOI: 10.1111/j.1365-2044.2009.06007.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ishizuka M, Nagata H, Takagi K, Kubota K. Femoral Venous Catheterization Is a Major Risk Factor for Central Venous Catheter-Related Bloodstream Infection. J INVEST SURG 2009; 22:16-21. [DOI: 10.1080/08941930802566698] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Whitehouse M, Patel A, Morgan J. The necessity of routine post-thoracostomy tube chest radiographs in post-operative thoracic surgery patients. Surgeon 2009; 7:79-81. [DOI: 10.1016/s1479-666x(09)80020-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Hejblum G, Ioos V, Vibert JF, Böelle PY, Chalumeau-Lemoine L, Chouaid C, Valleron AJ, Guidet B. A Web-Based Delphi Study on the Indications of Chest Radiographs for Patients in ICUs. Chest 2008; 133:1107-12. [DOI: 10.1378/chest.06-3014] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Antonaglia V, Ristagno G, Berlot G. Procedural and clinical data plus electrocardiographic guidance greatly reduce the need for routine chest radiograph following central line placement. ACTA ACUST UNITED AC 2008; 64:1146. [PMID: 18404090 DOI: 10.1097/ta.0b013e31815dd4ea] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Abstract
Imaging in the ICU plays a crucial role in patient care. The portable chest radiograph (CXR) is the most commonly requested radiographic examination, and, despite its limitations, it often reveals abnormalities that may not be detected clinically. Recent advances in CT technology have made it possible to obtain diagnostic-quality images even in the most dyspneic patient. This article reviews the significant contribution thoracic imaging makes in diagnosing and managing critically ill patients.
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Affiliation(s)
- Ami N Rubinowitz
- Department of Diagnostic Radiology, Thoracic Imaging Section, Yale University School of Medicine, 333 Cedar Street, Post Office Box 208042, New Haven, CT 06520, USA.
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Ishizuka M, Nagata H, Takagi K, Horie T, Furihata M, Nakagawa A, Kubota K. External Jugular Groshong Catheter Is Associated with Fewer Complications than a Subclavian Argyle Catheter. Eur Surg Res 2007; 40:197-202. [DOI: 10.1159/000110861] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2007] [Accepted: 07/02/2007] [Indexed: 11/19/2022]
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Hernández Hernández MA, Alvarez Antoñan C, Pérez-Ceballos MA. [Complications of the cannulation of a central venous line]. Rev Clin Esp 2006; 206:50-3. [PMID: 16527050 DOI: 10.1157/13084771] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Central venous catheters are essential in modern-day medical practice, particularly in intensive care units. Although such catheters provide necessary vascular access, their use puts patients at risk of mechanical and infectious complications. Unfortunately, these complications are associated with an increase of the morbidity-mortality, lengthen hospitalization and raise medical costs. Strategies should be implemented to reduce the incidence of these complications to improve clinical outcome and reduce health-care costs.
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Affiliation(s)
- M A Hernández Hernández
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria.
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Kanter G, Connelly NR. Unusual positioning of a central venous catheter. J Clin Anesth 2005; 17:293-5. [PMID: 15950856 DOI: 10.1016/j.jclinane.2004.06.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2003] [Accepted: 06/29/2004] [Indexed: 10/25/2022]
Abstract
Central venous cannulation, with or without a flow-directed pulmonary artery catheter, is commonly performed in patients undergoing cardiac surgery to measure central filling pressure and cardiac output, and to administer medications and fluids. The complications of central venous cannulation are numerous and include malposition, arterial puncture, pneumothorax, hemothorax, chylothorax, extravasation of infusate, thrombophlebitis, and infection. We describe a single-lumen catheter that was placed through the hemostatic valve of a 9F percutaneous introducer, which inadvertently entered the left internal mammary (internal thoracic) vein. The current case is unique in that it was diagnosed by visualization of the catheter during surgical dissection.
