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Hixson R, Jensen KS, Melamed KH, Qadir N. Device associated complications in the intensive care unit. BMJ 2024; 386:e077318. [PMID: 39137947 DOI: 10.1136/bmj-2023-077318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
Invasive devices are routinely used in the care of critically ill patients. Although they are often essential components of patient care, devices such as intravascular catheters, endotracheal tubes, and ventilators are a common source of complications in the intensive care unit. Critical care practitioners who use these devices need to use strategies for risk reduction and understand approaches to management when adverse events occur. This review discusses the identification, prevention, and management of complications of vascular, airway, and mechanical support devices commonly used in the intensive care unit.
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Affiliation(s)
- Roxana Hixson
- David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, CA, USA
| | - Kristin Schwab Jensen
- David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, CA, USA
| | - Kathryn H Melamed
- David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, CA, USA
| | - Nida Qadir
- David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, CA, USA
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Chua CKZ, Le Guen M, Lim R, Udy A. Using central venous pressure waveform to confirm the placement of an internal jugular central venous catheter in the intensive care unit. Aust Crit Care 2024; 37:628-631. [PMID: 38065796 DOI: 10.1016/j.aucc.2023.10.007] [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: 06/18/2023] [Revised: 09/08/2023] [Accepted: 10/14/2023] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND A mobile chest X-ray is traditionally performed to confirm the position of an internal jugular central venous catheter (CVC) after placement in the intensive care unit (ICU). Using chest radiography to confirm CVC position often results in delays in authorising the use of the CVC, requires the deployment of additional human resources, and is costly. OBJECTIVE This study aimed to determine the feasibility and accuracy of using the central venous pressure (CVP) waveform to confirm the placement of internal jugular CVCs. METHODS This retrospective study was conducted in a single quaternary ICU over a 6-month period. We included adult patients who had internal jugular CVC inserted and CVP transduced as part of their routine care in the ICU. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CVP waveform analysis in confirming the position of internal jugular CVC relative to chest radiography were calculated. RESULTS A total of 241 internal jugular CVCs were inserted (in 219 patients, 35.6% female), and the CVP waveform was assessed. In 231 cases, this suggested adequate placement in a central vein, which corresponded with a correct position on subsequent chest X-ray. On six occasions, the CVP waveforms were interpreted as suboptimal; however, on chest X-rays, the CVCs were noted to be in a suitable position (sensitivity: 97.5%). Four suboptimal CVP waveforms were obtained, and they correctly identified CVC malposition on subsequent chest X-ray (specificity: 100%). The average time from CVC insertion to radiological completion was 118 minutes. CONCLUSION CVP waveform analysis provides a feasible and reliable method for confirming adequate internal jugular CVC position. The use of chest radiography can be limited to cases where suboptimal CVP waveforms are obtained.
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Affiliation(s)
- Charlene Kit Zhen Chua
- Department of Intensive Care and Hyperbaric Medicine, Alfred Health, Melbourne, Victoria, Australia.
| | - Maurice Le Guen
- Department of Intensive Care and Hyperbaric Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Richard Lim
- Department of Intensive Care and Hyperbaric Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Andrew Udy
- Department of Intensive Care and Hyperbaric Medicine, Alfred Health, Melbourne, Victoria, Australia; The Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Stefano E, Dario D, Silvia C, Gloria C, Mariavittoria G, Francesco M, Jessica P, Mario R, Alberto L, Giuseppe F, Matteo P, Marco G. Impact of distance of the catheter tip from cavo-atrial junction on bubble test (delay) time: A prospective study. J Vasc Access 2024; 25:1187-1193. [PMID: 36765463 DOI: 10.1177/11297298231153517] [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: 02/12/2023] Open
Abstract
INTRODUCTION Correct tip positioning is a critical aspect in central vascular access devices insertion. The verification of positioning at the cavo-atrial junction is usually performed by intracavitary electrocardiography. Recently, echocardiographic techniques were proposed, including the direct visualization of the catheter or the visualization of a saline/air bolus (i.e. "bubble test"). As for the latter, a push-to-bubbles delay time below 2 s was proposed to indicate a correct positioning of the catheter tip. The aim of this study was to measure the variations of the push-to-bubbles time at increasing distance from the cavo-atrial junction, to verify if a cut-off of 1-2 s correspond to a well-positioned catheter. METHODS We performed a prospective study including patients with clinical indication of positioning a peripherally inserted central catheter. The catheter tip was positioned at the cavo-atrial junction (P0) via intracavitary electrocardiography, and the push-to-bubbles delay time was measured. The catheter was then retracted 5 cm (P1) and 10 cm (P2), and the test was repeated at this positioning. Push-to-bubbles time measurements were performed off-line by analyzing an audio/video recording which included the echography screen and the voice signal of the operator. RESULTS Forty-nine patients were included. The average push-to-bubble time when the catheter tip was in the reference position was 0.41 ± 0.21 s. Retraction of the PICC catheter of 5 and 10 cm determined a significant increase of the push-to-bubbles time: mean time difference was +0.34 (95% IC 0.25-0.43, p < 0.001) s between P0 and P1 (5 cm distance), and +0.77 (95% IC 0.62-0.92, p < 0.001) s between P0 and P2 (10 cm distance). When the catheter was at the reference position (i.e. cavo-atrial junction) only 2.1% of bubbles delay times were above 1 s. CONCLUSION The push-to-bubbles time is very low when the catheter tip is at the cavo-atrial junction. This delay increases progressively with increasing distance from the target. Push-to-bubbles delay time above 1 s might indicate a catheter not close to the cavo-atrial junction.
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Affiliation(s)
- Elli Stefano
- University of Milan-Bicocca, A.S.S.T. Monza, San Gerardo Hospital, Monza (MB), Italy
| | - D'amata Dario
- A.S.S.T. Monza, San Gerardo Hospital, Monza (MB), Italy
| | | | | | | | | | - Pozzoli Jessica
- IRCCS Foundation Maggiore Policlinico Hospital, Milan, Italy
| | - Russo Mario
- ASST-Brianza, Vimercate Hospital, Vimercate, Italy
| | - Lucchini Alberto
- University of Milan-Bicocca, A.S.S.T. Monza, San Gerardo Hospital, Monza (MB), Italy
| | - Foti Giuseppe
- University of Milan-Bicocca, A.S.S.T. Monza, San Gerardo Hospital, Monza (MB), Italy
| | - Pozzi Matteo
- University of Milan-Bicocca, A.S.S.T. Monza, San Gerardo Hospital, Monza (MB), Italy
| | - Giani Marco
- University of Milan-Bicocca, A.S.S.T. Monza, San Gerardo Hospital, Monza (MB), Italy
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Rudolph J, Huemmer C, Preuhs A, Buizza G, Hoppe BF, Dinkel J, Koliogiannis V, Fink N, Goller SS, Schwarze V, Mansour N, Schmidt VF, Fischer M, Jörgens M, Ben Khaled N, Liebig T, Ricke J, Rueckel J, Sabel BO. Nonradiology Health Care Professionals Significantly Benefit From AI Assistance in Emergency-Related Chest Radiography Interpretation. Chest 2024; 166:157-170. [PMID: 38295950 PMCID: PMC11251081 DOI: 10.1016/j.chest.2024.01.039] [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: 11/06/2023] [Revised: 01/23/2024] [Accepted: 01/23/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Chest radiographs (CXRs) are still of crucial importance in primary diagnostics, but their interpretation poses difficulties at times. RESEARCH QUESTION Can a convolutional neural network-based artificial intelligence (AI) system that interprets CXRs add value in an emergency unit setting? STUDY DESIGN AND METHODS A total of 563 CXRs acquired in the emergency unit of a major university hospital were retrospectively assessed twice by three board-certified radiologists, three radiology residents, and three emergency unit-experienced nonradiology residents (NRRs). They used a two-step reading process: (1) without AI support; and (2) with AI support providing additional images with AI overlays. Suspicion of four suspected pathologies (pleural effusion, pneumothorax, consolidations suspicious for pneumonia, and nodules) was reported on a five-point confidence scale. Confidence scores of the board-certified radiologists were converted into four binary reference standards of different sensitivities. Performance by radiology residents and NRRs without AI support/with AI support were statistically compared by using receiver-operating characteristics (ROCs), Youden statistics, and operating point metrics derived from fitted ROC curves. RESULTS NRRs could significantly improve performance, sensitivity, and accuracy with AI support in all four pathologies tested. In the most sensitive reference standard (reference standard IV), NRR consensus improved the area under the ROC curve (mean, 95% CI) in the detection of the time-critical pathology pneumothorax from 0.846 (0.785-0.907) without AI support to 0.974 (0.947-1.000) with AI support (P < .001), which represented a gain of 30% in sensitivity and 2% in accuracy (while maintaining an optimized specificity). The most pronounced effect was observed in nodule detection, with NRR with AI support improving sensitivity by 53% and accuracy by 7% (area under the ROC curve without AI support, 0.723 [0.661-0.785]; with AI support, 0.890 [0.848-0.931]; P < .001). Radiology residents had smaller, mostly nonsignificant gains in performance, sensitivity, and accuracy with AI support. INTERPRETATION We found that in an emergency unit setting without 24/7 radiology coverage, the presented AI solution features an excellent clinical support tool to nonradiologists, similar to a second reader, and allows for a more accurate primary diagnosis and thus earlier therapy initiation.
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Affiliation(s)
- Jan Rudolph
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany.
| | - Christian Huemmer
- XP Technology and Innovation, Siemens Healthcare GmbH, Forchheim, Germany
| | - Alexander Preuhs
- XP Technology and Innovation, Siemens Healthcare GmbH, Forchheim, Germany
| | - Giulia Buizza
- XP Technology and Innovation, Siemens Healthcare GmbH, Forchheim, Germany
| | - Boj F Hoppe
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Julien Dinkel
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany; Comprehensive Pneumology Center, German Center for Lung Research, Munich, Germany; Department of Radiology, Asklepios Fachklinik München, Gauting, Germany
| | | | - Nicola Fink
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Sophia S Goller
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Vincent Schwarze
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Nabeel Mansour
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Vanessa F Schmidt
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Fischer
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Jörgens
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Najib Ben Khaled
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Thomas Liebig
- Institute of Neuroradiology, University Hospital, LMU Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Johannes Rueckel
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany; Institute of Neuroradiology, University Hospital, LMU Munich, Munich, Germany
| | - Bastian O Sabel
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
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Waxman MJ, Schechter-Perkins EM. Peripheral Intravenous Catheters Are Preferable for Emergency Department Patients With Septic Shock. Ann Emerg Med 2024; 83:607-608. [PMID: 38456867 DOI: 10.1016/j.annemergmed.2024.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 01/15/2024] [Accepted: 01/23/2024] [Indexed: 03/09/2024]
Affiliation(s)
- Michael J Waxman
- Department of Emergency Medicine, Albany Medical College, Albany, NY
| | - Elissa M Schechter-Perkins
- Department of Emergency Medicine, Boston Medical Center/Boston University Chobanian and Avedisian School of Medicine, Boston, MA
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Brindley PG, Deschamps J, Milovanovic L, Buchanan BM. Are routine chest radiographs still indicated after central line insertion? A scoping review. J Intensive Care Soc 2024; 25:190-207. [PMID: 38737308 PMCID: PMC11086721 DOI: 10.1177/17511437241227739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2024] Open
Abstract
Introduction Central venous catheters are increasingly inserted using point-of-care ultrasound (POCUS) guidance. Following insertion, it is still common to request a confirmatory chest radiograph for subclavian and internal jugular lines, at least outside of the operating theater. This scoping review addresses: (i) the justification for routine post-insertion radiographs, (ii) whether it would better to use post-insertion POCUS instead, and (iii) the perceived barriers to change. Methods We searched the electronic databases, Ovid MEDLINE (1946-) and Ovid EMBASE (1974-), using the MESH terms ("Echography" OR "Ultrasonography" OR "Ultrasound") AND "Central Venous Catheter" up until February 2023. We also searched clinical practice guidelines, and targeted literature, including cited and citing articles. We included adults (⩾18 years) and English and French language publications. We included randomized control trials, prospective and retrospective cohort studies, systematic reviews, and surveys. Results Four thousand seventy-one articles were screened, 117 full-text articles accessed, and 41 retained. Thirteen examined cardiac/vascular methods; 5 examined isolated contrast-enhanced ultrasonography; 7 examined isolated rapid atrial swirl sign; and 13 examined combined/integrated methods. In addition, three systematic reviews/meta-analyses and one survey addressed barriers to POCUS adoption. Discussion We believe that the literature supports retiring the routine post-central line chest radiograph. This is not only because POCUS has made line insertion safer, but because POCUS performs at least as well, and is associated with less radiation, lower cost, time savings, and greater accuracy. There has been less written about perceived barriers to change, but the literature shows that these concerns- which include upfront costs, time-to-train, medicolegal concerns and habit- can be challenged and hence overcome.
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Affiliation(s)
- P. G. Brindley
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - J. Deschamps
- Department of Intensive Care and Resuscitation, Integrated Hospital Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - L. Milovanovic
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - B. M. Buchanan
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
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Munroe ES, Weinstein J, Gershengorn HB, Karlic KJ, Seelye S, Sjoding MW, Valley TS, Prescott HC. Understanding How Clinicians Personalize Fluid and Vasopressor Decisions in Early Sepsis Management. JAMA Netw Open 2024; 7:e247480. [PMID: 38639934 PMCID: PMC11031682 DOI: 10.1001/jamanetworkopen.2024.7480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 02/21/2024] [Indexed: 04/20/2024] Open
Abstract
Importance Recent sepsis trials suggest that fluid-liberal vs fluid-restrictive resuscitation has similar outcomes. These trials used generalized approaches to resuscitation, and little is known about how clinicians personalize fluid and vasopressor administration in practice. Objective To understand how clinicians personalize decisions about resuscitation in practice. Design, Setting, and Participants This survey study of US clinicians in the Society of Critical Care Medicine membership roster was conducted from November 2022 to January 2023. Surveys contained 10 vignettes of patients with sepsis where pertinent clinical factors (eg, fluid received and volume status) were randomized. Respondents selected the next steps in management. Data analysis was conducted from February to September 2023. Exposure Online Qualtrics clinical vignette survey. Main Outcomes and Measures Using multivariable logistic regression, the associations of clinical factors with decisions about fluid administration, vasopressor initiation, and vasopressor route were tested. Results are presented as adjusted proportions with 95% CIs. Results Among 11 203 invited clinicians, 550 (4.9%; 261 men [47.5%] and 192 women [34.9%]; 173 with >15 years of practice [31.5%]) completed at least 1 vignette and were included. A majority were physicians (337 respondents [61.3%]) and critical care trained (369 respondents [67.1%]). Fluid volume already received by a patient was associated with resuscitation decisions. After 1 L of fluid, an adjusted 82.5% (95% CI, 80.2%-84.8%) of respondents prescribed additional fluid and an adjusted 55.0% (95% CI, 51.9%-58.1%) initiated vasopressors. After 5 L of fluid, an adjusted 17.5% (95% CI, 15.1%-19.9%) of respondents prescribed more fluid while an adjusted 92.7% (95% CI, 91.1%-94.3%) initiated vasopressors. More respondents prescribed fluid when the patient examination found dry vs wet (ie, overloaded) volume status (adjusted proportion, 66.9% [95% CI, 62.5%-71.2%] vs adjusted proportion, 26.5% [95% CI, 22.3%-30.6%]). Medical history, respiratory status, lactate trend, and acute kidney injury had small associations with fluid and vasopressor decisions. In 1023 of 1127 vignettes (90.8%) where the patient did not have central access, respondents were willing to start vasopressors through a peripheral intravenous catheter. In cases where patients were already receiving peripheral norepinephrine, respondents were more likely to place a central line at higher norepinephrine doses of 0.5 µg/kg/min (adjusted proportion, 78.0%; 95% CI, 74.7%-81.2%) vs 0.08 µg/kg/min (adjusted proportion, 25.2%; 95% CI, 21.8%-28.5%) and after 24 hours (adjusted proportion, 59.5%; 95% CI, 56.6%-62.5%) vs 8 hours (adjusted proportion, 47.1%; 95% CI, 44.0%-50.1%). Conclusions and Relevance These findings suggest that fluid volume received is the predominant factor associated with ongoing fluid and vasopressor decisions, outweighing many other clinical factors. Peripheral vasopressor use is common. Future studies aimed at personalizing resuscitation must account for fluid volumes and should incorporate specific tools to help clinicians personalize resuscitation.
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Affiliation(s)
- Elizabeth S. Munroe
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
| | - Julien Weinstein
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Hayley B. Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | | | - Sarah Seelye
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Michael W. Sjoding
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
| | - Thomas S. Valley
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Hallie C. Prescott
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor
- VA Center for Clinical Management Research, Ann Arbor, Michigan
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Darwish D, Karamchandani K. PRO: Vasopressors Can Be Administered Safely via a Peripheral Intravenous Catheter. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00105-8. [PMID: 38453557 DOI: 10.1053/j.jvca.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 03/09/2024]
Affiliation(s)
- Dana Darwish
- Department of Anesthesiology and Pain Management, Division of Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kunal Karamchandani
- Department of Anesthesiology and Pain Management, Division of Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX.
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Gidaro A, Casella F, Cogliati C, La Greca A, Lugli F, Trione C, Calloni M, Melchionda C, Samartin F, Salvi E, Ceriani E. Pulsed-wave Doppler for ultrasound-based tip location using bubble test: A pilot study. J Vasc Access 2024; 25:287-293. [PMID: 35791079 DOI: 10.1177/11297298221109662] [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: 11/16/2022] Open
Abstract
BACKGROUND MicroBubbles Time test (MBT), consisting in the rapid infusion of saline with addition of air microbubbles, visualized by B-mode echocardiography, represents a potential alternative to Intracavitary ECG (IC-ECG) and chest X-ray for central venous catheters (CVCs) tip location. Even if promising, this technique lacks of standardization: a clear time cut-off between bubble infusion and their detection in heart's right chambers hasn't been yet established. At these regard, microbubbles could be also detected as microembolic signals (MES) with an alternative ultrasound technique: the pulse wave Doppler (PW). OBJECTIVE AND METHODS The first aim of this pilot study is to establish agreement of MBT with PW test (MBT-PW) compared with reference standard IC-ECG and normal MBT for tip location on CVCs. Corrected tip's position was established through reference standard IC-ECG, afterward MBT-PW was performed, with the sample volume placed at tricuspid valve to detect MES simultaneously with micro-bubbles injection in CVCs. The second aim was to evaluate inter-observer variability for MES detection and grading. RESULTS Eight patients were enrolled; we obtained three records for each patients (24 with MBT and 24 with MBT-PW, the two techniques were acquired simultaneously). Inter-methods agreement through reference standard IC-ECG versus MBT-PW and MBT versus MBT-PW methodic was satisfying (Cohen's kappa value = 1). MBT-PW and MBT signals were recorded within the first heart beat after microbubble infusion in all patients. Mean time delay thorough MBT-PW and MBT was 0.76 ±0.07 and 0.78 ± 0.07 s respectively; Intraclass correlation coefficient was 0.992 (95% CI: 0.981-0.996) suggesting excellent correlation. Inter-observer variability for positive MBT-PW evaluation was optimal (Cohen's kappa value was 1), while indicated substantial agreement for MES grade evaluation (Fleiss' Kappa value was 0.704; 95% CI: 0.328-1.000). CONCLUSIONS Our study supports agreement between MBT-PW and reference standard IC-ECG for tip location. Satisfactory agreement was observed also for MBT-PW and MBT.
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Affiliation(s)
- Antonio Gidaro
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Francesco Casella
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Chiara Cogliati
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
| | | | - Francesca Lugli
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Chiara Trione
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Maria Calloni
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Chiara Melchionda
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Federica Samartin
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Emanuele Salvi
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Elisa Ceriani
- Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Luigi Sacco Hospital, Milan, Italy
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10
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Ablordeppey EA, Keating SM, Brown KM, Theodoro DL, Griffey RT, James AS. Implementation of ultrasound after central venous catheter insertion: A qualitative study in early adopters. J Vasc Access 2023; 24:879-888. [PMID: 34763555 DOI: 10.1177/11297298211053447] [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: 11/15/2022] Open
Abstract
BACKGROUND The adoption rate of point of care ultrasound (POCUS) for the confirmation of central venous catheter (CVC) positioning and exclusion of post procedure pneumothorax is low despite advantages in workflow compared to traditional chest X-ray (CXR). To explore why, we convened focus groups to address barriers and facilitators of implementation for POCUS guided CVC confirmation and de-implementation of post-procedure CXR. METHODS We conducted focus groups with emergency medicine and critical care providers to discuss current practices in POCUS for CVC confirmation. The semi-structured focus group interview guide was informed by the Consolidated Framework for Implementation Research (CFIR). We performed qualitative content analysis of the resulting transcripts using a consensual qualitative research approach (NVivo software), aiming to identify priority categories that describe the barriers and facilitators of POCUS guided CVC confirmation. RESULTS The coding dictionary of barriers and facilitators consisted of 21 codes from the focus group discussions. Our qualitative analysis revealed that 12 codes emerged spontaneously (inductively) within the focus group discussions and aligned directly to CFIR constructs. Common barriers included provider influences (e.g. knowledge and beliefs about POCUS for CVC confirmation), external network (e.g. societal guidelines, ancillary staff, and consultants), and inertia (habit or reflexive processes). Common facilitators included ultrasound protocol advantage and champions. Time and provider outcomes (cognitive offload, ownership, and independence) emerged as early barriers but late facilitators. CONCLUSION Our qualitative analysis demonstrates real and perceived barriers against implementation of POCUS for CVC position confirmation and pneumothorax exclusion. Our findings discovered organizational and personal constructs that will inform development of multifaceted strategies toward implementation of POCUS after CVC insertion.
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Affiliation(s)
- Enyo A Ablordeppey
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Shannon M Keating
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Katherine M Brown
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Daniel L Theodoro
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Richard T Griffey
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Aimee S James
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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Greca AL, Iacobone E, Elisei D, Biasucci DG, D'Andrea V, Barone G, Zito Marinosci G, Pittiruti M. ECHOTIP: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in adult patients. J Vasc Access 2023; 24:535-544. [PMID: 34494474 DOI: 10.1177/11297298211044325] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Central venous access devices are routinely used in clinical practice for administration of fluids and medications, for drawing blood samples and for hemodynamic monitoring. The adoption of ultrasound guided venipuncture has significantly reduced procedure-related complications, as documented by the recommendations of most recent guidelines. Ultrasound has also an important role also in other aspects of central venous catheterization, such as in the pre-procedural evaluation of the venous patrimony and in the detection of early and late non-infective complications. Recently, bedside ultrasound has been regarded as a promising tool also for ensuring an accurate and intraprocedural method of tip navigation and tip location. The aim of this paper is to review all the evidence about the accuracy of ultrasound methods for tip navigation and tip location in adult patients, and to suggest a structured standardized protocol for clinical practice.