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Affiliation(s)
- Gary Kanter
- Department of Anesthesiology, Baystate Medical Center, Springfield, MA 01199, USA
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Lessnau KD. Is Chest Radiography Necessary After Uncomplicated Insertion of a Triple-Lumen Catheter in the Right Internal Jugular Vein, Using the Anterior Approach? Chest 2005; 127:220-3. [PMID: 15653987 DOI: 10.1378/chest.127.1.220] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES Chest radiographs are required in many institutions by protocol after the insertion of a right internal jugular vein triple-lumen catheter (TLC), even if the anterior approach is used. This study investigates whether correct placement can be predicted during insertion and whether a "routine" postprocedural chest radiograph can be safely omitted. DESIGN The operators included 18 first-, second-, or third-year medical residents, 3 pulmonary fellows, and a board-certified pulmonary medicine and critical care attending, with at least 1 certified physician present during the procedure. All operators were trained in the "seven number rule." PATIENTS One hundred consecutive patients who required central venous access. Patients with left internal jugular vein or subclavian catheters were excluded. SETTING Single institution, medical ICU, step-down unit, and floors. INTERVENTIONS Right internal jugular vein TLC insertion, anterior approach, with subsequent chest radiograph. MEASUREMENTS AND RESULTS Eighty-eight patients had uncomplicated insertions, as defined by fewer than four sticks with a 22-gauge pathfinder needle and fewer than four slides with the 18-gauge introducer needle. Ninety-eight catheters were in accurate position, 1 catheter was in the distal superior cava vein, and 1 catheter was in an S-shaped position. CONCLUSIONS It is safe to omit the routine chest radiograph after uncomplicated insertion of a TLC. i.v. treatment can be initiated early. However, if there is any doubt about the correct position, a chest radiograph should be obtained.
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Molgaard O, Nielsen MS, Handberg BB, Jensen JM, Kjaergaard J, Juul N. Routine X-ray control of upper central venous lines: Is it necessary? Acta Anaesthesiol Scand 2004; 48:685-9. [PMID: 15196099 DOI: 10.1111/j.0001-5172.2004.00400.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Insertion of central venous catheters (CVCs) is a procedure associated with a varying risk of complications, depending on the setting and the skill of the clinician who undertakes the procedure. The aim of this study was to monitor the complication rate of CVC insertion and evaluate the value of routine chest X-ray control. METHODS Anesthesiologists at eight hospitals filled in a questionnaire immediately after insertion of a CVC. The post-procedural clinical evaluation, including expected complications, was compared to actual radiological findings. Chest X-ray was ordered by the anesthesiologist, and described by staff radiologists. RESULTS The clinicians had from 2 months to 30 years of experience as anesthesiologists, and trainees inserted 34% and specialists 66% of the catheters, using landmark techniques. Over a period of 2 months, 473 CVC-insertion procedures were included in the investigation. Two patients (0.4%) had a pneumothorax: one was among the 11 cases in which the clinician suspected complications after the procedure, and another was found in a high-risk patient 13 h after CVC insertion. Both patients were treated successfully with chest tubes. The favorite approach was right vena jugularis interna with 324 (69%) catheters; of these patients one had a pneumothorax, catheter-tip placement was correctly predicted in 317 (97%), and no catheters were repositioned. CONCLUSION In the hands of trained clinicians, insertion of CVCs is a safe procedure. We found no value of routine X-ray control and omission of routine chest X-ray must be considered.
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Affiliation(s)
- O Molgaard
- Department of Anesthesiology, Aarhus University Hospital, Denmark.
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Abstract
The increasing complexity of the intensive care patient combined with the recent advances in imaging technology has generated a new perspective on intensive care radiology. The purpose of this 2-part review article is to describe the contribution of radiology to the management of these critically ill patients. The first article will discuss the impact of picture archiving and communication system (PACS) on critical care management and utility of the portable chest radiograph in the detection and evaluation of pulmonary disease with correlation to computed tomography (CT). The second article describes in more detail the increasing role of CT in diagnosis and therapeutic procedures. In particular, the implementation of CT pulmonary angiography in the evaluation of pulmonary emboli and the introduction of the new multislice detector CT scanners that allow even the most dyspneic patient to be evaluated. Pleural complications in the intensive care unit and image-guided intervention will also be discussed.