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Affiliation(s)
- Antonio La Greca
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Emanuele Iacobone
- Department of Intensive Care and Anesthesia, Central Hospital, Macerata, Italy
| | - Daniele Elisei
- Department of Intensive Care and Anesthesia, Central Hospital, Macerata, Italy
| | - Daniele Guerino Biasucci
- Department of Emergency, Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Vito D'Andrea
- Neonatal Intensive Care Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Barone
- Neonatal Intensive Care Unit, Ospedale Infermi di Rimini, Azienda Unità Sanitaria Locale della Romagna, Rimini, Italy
| | - Geremia Zito Marinosci
- UOC di Rianimazione e Neuroanestesia, Azienda Ospedaliera Santobono-Pausilipon, Naples, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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12
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Walsh E, Fitzsimons M. Preventing mechanical complications associated with central venous catheter placement. BJA Educ 2023; 23:229-237. [PMID: 37223695 PMCID: PMC10201402 DOI: 10.1016/j.bjae.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/01/2023] [Accepted: 02/22/2023] [Indexed: 05/25/2023] Open
Affiliation(s)
- E.C. Walsh
- Massachusetts General Hospital, Boston, MA, USA
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13
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Ablordeppey EA, Koenig AM, Barker AR, Hernandez EE, Simkovich SM, Krings JG, Brown DS, Griffey RT. Response to "Comments on Economic Evaluation of Ultrasound-guided Central Venous Catheter Confirmation vs Chest Radiography in Critically Ill Patients: A Labor Cost Model". West J Emerg Med 2023; 24:370-371. [PMID: 36976609 PMCID: PMC10047731 DOI: 10.5811/westjem.2023.1.60160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 01/23/2023] [Indexed: 03/29/2023] Open
Affiliation(s)
- Enyo A Ablordeppey
- Washington University School of Medicine, Department of Anesthesiology, St. Louis, Missouri
- Washington University School of Medicine, Department of Emergency Medicine, St. Louis, Missouri
| | - Adam M Koenig
- Washington University School of Medicine, St. Louis, Missouri
| | - Abigail R Barker
- Washington University, Center for Health Economics and Policy at the Institute for Public Health, St. Louis, Missouri
| | - Emily E Hernandez
- Washington University, Center for Health Economics and Policy at the Institute for Public Health, St. Louis, Missouri
| | - Suzanne M Simkovich
- Medstar Health Research Institute, Division of Healthcare Delivery Research, Hyattsville, Maryland
- Georgetown University School of Medicine, Department of Medicine, Washington, DC
| | - James G Krings
- Washington University School of Medicine, Division of Pulmonary Critical Care Medicine, Department of Medicine, St. Louis, Missouri
| | - Derek S Brown
- Washington University in St. Louis, Brown School, St. Louis, Missouri
| | - Richard T Griffey
- Washington University School of Medicine, Department of Emergency Medicine, St. Louis, Missouri
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14
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Austin S, Tran QK, Pourmand A, Matta A, Haase D. Comments on "Economic Evaluation of Ultrasound-guided Central Venous Catheter Confirmation vs Chest Radiography in Critically Ill Patients: A Labor Cost Model". West J Emerg Med 2023; 24:368-369. [PMID: 36976610 PMCID: PMC10047744 DOI: 10.5811/westjem.2022.10.59187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 10/13/2022] [Indexed: 03/29/2023] Open
Affiliation(s)
- Samuel Austin
- University of Maryland School of Medicine, The R Adams Cowley Shock Trauma Center, Department of Surgical Critical Care, Baltimore, Maryland
| | - Quincy K Tran
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Ali Pourmand
- George Washington University School of Medicine and Health Sciences, Department of Emergency Medicine, Washington, DC
| | - Ann Matta
- University of Maryland School of Medicine, The R Adams Cowley Shock Trauma Center, Department of Surgical Critical Care, Baltimore, Maryland
| | - Daniel Haase
- University of Maryland School of Medicine, The R Adams Cowley Shock Trauma Center, Department of Surgical Critical Care, Baltimore, Maryland
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
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15
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Ultrasound-Guided Infraclavicular Axillary Vein Versus Internal Jugular Vein Cannulation in Critically Ill Mechanically Ventilated Patients: A Randomized Trial. Crit Care Med 2023; 51:e37-e44. [PMID: 36476809 PMCID: PMC9847684 DOI: 10.1097/ccm.0000000000005740] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES This clinical trial aimed to compare the ultrasound-guided in-plane infraclavicular cannulation of the axillary vein (AXV) and the ultrasound-guided out-of-plane cannulation of the internal jugular vein (IJV). DESIGN A prospective, single-blinded, open label, parallel-group, randomized trial. SETTING Two university-affiliated ICUs in Poland (Opole and Lublin). PATIENTS Mechanically ventilated intensive care patients with clinical indications for central venous line placement. INTERVENTIONS Patients were randomly assigned into two groups: the IJV group ( n = 304) and AXV group ( n = 306). The primary outcome was to compare the IJV group and AXV group through the venipuncture and catheterization success rates. Secondary outcomes were catheter tip malposition and early mechanical complication rates. All catheterizations were performed by advanced residents and consultants in anesthesiology and intensive care. MEASUREMENTS AND MAIN RESULTS The IJV puncture rate was 100%, and the AXV was 99.7% (chi-square, p = 0.19). The catheterization success rate in the IJV group was 98.7% and 96.7% in the AXV group (chi-square, p = 0.11). The catheter tip malposition rate was 9.9% in the IJV group and 10.1% in the AXV group (chi-square, p = 0.67). The early mechanical complication rate in the IJV group was 3% (common carotid artery puncture-4 cases, perivascular hematoma-2 cases, vertebral artery puncture-1 case, pneumothorax-1 case) and 2.6% in the AXV group (axillary artery puncture-4 cases, perivascular hematoma-4 cases) (chi-square, p = 0.79). CONCLUSIONS No difference was found between the real-time ultrasound-guided out-of-plane cannulation of the IJV and the infraclavicular real-time ultrasound-guided in-plane cannulation of the AXV. Both techniques are equally efficient and safe in mechanically ventilated critically ill patients.
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16
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D'Arrigo S, Annetta MG, Pittiruti M. An ultrasound-based technique in the management of totally implantable venous access devices with persistent withdrawal occlusion. J Vasc Access 2023; 24:140-144. [PMID: 34096379 DOI: 10.1177/11297298211023275] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Persistent withdrawal occlusion is a specific catheter malfunction characterized by inability to withdraw blood through the device while infusion is maintained. The main causes are fibroblastic sleeve and tip malposition (associated or not to venous thrombosis around the tip). All current guidelines recommend infusing vesicant/antiblastic drugs through a central venous port only after assessment of blood return. In PWO, blood return is impossible. We have recently started to assess the intravascular position of the tip and the delivery of the infusion in the proximity of the cavo-atrial junction utilizing transthoracic/subxiphoid ultrasound with the 'bubble test'. We found that this is an easy, real-time, accurate and safe method for verifying the possibility of using a port for chemotherapy even in the absence of blood return, as it occurs with persistent withdrawal occlusion.
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Affiliation(s)
- Sonia D'Arrigo
- Deptartment of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Giuseppina Annetta
- Deptartment of Anesthesia and Intensive Care, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Mauro Pittiruti
- Deptartment of Surgery, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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17
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Zito Marinosci G, Biasucci DG, Barone G, D'Andrea V, Elisei D, Iacobone E, La Greca A, Pittiruti M. ECHOTIP-Ped: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in pediatric patients. J Vasc Access 2023; 24:5-13. [PMID: 34256613 DOI: 10.1177/11297298211031391] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Central venous access devices are routinely used in pediatric care for administration of fluids and medications and for drawing blood samples. The adoption of ultrasound guided venipuncture, the availability of bedside ultrasound devices and the use of intraprocedural methods for tip location have been shown to reduce procedure-related complications, as documented by the recommendations of most recent guidelines. In pediatric patients, bedside ultrasound is a promising tool not only for optimizing the choice of the vein and guiding the venipuncture, but also for ensuring an accurate and intraprocedural method of tip navigation and tip location. The aim of this paper is to review all the evidence about the accuracy of ultrasound methods for tip navigation and tip location in pediatric patients, and to suggest a structured protocol for clinical practice.
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Affiliation(s)
- Geremia Zito Marinosci
- UOC di Rianimazione e Neuroanestesia, Azienda Ospedaliera di Rilievo Nazionale Santobono-Pausilipon, Neaples, Italy
| | - Daniele Guerino Biasucci
- Department of Emergency, Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Barone
- Neonatal Intensive Care Unit, Ospedale Infermi di Rimini, Azienda Unità Sanitaria Locale della Romagna, Rimini, Italy
| | - Vito D'Andrea
- Neonatal Intensive Care Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Daniele Elisei
- Department of Intensive Care and Anesthesia, Central Hospital, Macerata, Italy
| | - Emanuele Iacobone
- Department of Intensive Care and Anesthesia, Central Hospital, Macerata, Italy
| | - Antonio La Greca
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Mauro Pittiruti
- Department of Surgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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18
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Toy D, Siegel MD, Rubinowitz AN. Imaging in the Intensive Care Unit. Semin Respir Crit Care Med 2022; 43:899-923. [PMID: 36442475 DOI: 10.1055/s-0042-1750041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Radiology plays an important role in the management of the most seriously ill patients in the hospital. Over the years, continued advances in imaging technology have contributed to an improvement in patient care. However, even with such advances, the portable chest radiograph (CXR) remains one of the most commonly requested radiographic examinations. While they provide valuable information, CXRs remain relatively insensitive at revealing abnormalities and are often nonspecific. Chest computed tomography (CT) can display findings that are occult on CXR and is particularly useful at identifying and characterizing pleural effusions, detecting barotrauma including small pneumothoraces, distinguishing pneumonia from atelectasis, and revealing unsuspected or additional abnormalities which could result in increased morbidity and mortality if left untreated. CT pulmonary angiography is the modality of choice in the evaluation of pulmonary emboli which can complicate the hospital course of the ICU patient. This article will provide guidance for interpretation of CXR and thoracic CT images, discuss some of the invasive devices routinely used, and review the radiologic manifestations of common pathologic disease states encountered in ICU patients. In addition, imaging findings and complications of more specific clinical scenarios in which the incidence has increased in the ICU setting, such as patients who are immunocompromised, have interstitial lung disease, or COVID-19, will also be discussed. Communication between the radiologist and intensivist, particularly on complicated cases, is important to help increase diagnostic accuracy and leads to an improvement in the management of the most critically ill patients.
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Affiliation(s)
- Dennis Toy
- Department of Medical Imaging, Colorado Permanente Medical Group, Lafayette, Colorado
| | - Mark D Siegel
- Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ami N Rubinowitz
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
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19
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Ross DW, Moses AA, Niyyar VD. Point-of-care ultrasonography in nephrology comes of age. Clin Kidney J 2022; 15:2220-2227. [PMID: 36381376 PMCID: PMC9664573 DOI: 10.1093/ckj/sfac160] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Indexed: 03/22/2024] Open
Abstract
The physical exam is changing. Many have argued that the physical exam of the 21st century should include point-of-care ultrasound (POCUS). POCUS is being taught in medical schools and has been endorsed by the major professional societies of internal medicine. In this review we describe the trend toward using POCUS in medicine and describe where the practicing nephrologist fits in. We discuss what a nephrologist's POCUS exam should entail and we give special attention to what nephrologists can gain from learning POCUS. We suggest a 'nephro-centric' approach that includes not only ultrasound of the kidney and bladder, but of the heart, lungs and vascular access. We conclude by reviewing some of the sparse data available to guide training initiatives and give suggested next steps for advancing POCUS in nephrology.
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Affiliation(s)
- Daniel W Ross
- Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Division of Kidney Diseases and Hypertension, Great Neck, NY, USA
| | - Andrew A Moses
- Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Lenox Hill Division of Nephrology, New York, NY, USA
| | - Vandana Dua Niyyar
- Emory University, Division of Nephrology, Woodruff Memorial Research Building, Atlanta GA, USA
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20
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Che Rahim MJ, Abdull Wahab SF, Fauzi MH, Nadarajan C, Ab Hamid SA. Supradiaphragmatic central venous catheter malposition detection using the parasternal long-axis echocardiographic view and dextrose 50% contrast solution: A pilot study. ULTRASOUND (LEEDS, ENGLAND) 2022; 30:292-298. [PMID: 36969538 PMCID: PMC10034659 DOI: 10.1177/1742271x211051767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/03/2021] [Indexed: 11/15/2022]
Abstract
Background Contrast-enhanced ultrasonography (CEUS) using saline was studied to detect supradiaphragmatic central venous catheter malposition. Commonly used echocardiographic views are apical 4-chamber (A4c) and subcostal views. However, this standard method is not feasible in certain situations. We explored the feasibility of the right ventricle inflow parasternal long axis (RVI-PLAX) echocardiographic view and dextrose 50% (D50%) contrast solution for detecting supradiaphragmatic central venous catheter malposition. Method This pilot study screened 60 patients who underwent ultrasound-guided supradiaphragmatic central venous catheter insertion. We compared the investigators' guidewire's J-tip detection, D50% rapid atrial swirl sign (RASS) findings on the RVI-PLAX view and the central venous catheter tip on chest radiograph. We also compared the mean capillary blood sugar level before and after the 5 ml D50% flush. Results No guidewire J-tips were detected from the RVI-PLAX view. The first and second investigators' diagnosis of central venous catheter malposition detected on RVI-PLAX CEUS achieved an almost perfect agreement (κ = 1.0 (95% confidence interval (CI): 0.90 to 1.0), p < .0001). The RVI-PLAX CEUS was not able to detect two central venous catheter malpositions (one atrial malposition and one left brachiocephalic vein venous catheter malposition). The capillary blood sugar was significantly elevated (8.96 mmol/L vs. 9.75 mmol/L) after D50% flush (p < 0.005) with no complications reported within 30 minutes after the D50% flush. Conclusion RVI-PLAX view should not be used for guidewire detection. CEUS using D50% and RVI-PLAX view are potentially useful tools in detecting central venous catheter malposition. Further studies comparing them with conventional methods are needed.
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Affiliation(s)
- Mohd Jazman Che Rahim
- School of Medical Sciences, Universiti Sains Malaysia – Kampus
Kesihatan, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Kelantan, Malaysia
| | - Shaik Farid Abdull Wahab
- School of Medical Sciences, Universiti Sains Malaysia – Kampus
Kesihatan, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Kelantan, Malaysia
| | - Mohd Hashairi Fauzi
- School of Medical Sciences, Universiti Sains Malaysia – Kampus
Kesihatan, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Kelantan, Malaysia
| | - Chandran Nadarajan
- School of Medical Sciences, Universiti Sains Malaysia – Kampus
Kesihatan, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Kelantan, Malaysia
| | - Siti Azrin Ab Hamid
- School of Medical Sciences, Universiti Sains Malaysia – Kampus
Kesihatan, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, Kelantan, Malaysia
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21
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Ablordeppey EA, Koenig AM, Barker AR, Hernandez EE, Simkovich SM, Krings JG, Brown DS, Griffey RT. Economic Evaluation of Ultrasound-guided Central Venous Catheter Confirmation vs Chest Radiography in Critically Ill Patients: A Labor Cost Model. West J Emerg Med 2022; 23:760-768. [PMID: 36205669 PMCID: PMC9541994 DOI: 10.5811/westjem.2022.7.56501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 06/23/2022] [Accepted: 07/04/2022] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Despite evidence suggesting that point-of-care ultrasound (POCUS) is faster and non-inferior for confirming position and excluding pneumothorax after central venous catheter (CVC) placement compared to traditional radiography, millions of chest radiographs (CXR) are performed annually for this purpose. Whether the use of POCUS results in cost savings compared to CXR is less clear but could represent a relative advantage in implementation efforts. Our objective in this study was to evaluate the labor cost difference for POCUS-guided vs CXR-guided CVC position confirmation practices. METHODS We developed a model to evaluate the per patient difference in labor cost between POCUS-guided vs CXR-guided CVC confirmation at our local urban, tertiary academic institution. We used internal cost data from our institution to populate the variables in our model. RESULTS The estimated labor cost per patient was $18.48 using CXR compared to $14.66 for POCUS, resulting in a net direct cost savings of $3.82 (21%) per patient using POCUS for CVC confirmation. CONCLUSION In this study comparing the labor costs of two approaches for CVC confirmation, the more efficient alternative (POCUS-guided) is not more expensive than traditional CXR. Performing an economic analysis framed in terms of labor costs and work efficiency may influence stakeholders and facilitate earlier adoption of POCUS for CVC confirmation.
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Affiliation(s)
- Enyo A Ablordeppey
- Washington University School of Medicine, Department of Anesthesiology, St. Louis, Missouri
- Washington University School of Medicine, Department of Emergency Medicine, St. Louis, Missouri
| | - Adam M Koenig
- Washington University School of Medicine, St. Louis, Missouri
| | - Abigail R Barker
- Washington University, Center for Health Economics and Policy at the Institute for Public Health, St. Louis, Missouri
| | - Emily E Hernandez
- Washington University, Center for Health Economics and Policy at the Institute for Public Health, St. Louis, Missouri
| | - Suzanne M Simkovich
- Medstar Health Research Institute, Division of Healthcare Delivery Research, Hyattsville, Maryland
- Georgetown University School of Medicine, Department of Medicine, Washington, DC
| | - James G Krings
- Washington University School of Medicine, Division of Pulmonary Critical Care Medicine, Department of Medicine, St. Louis, Missouri
| | - Derek S Brown
- Washington University in St. Louis, Brown School, St. Louis, Missouri
| | - Richard T Griffey
- Washington University School of Medicine, Department of Emergency Medicine, St. Louis, Missouri
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22
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Lewis LM, Steele MT, Szewczyk M. Anyone Anytime for Anything: The History of Emergency Medicine in Missouri. MISSOURI MEDICINE 2022; 119:460-466. [PMID: 36338000 PMCID: PMC9616461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The history of Emergency Medicine (EM) in Missouri reflects the larger history of EM as a burgeoning specialty throughout the United States, but with some important and unique contributions that may not be generally appreciated. We discuss historical events and important leaders of EM, but there are many we could not mention. Much of the information comes from personal interviews with the physicians who "were in the room where it happened.". We hope the article will illuminate the progress made in caring for critical illness and injury through the development of a new specialty focused on that goal. We recognize there are many emergency physicians not mentioned that have played a large role in maintaining and growing the academic programs, improving the delivery of care through administrative and legislative actions, and navigating the specialty through enormously challenging times.
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Affiliation(s)
- Lawrence M Lewis
- Professor, Emergency Medicine, at Washington University School of Medicine, St. Louis, Missouri
| | - Mark T Steele
- Professor, Emergency Medicine, University Health Truman Medical Center, University Health Emergency Department and Trauma Center, Kansas City, Missouri
| | - Michael Szewczyk
- Specializes in Emergency, Occupational, and Internal Medicine at Boone Hospital in Columbia, Missouri
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23
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Rudolph J, Schachtner B, Fink N, Koliogiannis V, Schwarze V, Goller S, Trappmann L, Hoppe BF, Mansour N, Fischer M, Ben Khaled N, Jörgens M, Dinkel J, Kunz WG, Ricke J, Ingrisch M, Sabel BO, Rueckel J. Clinically focused multi-cohort benchmarking as a tool for external validation of artificial intelligence algorithm performance in basic chest radiography analysis. Sci Rep 2022; 12:12764. [PMID: 35896763 PMCID: PMC9329327 DOI: 10.1038/s41598-022-16514-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 07/11/2022] [Indexed: 01/08/2023] Open
Abstract
Artificial intelligence (AI) algorithms evaluating [supine] chest radiographs ([S]CXRs) have remarkably increased in number recently. Since training and validation are often performed on subsets of the same overall dataset, external validation is mandatory to reproduce results and reveal potential training errors. We applied a multicohort benchmarking to the publicly accessible (S)CXR analyzing AI algorithm CheXNet, comprising three clinically relevant study cohorts which differ in patient positioning ([S]CXRs), the applied reference standards (CT-/[S]CXR-based) and the possibility to also compare algorithm classification with different medical experts’ reading performance. The study cohorts include [1] a cohort, characterized by 563 CXRs acquired in the emergency unit that were evaluated by 9 readers (radiologists and non-radiologists) in terms of 4 common pathologies, [2] a collection of 6,248 SCXRs annotated by radiologists in terms of pneumothorax presence, its size and presence of inserted thoracic tube material which allowed for subgroup and confounding bias analysis and [3] a cohort consisting of 166 patients with SCXRs that were evaluated by radiologists for underlying causes of basal lung opacities, all of those cases having been correlated to a timely acquired computed tomography scan (SCXR and CT within < 90 min). CheXNet non-significantly exceeded the radiology resident (RR) consensus in the detection of suspicious lung nodules (cohort [1], AUC AI/RR: 0.851/0.839, p = 0.793) and the radiological readers in the detection of basal pneumonia (cohort [3], AUC AI/reader consensus: 0.825/0.782, p = 0.390) and basal pleural effusion (cohort [3], AUC AI/reader consensus: 0.762/0.710, p = 0.336) in SCXR, partly with AUC values higher than originally published (“Nodule”: 0.780, “Infiltration”: 0.735, “Effusion”: 0.864). The classifier “Infiltration” turned out to be very dependent on patient positioning (best in CXR, worst in SCXR). The pneumothorax SCXR cohort [2] revealed poor algorithm performance in CXRs without inserted thoracic material and in the detection of small pneumothoraces, which can be explained by a known systematic confounding error in the algorithm training process. The benefit of clinically relevant external validation is demonstrated by the differences in algorithm performance as compared to the original publication. Our multi-cohort benchmarking finally enables the consideration of confounders, different reference standards and patient positioning as well as the AI performance comparison with differentially qualified medical readers.
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Affiliation(s)
- Jan Rudolph
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Balthasar Schachtner
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.,Comprehensive Pneumology Center, German Center for Lung Research, Munich, Germany
| | - Nicola Fink
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.,Comprehensive Pneumology Center, German Center for Lung Research, Munich, Germany
| | - Vanessa Koliogiannis
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Vincent Schwarze
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Sophia Goller
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Lena Trappmann
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Boj F Hoppe
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Nabeel Mansour
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Maximilian Fischer
- Department of Medicine I, University Hospital, LMU Munich, Munich, Germany
| | - Najib Ben Khaled
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Maximilian Jörgens
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Julien Dinkel
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.,Comprehensive Pneumology Center, German Center for Lung Research, Munich, Germany.,Department of Radiology, Asklepios Fachklinik München, Gauting, Germany
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Michael Ingrisch
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Bastian O Sabel
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Johannes Rueckel
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.,Institute of Neuroradiology, University Hospital, LMU Munich, Munich, Germany
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Kilian S, Surrey A, McCarron W, Mueller K, Wessman BT. Vasopressor Administration via Peripheral Intravenous Access for Emergency Department Stabilization in Septic Shock Patients. Indian J Crit Care Med 2022; 26:811-815. [PMID: 36864853 PMCID: PMC9973174 DOI: 10.5005/jp-journals-10071-24243] [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] [Indexed: 11/23/2022] Open
Abstract
Background Septic shock is commonly treated in the emergency department (ED) with vasopressors. Prior data have shown that vasopressor administration through a peripheral intravenous line (PIV) is feasible. Objectives To characterize vasopressor administration for patients presenting to an academic ED in septic shock. Materials and methods Retrospective observational cohort study evaluating initial vasopressor administration for septic shock. ED patients from June 2018 to May 2019 were screened. Exclusion criteria included other shock states, hospital transfers, or heart failure history. Patient demographics, vasopressor data, and length of stay (LOS) were collected. Cases were grouped by initiation site: PIV, ED placed central line (ED-CVL), or tunneled port/indwelling central line (Prior-CVL). Results Of the 136 patients identified, 69 were included. Vasopressors were initiated via PIV in 49%, ED-CVL in 25%, and prior-CVL in 26%. The time to initiation was 214.8 minutes in PIV and 294.7 minutes in ED-CVL (p = 0.240). Norepinephrine predominated all groups. No extravasation or ischemic complications were identified with PIV vasopressor administration. Twenty-eight-day mortality was 20.6% for PIV, 17.6% for ED-CVL, and 61.1% for prior-CVL. Of 28-day survivors, ICU LOS was 4.44 for PIV and 4.86 for ED-CVL (p = 0.687), while vasopressor days were 2.26 for PIV and 3.14 for ED-CVL (p = 0.050). Conclusion Vasopressors are being administered via PIVs for ED septic shock patients. Norepinephrine comprised the majority of initial PIV vasopressor administration. There were no documented episodes of extravasation or ischemia. Further studies should look at the duration of PIV administration with potential avoidance of central venous cannulation altogether in appropriate patients. How to cite this article Kilian S, Surrey A, McCarron W, Mueller K, Wessman BT. Vasopressor Administration via Peripheral Intravenous Access for Emergency Department Stabilization in Septic Shock Patients. Indian J Crit Care Med 2022;26(7):811-815.