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Puls LE, Twedt CA, Hunter JE, Langan EM, Crane M. Confirmatory Chest Radiographs after Central Line Placement: Are They Warranted? South Med J 2003; 96:1138-41. [PMID: 14632364 DOI: 10.1097/01.smj.0000053920.02489.a1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES This study was designed to determine the ability of physicians to predict complications associated with the placement of central venous access devices and to decide whether a confirmatory chest radiograph is warranted after placement. METHODS Patients receiving central venous access on an inpatient and outpatient gynecologic oncology service were studied. Data were collected regarding patient demographics, patient history, procedural details of the placement, and the type of catheter used. The physician then predicted which patients had a reasonable potential for placement complications. All of the patients then underwent radiography, which was then compared with the original prediction. RESULTS Ninety-eight patients who had central venous access devices placed were included in the study. Eighty of the 81 central lines thought by the practitioner to have been placed without incident caused no significant complications; one individual in this group had a minor pneumothorax. Two of 17 patients predicted to have complications were noted to have a pneumothorax that required hospitalization. No patients in the low-risk group were hospitalized for a placement complication, whereas two hospitalizations occurred in the high-risk group. CONCLUSION Confirmatory chest radiographs may potentially be omitted in certain cases after line placement when experienced clinicians use good technique, good clinical judgment, and discrimination.
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Affiliation(s)
- Larry E Puls
- Department of Gynecologic Oncology, Obstetrics and Gynecology, Vascular Surgery, and Research, Greenville Hospital System, Greenville, SC 29605, USA.
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Ruesch S, Walder B, Tramèr MR. Complications of central venous catheters: internal jugular versus subclavian access--a systematic review. Crit Care Med 2002; 30:454-60. [PMID: 11889329 DOI: 10.1097/00003246-200202000-00031] [Citation(s) in RCA: 365] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To test whether complications happen more often with the internal jugular or the subclavian central venous approach. DATA SOURCE Systematic search (MEDLINE, Cochrane Library, EMBASE, bibliographies) up to June 30, 2000, with no language restriction. STUDY SELECTION Reports on prospective comparisons of internal jugular vs. subclavian catheter insertion, with dichotomous data on complications. DATA EXTRACTION No valid randomized trials were found. Seventeen prospective comparative trials with data on 2,085 jugular and 2,428 subclavian catheters were analyzed. Meta-analyses were performed with relative risk (RR) and 95% confidence interval (CI), using fixed and random effects models. DATA SYNTHESIS In six trials (2,010 catheters), there were significantly more arterial punctures with jugular catheters compared with subclavian (3.0% vs. 0.5%, RR 4.70 [95% CI, 2.05-10.77]). In six trials (1,299 catheters), there were significantly less malpositions with the jugular access (5.3% vs. 9.3%, RR 0.66 [0.44-0.99]). In three trials (707 catheters), the incidence of bloodstream infection was 8.6% with the jugular access and 4.0% with the subclavian access (RR 2.24 [0.62-8.09]). In ten trials (3,420 catheters), the incidence of hemato- or pneumothorax was 1.3% vs. 1.5% (RR 0.76 [0.43--1.33]). In four trials (899), the incidence of vessel occlusion was 0% vs. 1.2% (RR 0.29 [0.07-1.33]). CONCLUSIONS There are more arterial punctures but less catheter malpositions with the internal jugular compared with the subclavian access. There is no evidence of any difference in the incidence of hemato- or pneumothorax and vessel occlusion. Data on bloodstream infection are scarce. These data are from nonrandomized studies; selection bias cannot be ruled out. In terms of risk, the data most likely represent a best case scenario. For rational decision-making, randomized trials are needed.