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Affiliation(s)
- Scott Kilian
- Department of Emergency Medicine, Washington University in St Louis, School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri, United States of America
| | - Aaron Surrey
- Division of Critical Care Medicine, Department of Anesthesiology, Washington University in St Louis, School of Medicine, St Louis, Missouri, United States of America
| | - Weston McCarron
- Department of Emergency Medicine, Washington University in St Louis, School of Medicine, Barnes-Jewish Hospital, St Louis, Missouri, United States of America
| | - Kristen Mueller
- Department of Emergency Medicine, Washington University in St Louis, School of Medicine, St Louis, Missouri, United States of America
| | - Brian Todd Wessman
- Department of Anesthesiology and Emergency Medicine, Washington University in St Louis, School of Medicine, St Louis, Missouri, United States of America,Brian Todd Wessman, Department of Anesthesiology and Emergency Medicine, Washington University in St Louis, School of Medicine, St Louis, Missouri, United States of America, Phone: +13143628538, e-mail:
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Guo NN, Wang HL, Zhao MY, Li JG, Liu HT, Zhang TX, Zhang XY, Chu YJ, Yu KJ, Wang CS. Management of procedural pain in the intensive care unit. World J Clin Cases 2022; 10:1473-1484. [PMID: 35211585 PMCID: PMC8855268 DOI: 10.12998/wjcc.v10.i5.1473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 07/22/2021] [Accepted: 01/20/2022] [Indexed: 02/06/2023] Open
Abstract
Pain is a common experience for inpatients, and intensive care unit (ICU) patients undergo more pain than other departmental patients, with an incidence of 50% at rest and up to 80% during common care procedures. At present, the management of persistent pain in ICU patients has attracted considerable attention, and there are many related clinical studies and guidelines. However, the management of transient pain caused by certain ICU procedures has not received sufficient attention. We reviewed the different management strategies for procedural pain in the ICU and reached a conclusion. Pain management is a process of continuous quality improvement that requires multidisciplinary team cooperation, pain-related training of all relevant personnel, effective relief of all kinds of pain, and improvement of patients' quality of life. In clinical work, which involves complex and diverse patients, we should pay attention to the following points for procedural pain: (1) Consider not only the patient's persistent pain but also his or her procedural pain; (2) Conduct multimodal pain management; (3) Provide combined sedation on the basis of pain management; and (4) Perform individualized pain management. Until now, the pain management of procedural pain in the ICU has not attracted extensive attention. Therefore, we expect additional studies to solve the existing problems of procedural pain management in the ICU.
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Affiliation(s)
- Na-Na Guo
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, Heilongjiang Province, China
| | - Hong-Liang Wang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang Province, China
| | - Ming-Yan Zhao
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang Province, China
| | - Jian-Guo Li
- Department of Intensive Care Unit, Zhongnan Hospital of Wuhan University, Wuhan 430000, Hubei Province, China
| | - Hai-Tao Liu
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, Heilongjiang Province, China
| | - Ting-Xin Zhang
- Department of Orthopedics, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang Province, China
| | - Xin-Yu Zhang
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, Heilongjiang Province, China
| | - Yi-Jun Chu
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, Heilongjiang Province, China
| | - Kai-Jiang Yu
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang Province, China
| | - Chang-Song Wang
- Department of Critical Care Medicine, Harbin Medical University Cancer Hospital, Harbin 150081, Heilongjiang Province, China
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Rudolph J, Huemmer C, Ghesu FC, Mansoor A, Preuhs A, Fieselmann A, Fink N, Dinkel J, Koliogiannis V, Schwarze V, Goller S, Fischer M, Jörgens M, Ben Khaled N, Vishwanath RS, Balachandran A, Ingrisch M, Ricke J, Sabel BO, Rueckel J. Artificial Intelligence in Chest Radiography Reporting Accuracy: Added Clinical Value in the Emergency Unit Setting Without 24/7 Radiology Coverage. Invest Radiol 2022; 57:90-98. [PMID: 34352804 DOI: 10.1097/rli.0000000000000813] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Chest radiographs (CXRs) are commonly performed in emergency units (EUs), but the interpretation requires radiology experience. We developed an artificial intelligence (AI) system (precommercial) that aims to mimic board-certified radiologists' (BCRs') performance and can therefore support non-radiology residents (NRRs) in clinical settings lacking 24/7 radiology coverage. We validated by quantifying the clinical value of our AI system for radiology residents (RRs) and EU-experienced NRRs in a clinically representative EU setting. MATERIALS AND METHODS A total of 563 EU CXRs were retrospectively assessed by 3 BCRs, 3 RRs, and 3 EU-experienced NRRs. Suspected pathologies (pleural effusion, pneumothorax, consolidations suspicious for pneumonia, lung lesions) were reported on a 5-step confidence scale (sum of 20,268 reported pathology suspicions [563 images × 9 readers × 4 pathologies]) separately by every involved reader. Board-certified radiologists' confidence scores were converted into 4 binary reference standards (RFSs) of different sensitivities. The RRs' and NRRs' performances were statistically compared with our AI system (trained on nonpublic data from different clinical sites) based on receiver operating characteristics (ROCs) and operating point metrics approximated to the maximum sum of sensitivity and specificity (Youden statistics). RESULTS The NRRs lose diagnostic accuracy to RRs with increasingly sensitive BCRs' RFSs for all considered pathologies. Based on our external validation data set, the AI system/NRRs' consensus mimicked the most sensitive BCRs' RFSs with areas under ROC of 0.940/0.837 (pneumothorax), 0.953/0.823 (pleural effusion), and 0.883/0.747 (lung lesions), which were comparable to experienced RRs and significantly overcomes EU-experienced NRRs' diagnostic performance. For consolidation detection, the AI system performed on the NRRs' consensus level (and overcomes each individual NRR) with an area under ROC of 0.847 referenced to the BCRs' most sensitive RFS. CONCLUSIONS Our AI system matched RRs' performance, meanwhile significantly outperformed NRRs' diagnostic accuracy for most of considered CXR pathologies (pneumothorax, pleural effusion, and lung lesions) and therefore might serve as clinical decision support for NRRs.
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Affiliation(s)
- Jan Rudolph
- From the Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | | | | | - Awais Mansoor
- Digital Technology and Innovation, Siemens Healthineers, Princeton, NJ
| | | | | | | | | | - Vanessa Koliogiannis
- From the Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Vincent Schwarze
- From the Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Sophia Goller
- From the Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | | | - Maximilian Jörgens
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU, Munich, Germany
| | - Najib Ben Khaled
- Department of Medicine II, University Hospital, LMU, Munich, Germany
| | | | | | - Michael Ingrisch
- From the Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Jens Ricke
- From the Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Bastian Oliver Sabel
- From the Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Johannes Rueckel
- From the Department of Radiology, University Hospital, LMU Munich, Munich, Germany
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27
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Doyle SC, Bergin NM, Young R, England A, McEntee MF. Diagnostic accuracy of ultrasound for localising peripherally inserted central catheter tips in infants in the neonatal intensive care unit: a systematic review and meta-analysis. Pediatr Radiol 2022; 52:2421-2430. [PMID: 35511256 PMCID: PMC9616767 DOI: 10.1007/s00247-022-05379-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/24/2022] [Accepted: 04/06/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Chest radiography after peripherally inserted central catheter insertion in infants is the reference standard method for verifying catheter tip position. The utilisation of ultrasound (US) for catheter placement confirmation in the neonatal and paediatric population has been the focus of many recent studies. OBJECTIVE In this systematic review we investigated the diagnostic accuracy of US for peripherally inserted central catheter tip confirmation in infants in the neonatal intensive care unit (NICU) MATERIALS AND METHODS: We conducted a systematic literature search of multiple databases. The study selection yielded eight articles, all of which had acceptable quality and homogeneity for inclusion in the meta-analysis. Sensitivity and specificity values were reported together with their respective 95% confidence intervals (CI). RESULTS After synthesising the eligible studies, we found that US had a sensitivity of 95.2% (95% CI 91.9-97.4%) and specificity of 71.4% (95% CI 59.4-81.6%) for confirming catheter tip position. CONCLUSION Analyses indicated that US is an excellent imaging test for localising catheter tip position in the NICU when compared to radiography. Ultrasonography is a sensitive, specific and timely imaging modality for confirming PICC tip position. In cases where US is unable to locate malpositioned PICC tips, a chest or combined chest-abdominal radiograph should be performed.
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Affiliation(s)
- Shauna C Doyle
- Discipline of Medical Imaging & Radiation Therapy, ASSERT Building, Brookfield Health and Sciences Complex, School of Medicine, University College of Cork, Cork, T12 AK24, Ireland
| | - Niamh M Bergin
- Discipline of Medical Imaging & Radiation Therapy, ASSERT Building, Brookfield Health and Sciences Complex, School of Medicine, University College of Cork, Cork, T12 AK24, Ireland
| | - Rena Young
- Discipline of Medical Imaging & Radiation Therapy, ASSERT Building, Brookfield Health and Sciences Complex, School of Medicine, University College of Cork, Cork, T12 AK24, Ireland
| | - Andrew England
- Discipline of Medical Imaging & Radiation Therapy, ASSERT Building, Brookfield Health and Sciences Complex, School of Medicine, University College of Cork, Cork, T12 AK24, Ireland.
| | - Mark F McEntee
- Discipline of Medical Imaging & Radiation Therapy, ASSERT Building, Brookfield Health and Sciences Complex, School of Medicine, University College of Cork, Cork, T12 AK24, Ireland
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Point of care ultrasonography: And now, where shall we go in perioperative medicine? Anaesth Crit Care Pain Med 2021; 41:101014. [PMID: 34954222 DOI: 10.1016/j.accpm.2021.101014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 11/20/2022]
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29
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Baehner T, Rohner M, Heinze I, Schindler E, Wittmann M, Strassberger-Nerschbach N, Kim SC, Velten M. Point-of-Care Ultrasound-Guided Protocol to Confirm Central Venous Catheter Placement in Pediatric Patients Undergoing Cardiothoracic Surgery: A Prospective Feasibility Study. J Clin Med 2021; 10:jcm10245971. [PMID: 34945270 PMCID: PMC8706795 DOI: 10.3390/jcm10245971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 01/06/2023] Open
Abstract
Background: Central venous catheters (CVC) are commonly required for pediatric congenital cardiac surgeries. The current standard for verification of CVC positioning following perioperative insertion is postsurgical radiography. However, incorrect positioning may induce serious complications, including pleural and pericardial effusion, arrhythmias, valvular damage, or incorrect drug release, and point of care diagnostic may prevent these serious consequences. Furthermore, pediatric patients with congenital heart disease receive various radiological procedures. Although relatively low, radiation exposure accumulates over the lifetime, potentially reaching high carcinogenic values in pediatric patients with chronic disease, and therefore needs to be limited. We hypothesized that correct CVC positioning in pediatric patients can be performed quickly and safely by point-of-care ultrasound diagnostic. Methods: We evaluated a point-of-care ultrasound protocol, consistent with the combination of parasternal craniocaudal, parasternal transversal, suprasternal notch, and subcostal probe positions, to verify tip positioning in any of the evaluated views at initial CVC placement in pediatric patients undergoing cardiothoracic surgery for congenital heart disease. Results: Using the combination of the four views, the CVC tip could be identified and positioned in 25 of 27 examinations (92.6%). Correct positioning was confirmed via chest X-ray after the surgery in all cases. Conclusions: In pediatric cardiac patients, point-of-care ultrasound diagnostic may be effective to confirm CVC positioning following initial placement and to reduce radiation exposure.
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Affiliation(s)
- Torsten Baehner
- St. Nikolaus-Stiftshospital Andernach, Ernestus-Platz 1, 56626 Andernach, Germany;
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (M.R.); (I.H.); (E.S.); (M.W.); (N.S.-N.); (S.-C.K.)
| | - Marc Rohner
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (M.R.); (I.H.); (E.S.); (M.W.); (N.S.-N.); (S.-C.K.)
| | - Ingo Heinze
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (M.R.); (I.H.); (E.S.); (M.W.); (N.S.-N.); (S.-C.K.)
| | - Ehrenfried Schindler
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (M.R.); (I.H.); (E.S.); (M.W.); (N.S.-N.); (S.-C.K.)
| | - Maria Wittmann
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (M.R.); (I.H.); (E.S.); (M.W.); (N.S.-N.); (S.-C.K.)
| | - Nadine Strassberger-Nerschbach
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (M.R.); (I.H.); (E.S.); (M.W.); (N.S.-N.); (S.-C.K.)
| | - Se-Chan Kim
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (M.R.); (I.H.); (E.S.); (M.W.); (N.S.-N.); (S.-C.K.)
| | - Markus Velten
- Department of Anesthesiology and Intensive Care Medicine, Rheinische Friedrich-Wilhelms-University, University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (M.R.); (I.H.); (E.S.); (M.W.); (N.S.-N.); (S.-C.K.)
- Correspondence: ; Tel.: +49-228-287-14116
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Galante O, Sadeh R, Smoliakov A, Muraveva A, Almog Y, Schneider E, Frenkel A, Fuchs L. Real time wire localization by ultrasound during central line insertion improves accurate positioning in all upper torso sites. J Crit Care 2021; 67:79-84. [PMID: 34717163 DOI: 10.1016/j.jcrc.2021.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 10/05/2021] [Accepted: 10/10/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To investigate whether point of care ultrasound can improve central venous catheter tip positioning. MATERIAL AND METHODS A single center retrospective case control study. We compared the precision of central venous catheter tip positioning between two intensive care units while in only one of the units, we used point of care ultrasound for guidewire identification. RESULTS 207 cases in which central venous catheter was inserted using point of care ultrasound guided method, compared to 192 controls. The primary outcome of correct placement of the central venous catheter tip was significantly higher in the point of care ultrasound guided group (97.6% vs 88.0% p = 0.001). Central venous catheter tip was located too low among 12% of patients in the control group while in only 2.4% of patients in the point of care ultrasound group (p = 0.001). Logistics regression analysis revealed that the correct placement of central venous catheter tip in the point of care ultrasound group versus the control group had an odds ratio of 4.9 (CI 1.6-14.5 P = 0.004). CONCLUSION Point of care ultrasound for guidewire identification and localization, while inserting central venous catheter from all upper torso sites, improves precision positioning.
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Affiliation(s)
- Ori Galante
- Medical Intensive Care Unit, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel.
| | - Re'em Sadeh
- Faculty of Health Sience, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel; Clinical Research Center, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Alexander Smoliakov
- Institute of Diagnostic Radiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Alona Muraveva
- Institute of Diagnostic Radiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Yaniv Almog
- Medical Intensive Care Unit, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Eyal Schneider
- Faculty of Health Sience, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Amit Frenkel
- General Intensive Care Unit, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Lior Fuchs
- Medical Intensive Care Unit, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
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Groetzinger LM, Williams J, Svec S, Donahoe MP, Lamberty PE, Barbash IJ. Peripherally Infused Norepinephrine to Avoid Central Venous Catheter Placement in a Medical Intensive Care Unit: A Pilot Study. Ann Pharmacother 2021; 56:773-781. [PMID: 34674566 DOI: 10.1177/10600280211053318] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Reducing central venous catheter (CVC) utilization can reduce complications in the intensive care unit (ICU). While norepinephrine (NE) is traditionally administered via a CVC, lower concentrations may be safely administered via peripheral intravenous (PIV) lines. OBJECTIVE We aimed to describe the implementation of a pilot protocol utilizing PIVs to administer a low-dose and lower-concentration NE, review the number of CVCs avoided, and evaluate any adverse events. METHODS In a quaternary medical intensive care unit (MICU), from March 1, 2019, to February 29, 2020, we reviewed charts for CVC placement and adverse events from the pNE infusion. We also measured unit-level CVC utilization in all MICU patients and assessed the change in utilization associated with the peripheral norepinephrine (pNE) protocol. RESULTS Over a 1-year period, 87 patients received a pNE infusion. Overall, 44 patients (51%) never required CVC placement during their MICU stay. Three patients (3%) experienced adverse events, none of which were documented as serious and or required antidote for treatment. Implementation of the protocol was associated with a decrease in the number of patients at the unit level who received CVCs, even if they did not receive pNE. CONCLUSION AND RELEVANCE In this small pilot study, we pragmatically demonstrated that pNE is safe and may reduce the need for CVC placement. This information can be used to aid in pNE protocol development and implementation at other institutions, but further research should be done to confirm the safety of routine use of pNE in clinical practice.
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Affiliation(s)
| | - Julia Williams
- Department of Nursing, UPMC Presbyterian Hospital, Pittsburgh, PA, USA
| | - Susan Svec
- Department of Nursing, UPMC Presbyterian Hospital, Pittsburgh, PA, USA
| | - Michael P Donahoe
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Phillip E Lamberty
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ian J Barbash
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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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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Schrift D, Barron K, Arya R, Choe C. The Use of POCUS to Manage ICU Patients With COVID-19. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:1749-1761. [PMID: 33174650 DOI: 10.1002/jum.15566] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/12/2020] [Accepted: 10/15/2020] [Indexed: 06/11/2023]
Abstract
Since the advent of SARS-CoV-2, the virus that causes COVID-19, clinicians have had to modify how they provide high-value care while mitigating the risk of viral spread. Routine imaging studies have been discouraged due to elevated transmission risk. Patients who have been diagnosed with COVID-19 often have a protracted hospital course with progression of disease. Given the need for close follow-up of patients, we recommend the use of ultrasonography, particularly point-of-care ultrasound (POCUS), to manage patients with COVID-19 through their entire ICU course. POCUS will allow a clinician to evaluate and monitor cardiac and pulmonary function, as well as evaluate for thromboembolic disease, place an endotracheal tube, confirm central venous catheter placement, and rule out a pneumothorax. If a patient improves sufficiently to perform weaning trials, POCUS can also help evaluate readiness for ventilator liberation.
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Affiliation(s)
- David Schrift
- Division of Pulmonary, Critical Care, and Sleep Medicine, Prisma Health USC Medical Group, Columbia, South Carolina, USA
| | - Keith Barron
- Department of Internal Medicine, Prisma Health USC Medical Group, Columbia, South Carolina, USA
| | - Rohan Arya
- Division of Pulmonary, Critical Care, and Sleep Medicine, Prisma Health USC Medical Group, Columbia, South Carolina, USA
| | - Carol Choe
- Department of Critical Care Medicine, Lexington Medical Center, West Columbia, South Carolina, USA
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Furlong-Dillard J, Aljabari S, Hirshberg E. Diagnostic accuracy among trainees to safely confirm peripherally inserted central catheter (PICC) placement using bedside ultrasound. ACTA ACUST UNITED AC 2021; 29:S20-S28. [PMID: 33104434 DOI: 10.12968/bjon.2020.29.19.s20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Real-time utilization of ultrasound to confirm peripherally inserted central catheter (PICC) placement improves efficacy and reduces patient radiation exposure. We evaluated if novice ultrasound users could accurately confirm appropriate PICC tip location via ultrasound assessment. METHODOLOGY A prospective data collection study was conducted in an academic center with an established PICC team. Novice ultrasonography users performed 2 echocardiographic views (subcostal and apical 4 chamber) and noted position of visible wire. The presence of central bubbles (visualized in the heart) after a saline infusion, as well as time to bubbles (push-to-bubbles) seen in all patients, was also recorded. Image quality and confidence in imaging acquisition was also recorded. RESULTS Twenty-eight patients between ages 0 and 18 were enrolled over the study period with mean patient age of 10 years and median weight of 34 kg. The quality of image acquisition was rated as great only 34-44%. The wire was visualized only 25% of the time. The median push-to-bubble time when the PICC was later confirmed to be in appropriate positioning was 1.5 seconds with a delay of greater than 3 seconds 40% of the time when the line was malpositioned. The overall positive predictive value of ultrasound identifying malpositioned lines in this study was 43%. CONCLUSIONS With this PICC placement technique, ultrasound confirmation of PICC placement by novice ultrasound users was not superior to confirmation with chest radiograph. There may remain potential for future ultrasound protocols, with pediatric-specific technology or echogenic catheter tips, to reduce radiation exposure from chest radiograph during PICC line positioning verification.
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Affiliation(s)
- Jamie Furlong-Dillard
- DO, University of Louisville, Department of Pediatrics, Division of Pediatric Critical Care, Louisville, KY
| | - Salim Aljabari
- MD, University of Missouri, Department of Pediatrics, Division of Pediatric Critical Care, Columbia, MO
| | - Ellie Hirshberg
- MD, University of Utah School of Medicine, Department of Medicine, Division of Pulmonary and Critical Care, Salt Lake City, UT
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Ablordeppey EA, Drewry AM, Anderson AL, Casali D, Wallace LA, Kane DS, Tian L, House SL, Fuller BM, Griffey RT, Theodoro DL. Point-of-care Ultrasound-guided Central Venous Catheter Confirmation in Ultrasound Nonexperts. AEM EDUCATION AND TRAINING 2021; 5:e10530. [PMID: 34124497 PMCID: PMC8173448 DOI: 10.1002/aet2.10530] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Emerging evidence suggests that chest radiography (CXR) following central venous catheter (CVC) placement is unnecessary when point-of-care ultrasound (POCUS) is used to confirm catheter position and exclude pneumothorax. However, few providers have adopted this practice, and it is unknown what contributing factors may play a role in this lack of adoption, such as ultrasound experience. The objective of this study was to evaluate the diagnostic accuracy of POCUS to confirm CVC position and exclude a pneumothorax after brief education and training of nonexperts. METHODS We performed a prospective cohort study in a single academic medical center to determine the diagnostic characteristics of a POCUS-guided CVC confirmation protocol after brief training performed by POCUS nonexperts. POCUS nonexperts (emergency medicine senior residents and critical care fellows) independently performed a POCUS-guided CVC confirmation protocol after a 30-minute didactic training. The primary outcome was the diagnostic accuracy of the POCUS-guided CVC confirmation protocol for malposition and pneumothorax detection. Secondary outcomes were efficiency and feasibility of adequate image acquisition, adjudicated by POCUS experts. RESULTS Twenty-six POCUS nonexperts collected data on 190 patients in the final analysis. There were five (2.5%) CVC malpositions and six (3%) pneumothoraxes on CXR. The positive likelihood ratios of POCUS for malposition detection and pneumothorax were 12.33 (95% confidence interval [CI] = 3.26 to 46.69) and 3.41 (95% CI = 0.51 to 22.76), respectively. The accuracy of POCUS for pneumothorax detection compared to CXR was 0.93 (95% CI = 0.88 to 0.96) and the sensitivity was 0.17 (95% CI = 0.00 to 0.64). The median (interquartile range) time for CVC confirmation was lower for POCUS (9 minutes [8.5-9.5 minutes]) compared to CXR (29 minutes [1-269 minutes]; Mann-Whitney U, p < 0.01). Adequate protocol image acquisition was achieved in 76% of the patients. CONCLUSION Thirty-minute training of POCUS in nonexperts demonstrates adequate diagnostic accuracy, efficiency, and feasibility of POCUS-guided CVC position confirmation, but not exclusion of pneumothorax.