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Affiliation(s)
- Sibylle Ruesch
- Division of Anaesthesiology, Department Anaesthesiology, Pharmacology, and Surgical Intensive Care, University Hospitals of Geneva, Geneva, Switzerland
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Kirchner J, Stueckle CA, Schilling EM, Peters J. Efficacy of daily bedside chest radiography as visualized by digital luminescence radiography. AUSTRALASIAN RADIOLOGY 2001; 45:444-7. [PMID: 11903176 DOI: 10.1046/j.1440-1673.2001.00954.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
To determine the diagnostic impact of daily bedside chest radiography in comparison with digital luminescence technique (DLR; storage phosphor radiography) and conventional film screen radiography, a prospective randomized study was completed in 210 mechanically ventilated patients with a total of 420 analysed radiographs. The patients were allocated to two groups: 150 patients underwent DLR, and 60 patients underwent conventional film screen radiography. Radiological analysis was performed consensually and therapeutic efficacy was assessed by the clinicians. There was no statistical significant difference between the frequency of abnormal findings seen on DLR and conventional film screen radiography. In total, 448 abnormal findings were present in 249 of 300 DLR and 97 of 120 conventional film screen radiographs. The most common findings were signs of overhydration (41%), pleural effusion (31%), partial collapse of the lung (11%) and pneumothorax (2%). One hundred and twenty-three of 448 (27%) of these abnormal findings were thought to have a considerable impact on patient management. The high rate of abnormal findings with significant impact on patient management suggests that the use of daily bedside chest radiography may be reasonable.
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Affiliation(s)
- J Kirchner
- Department of Diagnostic and Interventional Radiology, Klinikum Niederberg Velbert, University Essen, Germany.
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Maury E, Guglielminotti J, Alzieu M, Guidet B, Offenstadt G. Ultrasonic examination: an alternative to chest radiography after central venous catheter insertion? Am J Respir Crit Care Med 2001; 164:403-5. [PMID: 11500340 DOI: 10.1164/ajrccm.164.3.2009042] [Citation(s) in RCA: 124] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We evaluated ultrasonic examination as a diagnostic tool for catheter misplacement and pneumothorax after central venous catheter insertion. Physicians in the intensive care unit (ICU) performed the ultrasonic examinations, and the results were compared with those of chest radiography. Eighty-five central venous catheters (70 subclavian and 15 internal jugular) were inserted into 81 patients; 10 misplacements and one pneumothorax occurred. Ultrasonic examination feasibility was 99.6%. The only pneumothorax and all misplacements except one were diagnosed by ultrasound. Taking into consideration misplacements and pneumothorax research, ultrasonic examination did not give any false positive results. The mean time of the entire ultrasonic examination was 6.8 +/- 3.5 min, whereas 80.3 +/- 66.7 min were needed for the radiography (p < 0.0001). This study has suggested that ultrasonic diagnosis of catheter misplacement and pneumothorax related to central venous catheterization is a rapid and accurate method that can be easily performed by ICU physicians.
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Affiliation(s)
- E Maury
- Service de Réanimation Médicale, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
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Chahine-Malus N, Stewart T, Lapinsky SE, Marras T, Dancey D, Leung R, Mehta S. Utility of routine chest radiographs in a medical-surgical intensive care unit: a quality assurance survey. Crit Care 2001; 5:271-5. [PMID: 11737902 PMCID: PMC83854 DOI: 10.1186/cc1045] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2001] [Accepted: 08/16/2001] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE To determine the utility of routine chest radiographs (CXRs) in clinical decision-making in the intensive care unit (ICU). DESIGN A prospective evaluation of CXRs performed in the ICU for a period of 6 months. A questionnaire was completed for each CXR performed, addressing the indication for the radiograph, whether it changed the patient's management, and how it did so. SETTING A 14-bed medical-surgical ICU in a university-affiliated, tertiary care hospital. PATIENTS A total of 645 CXRs were analyzed in 97 medical patients and 205 CXRs were analyzed in 101 surgical patients. RESULTS Of the 645 CXRs performed in the medical patients, 127 (19.7%) led to one or more management changes. In the 66 surgical patients with an ICU stay <48 hours, 15.4% of routine CXRs changed management. In 35 surgical patients with an ICU stay > or = 48 hours, 26% of the 100 routine films changed management. In both the medical and surgical patients, the majority of changes were related to an adjustment of a medical device. CONCLUSIONS Routine CXRs have some value in guiding management decisions in the ICU. Daily CXRs may not, however, be necessary for all patients.