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Affiliation(s)
- Enyo A. Ablordeppey
- From theDepartment of AnesthesiologyWashington University School of MedicineSt. LouisMOUSA
- theDepartment of Emergency MedicineWashington University School of MedicineSt. LouisMOUSA
| | - Anne M. Drewry
- From theDepartment of AnesthesiologyWashington University School of MedicineSt. LouisMOUSA
| | - Adam L. Anderson
- theDepartment of Internal MedicineWashington University School of MedicineSt. LouisMOUSA
| | - Diego Casali
- and theDepartment of SurgeryWashington University School of MedicineSt. LouisMOUSA
- and theDepartment of SurgeryDivision of Cardiothoracic SurgeryCedars Sinai Medical CenterLos AngelesCAUSA
| | - Laura A. Wallace
- theDepartment of Emergency MedicineWashington University School of MedicineSt. LouisMOUSA
| | - Deborah S. Kane
- theDepartment of Emergency MedicineWashington University School of MedicineSt. LouisMOUSA
| | - LinLin Tian
- theDepartment of Emergency MedicineWashington University School of MedicineSt. LouisMOUSA
| | - Stacey L. House
- theDepartment of Emergency MedicineWashington University School of MedicineSt. LouisMOUSA
| | - Brian M. Fuller
- From theDepartment of AnesthesiologyWashington University School of MedicineSt. LouisMOUSA
- theDepartment of Emergency MedicineWashington University School of MedicineSt. LouisMOUSA
| | - Richard T. Griffey
- theDepartment of Emergency MedicineWashington University School of MedicineSt. LouisMOUSA
| | - Daniel L. Theodoro
- theDepartment of Emergency MedicineWashington University School of MedicineSt. LouisMOUSA
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Piano A, Carnicelli A, Gilardi E, Bonadia N, Wolde Sellasie K, Pittiruti M, Pennisi MA. Unusual malposition of a peripherally inserted central catheter into the left pericardiophrenic vein: A case report. J Vasc Access 2021; 23:969-972. [PMID: 34011220 DOI: 10.1177/11297298211018945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We report a case of primary malposition of a PICC inserted by guidewire replacement in the emergency room. Intraprocedural tip location by intracavitary electrocardiography was not feasible because the patient had atrial fibrillation; intraprocedural tip location by ultrasound (using the so-called "bubble test") showed that the tip was not in the superior vena cava or in the right atrium. A post-procedural chest X-ray confirmed the malposition but could not precise the location of the tip. A CT scan (scheduled for other purposes) finally visualized the tip in a very unusual location, the left pericardiophrenic vein.
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Affiliation(s)
- Alfonso Piano
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Annamaria Carnicelli
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Emanuele Gilardi
- Department of Emergency Medicine, Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Nicola Bonadia
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Kidane Wolde Sellasie
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Mauro Pittiruti
- Department of Emergency Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Mariano Alberto Pennisi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, 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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Montrief T, Auerbach J, Cabrera J, Long B. Use of Point-of-Care Ultrasound to Confirm Central Venous Catheter Placement and Evaluate for Postprocedural Complications. J Emerg Med 2021; 60:637-640. [PMID: 33640215 DOI: 10.1016/j.jemermed.2021.01.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/02/2021] [Accepted: 01/23/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Central venous catheter (CVC) placement is commonly performed in the emergency department (ED), but traditional confirmation of placement includes chest radiograph. OBJECTIVE This manuscript details the use of point-of-care ultrasound (POCUS) to confirm placement of a CVC and evaluate for postprocedural complications. DISCUSSION CVC access in the ED setting is an important procedure. Traditional confirmation includes chest radiograph. POCUS is a rapid, inexpensive, and accurate modality to confirm CVC placement and evaluate for postprocedural complications. POCUS after CVC can evaluate lung sliding for pneumothorax and the internal jugular vein for misdirected CVC. A bubble study with POCUS visualizing agitated saline microbubbles within the right heart can confirm venous placement. CONCLUSIONS POCUS can rapidly and reliably confirm CVC placement, as well as evaluate for postprocedural complications. Knowledge of this technique can assist emergency clinicians.
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Affiliation(s)
- Tim Montrief
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jonathan Auerbach
- Department of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Jorge Cabrera
- Department of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Brit Long
- San Antonio Uniformed Services Health Education Consortium (SAUSHEC), Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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Tozer J, Vitto MJ, Joyce M, Taylor L, Evans DP. Central Venous Catheter Confirmation by Ultrasonography: A Novel Instructional Protocol. South Med J 2020; 113:614-617. [PMID: 33263128 DOI: 10.14423/smj.0000000000001187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Ultrasound (US)-only confirmation of central venous catheter (CVC) placement has proven to be accurate and fast when compared with the current standard chest radiograph. This procedure depends on the detection of appropriately timed atrial bubbles during central line flushing, called the rapid atrial swirl sign (RASS). The most obvious barrier to increasing the use of this technique is appropriate education and training; therefore, we proposed a novel educational approach to training emergency department (ED) physicians in the confirmation of CVC location using US and then tested its effectiveness. METHODS Using an online educational model, participants were taught the background and procedural steps to confirm CVC placement using US. Subsequently, they were asked to use this knowledge to place central lines in simulation and confirm them using US. They were tested with various scenarios, including correctly and incorrectly placed lines. Their accuracy was measured, and a survey was used to assess their satisfaction with the training and applicability to practice. RESULTS A total of 47 ED physicians completed the online training module and 24 completed the simulation testing that followed. Results showed 100% accuracy in detecting appropriately timed RASS (<2 seconds), delayed RASS (>2 seconds), and no RASS in simulation. All of the participants "agreed" or "strongly agreed" that the didactic and simulation sessions improved their understanding of US confirmation of central line placement. CONCLUSIONS The use of US to confirm central line placement can be effectively taught to ED physicians using short didactic and simulation-based training. This is a reasonable approach to integrate this protocol into practice, and allow for more widespread use of this emerging technique.
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Affiliation(s)
- Jordan Tozer
- From the Division of Ultrasound, Department of Emergency Medicine, Virginia Commonwealth University, Richmond
| | - Michael J Vitto
- From the Division of Ultrasound, Department of Emergency Medicine, Virginia Commonwealth University, Richmond
| | - Michael Joyce
- From the Division of Ultrasound, Department of Emergency Medicine, Virginia Commonwealth University, Richmond
| | - Lindsay Taylor
- From the Division of Ultrasound, Department of Emergency Medicine, Virginia Commonwealth University, Richmond
| | - David P Evans
- From the Division of Ultrasound, Department of Emergency Medicine, Virginia Commonwealth University, Richmond
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Dávila-Román VG, Checkley W. Lung Ultrasound in Cardiac Intensive Care: More Than Just LUCK? Circ Cardiovasc Imaging 2020; 13:e010909. [PMID: 32536198 DOI: 10.1161/circimaging.120.010909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Victor G Dávila-Román
- Cardiovascular Imaging and Clinical Research Core Laboratory, Cardiovascular Division, Department of Medicine, and Global Health Center, Institute of Public Health, Washington University School of Medicine, St. Louis, MO (V.G.D.-R.)
| | - William Checkley
- Division of Pulmonary and Critical Care, Department of Medicine (W.C.), School of Medicine, Johns Hopkins University, Baltimore, MD.,Center for Global Non-Communicable Disease Research and Training (W.C.), School of Medicine, Johns Hopkins University, Baltimore, MD
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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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Oliveira L, Pilz L, Tognolo CM, Bischoff C, Becker KA, Oliveira GG, Neves PJF, Fachin CG, Agulham MA, Dias AIBS. Comparison between ultrasonography and X-ray as evaluation methods of central venous catheter positioning and their complications in pediatrics. Pediatr Surg Int 2020; 36:563-568. [PMID: 32232550 DOI: 10.1007/s00383-020-04642-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE This study evaluates the capacity of ultrasonography as a diagnostic method to confirm the proper positioning of central venous catheter (CVC) when compared to the current gold standard, chest radiography (CR). METHODS A prospective study was performed including children from 0 to 14 incomplete years, who underwent CVC placement between March and May 2018 at a teaching hospital in Brazil. A four-chamber view of the heart was performed with ultrasound during a rapid injection of saline solution to identify hyperechoic images and confirm the central position of the catheter. After that, a CR was performed. The diagnostic quality of ultrasound was evaluated based on accuracy, sensitivity, specificity, positive and negative predictive values. RESULTS A total of 21 patients were analyzed. The mean age was 3.95 ± 4.01 years. The preferred puncture site was the right internal jugular vein (71.4%). Ultrasound accuracy to detect CVC positioning was 81%. Sensitivity, specificity and positive and negative predictive values were 33%, 100%, 100% and 79%, respectively. CONCLUSION Ultrasound is a reliable method for detection of CVC positioning. Even so, with the four-chamber cardiac view, this method is unable to identify catheters inside heart chambers, therefore, needing to confirm the positioning with CR.
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Affiliation(s)
- L Oliveira
- Pediatric Surgery Department, Hospital de Clínicas, Universidade Federal Do Paraná, Pedro Viriato Parigot de Souza, 1609/602, Curitiba, Paraná, CEP 81200-100, Brazil.
| | - L Pilz
- Medical Student, Universidade Federal Do Paraná, Curitiba, Paraná, Brazil
| | - C M Tognolo
- Pediatric Surgery Department, Hospital de Clínicas, Universidade Federal Do Paraná, Pedro Viriato Parigot de Souza, 1609/602, Curitiba, Paraná, CEP 81200-100, Brazil
| | - C Bischoff
- Pediatric Surgery Department, Hospital de Clínicas, Universidade Federal Do Paraná, Pedro Viriato Parigot de Souza, 1609/602, Curitiba, Paraná, CEP 81200-100, Brazil
| | - K A Becker
- Pediatric Surgery Department, Hospital de Clínicas, Universidade Federal Do Paraná, Pedro Viriato Parigot de Souza, 1609/602, Curitiba, Paraná, CEP 81200-100, Brazil
| | - G G Oliveira
- Pediatric Surgery Department, Hospital de Clínicas, Universidade Federal Do Paraná, Pedro Viriato Parigot de Souza, 1609/602, Curitiba, Paraná, CEP 81200-100, Brazil
| | - P J F Neves
- Medical Student, Universidade Federal Do Paraná, Curitiba, Paraná, Brazil
| | - C G Fachin
- Pediatric Surgery Department, Hospital de Clínicas, Universidade Federal Do Paraná, Pedro Viriato Parigot de Souza, 1609/602, Curitiba, Paraná, CEP 81200-100, Brazil
| | - M A Agulham
- Pediatric Surgery Department, Hospital de Clínicas, Universidade Federal Do Paraná, Pedro Viriato Parigot de Souza, 1609/602, Curitiba, Paraná, CEP 81200-100, Brazil
| | - A I B S Dias
- Pediatric Surgery Department, Hospital de Clínicas, Universidade Federal Do Paraná, Pedro Viriato Parigot de Souza, 1609/602, Curitiba, Paraná, CEP 81200-100, Brazil
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Iacobone E, Elisei D, Gattari D, Carbone L, Capozzoli G. Transthoracic echocardiography as bedside technique to verify tip location of central venous catheters in patients with atrial arrhythmia. J Vasc Access 2020; 21:861-867. [DOI: 10.1177/1129729820905200] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: Transthoracic echocardiography with bubble test is an accurate, reproducible, and safe technique to verify the location of the tip of the central venous catheter. The aim of this study is to confirm the effectiveness of this method for tip location in patients with atrial arrhythmia. Methods: Transthoracic echocardiography with bubble test was adopted as a method of tip location in patients with atrial arrhythmia requiring central venous catheter. If bubbles were evident in the right atrium in less than 2 s after simple saline injection, tip placement was assumed as correct. In cases of uncertain visualization of the bubble effect, the test was repeated injecting a saline–air mixture. Tip location was also assessed by post-procedural chest X-ray. Results: In 42 patients with no evident P-wave at the electrocardiography, we placed 34 centrally inserted central catheters and 8 peripherally inserted central catheters. Transthoracic echocardiography with bubble test detected two centrally inserted central catheter malpositions. In four patients with peripherally inserted central catheter, transthoracic echocardiography with bubble test was positive only when repeated with the saline–air mixture. When the transthoracic echocardiography was positive, the mean (±standard deviation) time for onset of the bubble effect was 0.89 ± 0.33 s in patients with centrally inserted central catheter and 1.1 ± 0.20 s in those with peripherally inserted central catheter; such time difference was not statistically significant (p > 0.05). Conclusion: Tip location of central venous catheter by transthoracic echocardiography with bubble test is feasible, safe, and accurate in patients with atrial arrhythmia. This method can also be applied in peripherally inserted central catheters; however, further studies may be needed to confirm its use in this type of catheters.