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Bailey SH, Shapiro SB, Mone MC, Saffle JR, Morris SE, Barton RG. Is immediate chest radiograph necessary after central venous catheter placement in a surgical intensive care unit? Am J Surg 2000; 180:517-21; discussion 521-2. [PMID: 11182410 DOI: 10.1016/s0002-9610(00)00498-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Current standard of care dictates that central venous catheter (CVC) insertion should be followed by an immediate chest radiograph to confirm appropriate position and rule out complications. We hypothesized that a subset of monitored intensive care unit patients exists that is at low risk for complications and might safely have radiographic evaluation of line placement deferred until the next scheduled radiograph. METHODS Data regarding patient and procedural characteristics were obtained prospectively for 184 CVC placed between March 1, 1998, and June 30, 1999. Retrospective data regarding complications were obtained by chart review for an additional 174 CVC placed during the study period but for which data sheets were not completed. All procedures were followed by chest radiography. RESULTS We documented a complication rate of 9% with the vast majority (25 of 31, 81%) of complications consisting of incorrect positioning. The number of needle passes was greater in the group suffering pneumothorax and arterial puncture than the uncomplicated group (5.6 versus 1.9, P = 0.008). "Straightforward" operator gestalt (P = 0.04) and number of needle passes <3 (P = 0.03) were factors correlating with the absence of complications. These factors had negative predictive values of 94% and 96%, respectively. CONCLUSION Placement of CVC is safe in experienced hands. In monitored intensive care unit patients who undergo a "straightforward" procedure with <3 needle passes, chest radiograph can be safely deferred until the next scheduled examination.
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Affiliation(s)
- S H Bailey
- Department of Surgery, University of Utah Medical Center, Salt Lake City, Utah, USA
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Donaldson DR, Emami AJ, Wax MK. Chest radiographs after dilatational percutaneous tracheotomy: are they necessary? Otolaryngol Head Neck Surg 2000; 123:236-9. [PMID: 10964297 DOI: 10.1067/mhn.2000.107455] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The efficacy of routinely obtaining chest radiographs after standard open tracheotomy has been questioned. Recent literature would suggest that after a routine, uncomplicated tracheotomy, chest radiography is a low-yield procedure that incurs unnecessary expense. Percutaneous dilatational tracheotomy (PDT) is rapidly replacing open tracheotomy as the intensive care unit procedure of choice for airway management. Complication rates are equivalent between the two procedures. OBJECTIVE We examined the value and cost-effectiveness of routine postoperative chest radiographs in patients undergoing PDT. STUDY DESIGN AND SETTING The study was a prospective analysis of 54 consecutive PDTs performed at a tertiary care academic institution. RESULTS Eighteen (33%) patients had chest radiographs obtained within 1 hour of PDT (6 at the request of the otolaryngology service); 35 (66%) underwent radiography more than 2 hours later at the request of the intensive care unit for reasons other than PDT. There were no incidents of pneumothorax, pneumomediastinum, or tracheotomy tube malposition in any patient. Patients undergoing chest radiography within 1 hour of the PDT also had chest radiographs within 12 hours at the request of ICU staff for their underlying disease. CONCLUSIONS Routine chest radiography after PDT is of low yield. Because most of these patients require chest radiographs for their underlying disease within 12 hours, a cost savings of approximately $13,500 would be realized in this patient population. SIGNIFICANCE Routine chest radiography after PDT is unwarranted in most cases.
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Affiliation(s)
- D R Donaldson
- Department of Otolaryngology-Head and Neck Surgery, State University of New York at Buffalo, USA
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