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Affiliation(s)
- Emanuele Iacobone
- Department of Intensive Care and Anesthesia, Central Hospital of Macerata, Macerata, Italy
| | - Daniele Elisei
- Department of Intensive Care and Anesthesia, Central Hospital of Macerata, Macerata, Italy
| | - Diego Gattari
- Department of Intensive Care and Anesthesia, Central Hospital of Macerata, Macerata, Italy
| | - Luigi Carbone
- Department of Intensive Care and Anesthesia, Central Hospital of Macerata, Macerata, Italy
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Parmar MS. (F)utility of "routine" postprocedural chest radiograph after hemodialysis catheter (central venous catheter) insertion. J Vasc Access 2020; 22:4-8. [PMID: 32114897 DOI: 10.1177/1129729820907259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A routine postprocedural chest radiograph had been a safe, checklist-based final step of the procedure, since the start of central venous catheter insertion for hemodialysis to check the position of the catheter tip and to rule out complications. However, the chest radiograph is a suboptimal method to rule out complications like pneumothorax and is not a reliable test to confirm its position. Although it is relatively inexpensive, it is labor-intensive and exposes patient to unnecessary radiation exposure, cost, and often results in delayed use of the catheter. Various studies question the value of a routine chest radiograph as a screening test to rule out the mechanical complications of catheter insertion. We, in this brief viewpoint, present evidence to support the futility of a routine postprocedural chest radiograph in majority of asymptomatic patients and support Choosing Wisely Initiative to avoid low-value studies. However, it should be considered under specific indications, as discussed.
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Affiliation(s)
- Malvinder S Parmar
- Northern Ontario School of Medicine, Timmins and District Hospital, Timmins, ON, Canada
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Singh Y, Tissot C, Fraga MV, Yousef N, Cortes RG, Lopez J, Sanchez-de-Toledo J, Brierley J, Colunga JM, Raffaj D, Da Cruz E, Durand P, Kenderessy P, Lang HJ, Nishisaki A, Kneyber MC, Tissieres P, Conlon TW, De Luca D. International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). Crit Care 2020; 24:65. [PMID: 32093763 PMCID: PMC7041196 DOI: 10.1186/s13054-020-2787-9] [Citation(s) in RCA: 291] [Impact Index Per Article: 72.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 02/14/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children. METHODS Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document. RESULTS Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C). CONCLUSIONS Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.
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Affiliation(s)
- Yogen Singh
- Department of Paediatrics - Neonatology and Paediatric Cardiology, Cambridge University Hospitals and University of Cambridge School of Clinical Medicine, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
- Addenbrooke's Hospital, Box 402, Cambridge, UK.
| | - Cecile Tissot
- Paediatric Cardiology, Centre de Pédiatrie, Clinique des Grangettes, Geneva, Switzerland
| | - María V Fraga
- Department of Paediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, USA
| | - Nadya Yousef
- Division of Paediatrics and Neonatal Critical Care, APHP - Paris Saclay University Hospitals, "A. Béclère" Medical centre, Paris, France
| | - Rafael Gonzalez Cortes
- Department of Paediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Jorge Lopez
- Department of Paediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain
| | | | - Joe Brierley
- Department of Paediatric Intensive Care, Great Ormond Street Hospital, London, UK
| | - Juan Mayordomo Colunga
- Department of Paediatric Intensive Care, Hospital Universitario Central de Asturias, Oviedo. CIBER-Enfermedades Respiratorias. Instituto de Salud Carlos III, Madrid. Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Dusan Raffaj
- Department of Paediatric Intensive Care, Nottingham University Hospitals, Nottingham, UK
| | - Eduardo Da Cruz
- Department of Paediatric and Cardiac Intensive Care, Children's Hospital Colorado, Aurora, USA
| | - Philippe Durand
- Division of Paediatric Critical Care, APHP - Paris Saclay University Hospitals, "Kremlin Bicetre" Medical Centre, Paris, France
| | - Peter Kenderessy
- Department of Paediatric Anaesthesia and Intensive Care, Children's Hospital Banska Bystrica, Banska Bystrica, Slovakia
| | - Hans-Joerg Lang
- Department of Paediatrics, Medicins Sans Frontieres (Suisse), Geneva, Switzerland
| | - Akira Nishisaki
- Department of Anaesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, USA
| | - Martin C Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Pierre Tissieres
- Division of Paediatric Critical Care, APHP - Paris Saclay University Hospitals, "Kremlin Bicetre" Medical Centre, Paris, France
| | - Thomas W Conlon
- Department of Anaesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, USA
| | - Daniele De Luca
- Division of Paediatrics and Neonatal Critical Care, APHP - Paris Saclay University Hospitals, "A. Béclère" Medical centre, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM Unit U999, South Paris Medical School, Paris Saclay University, Paris, France
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Tran QK, Foster M, Bowler J, Lancaster M, Tchai J, Andersen K, Matta A, Haase DJ. Emergency and critical care providers' perception about the use of bedside ultrasound for confirmation of above-diaphragm central venous catheter placement. Heliyon 2020; 6:e03113. [PMID: 32042935 PMCID: PMC7002808 DOI: 10.1016/j.heliyon.2019.e03113] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 08/21/2019] [Accepted: 10/18/2019] [Indexed: 12/28/2022] Open
Abstract
Introduction Chest radiography (CXR) is commonly used to confirm the proper placement of above-diaphragm central venous catheters (CVCs) and to detect associated complications. Recent studies have shown that point-of-care ultrasound (POCUS) has better sensitivity and is faster than CXR for these purposes. We were interested in documenting how often emergency medicine and critical care practitioners perform POCUS to confirm proper CVC positioning as well as their confidence in performing it. Methods We surveyed members of our state's chapters of the College of Emergency Physicians and the Society of Critical Care Medicine between April and December 2018. Our primary outcome was the percentage of providers who would agree to perform only POCUS, forgoing CXR, for confirmation of CVC position. We performed multivariable logistic regressions to measure associations between demographic, clinical information, and outcomes. Results One hundred thirty-six providers participated (a 25% participation rate). Their specialties were as follows: emergency medicine, 75%; critical care, 13%; and emergency medicine/critical care, 11%. Thirty-one percent would use POCUS only for CVC confirmation, while 42% were confident in performing POCUS for this purpose. Multivariable logistic regressions showed that performing more non-procedural ultrasound examinations was associated with a higher likelihood of agreeing to perform POCUS only (OR, 2.9; 95% CI: 1.3-6.3). Forty-six percent of relevant comments suggested more training to increase the use of POCUS. Conclusion Participants in this study did not frequently use POCUS for CVC confirmation. Designers of training curricula should consider including more instruction in the use of POCUS to confirm proper CVC placement and to detect complications.
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Affiliation(s)
- Quincy K Tran
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, MD, USA.,University of Maryland School of Medicine, The R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Mark Foster
- University of Maryland School of Medicine, The R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Justin Bowler
- University of Maryland at College Park, College Park, MD, USA
| | - Mia Lancaster
- University of Maryland at College Park, College Park, MD, USA
| | - Jennifer Tchai
- University of Maryland at College Park, College Park, MD, USA
| | - Katie Andersen
- University of Maryland School of Medicine, The R Adams Cowley Shock Trauma Center, Baltimore, MD, USA.,University of Maryland Medical Center, Baltimore, MD, USA
| | - Ann Matta
- University of Maryland School of Medicine, The R Adams Cowley Shock Trauma Center, Baltimore, MD, USA.,University of Maryland Medical Center, Baltimore, MD, USA
| | - Daniel J Haase
- University of Maryland School of Medicine, The R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
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Javeri Y, Jagathkar G, Dixit S, Chaudhary D, Zirpe KG, Mehta Y, Govil D, Mishra RC, Samavedam S, Pandit RA, Savio RD, Clerk AM, Srinivasan S, Juneja D, Ray S, Sahoo TK, Jakkinaboina S, Jampala N, Jain R. Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020. Indian J Crit Care Med 2020; 24:S6-S30. [PMID: 32205954 PMCID: PMC7085816 DOI: 10.5005/jp-journals-10071-g23183] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background and Purpose Short-term central venous catheterization (CVC) is one of the commonly used invasive interventions in ICU and other patient-care areas. Practice and management of CVC is not standardized, varies widely, and need appropriate guidance. Purpose of this document is to provide a comprehensive, evidence-based and up-to-date, one document source for practice and management of central venous catheterization. These recommendations are intended to be used by critical care physicians and allied professionals involved in care of patients with central venous lines. Methods This position statement for central venous catheterization is framed by expert committee members under the aegis of Indian Society of Critical Care Medicine (ISCCM). Experts group exchanged and reviewed the relevant literature. During the final meeting of the experts held at the ISCCM Head Office, a consensus on all the topics was made and the recommendations for final document draft were prepared. The final document was reviewed and accepted by all expert committee members and after a process of peer-review this document is finally accepted as an official ISCCM position paper. Modified grade system was utilized to classify the quality of evidence and the strength of recommendations. The draft document thus formulated was reviewed by all committee members; further comments and suggestions were incorporated after discussion, and a final document was prepared. Results This document makes recommendations about various aspects of resource preparation, infection control, prevention of mechanical complication and surveillance related to short-term central venous catheterization. This document also provides four appendices for ready reference and use at institutional level. Conclusion In this document, committee is able to make 54 different recommendations for various aspects of care, out of which 40 are strong and 14 weak recommendations. Among all of them, 42 recommendations are backed by any level of evidence, however due to paucity of data on 12 clinical questions, a consensus was reached by working committee and practice recommendations given on these topics are based on vast clinical experience of the members of this committee, which makes a useful practice point. Committee recognizes the fact that in event of new emerging evidences this document will require update, and that shall be provided in due time. Abbreviations list ABHR: Alcohol-based hand rub; AICD: Automated implantable cardioverter defibrillator; BSI: Blood stream infection; C/SS: CHG/silver sulfadiazine; Cath Lab: Catheterization laboratory (Cardiac Cath Lab); CDC: Centers for Disease Control and Prevention; CFU: Colony forming unit; CHG: Chlorhexidine gluconate; CL: Central line; COMBUX: Comparison of Bedside Ultrasound with Chest X-ray (COMBUX study); CQI: Continuous quality improvement; CRBSI: Catheter-related blood stream infection; CUS: Chest ultrasonography; CVC: Central Venous Catheter; CXR: Chest X-ray; DTTP: Differential time to positivity; DVT: Deep venous thrombosis; ECG: Electrocardiography; ELVIS: Ethanol lock and risk of hemodialysis catheter infection in critically ill patients; ER: Emergency room; FDA: Food and Drug Administration; FV: Femoral vein; GWE: Guidewire exchange; HD catheter: Hemodialysis catheter; HTS: Hypertonic saline; ICP: Intracranial pressure; ICU: Intensive Care Unit; IDSA: Infectious Disease Society of America; IJV: Internal jugular vein; IPC: Indian penal code; IRR: Incidence rate ratio; ISCCM: Indian Society of Critical Care Medicine; IV: Intravenous; LCBI: Laboratory confirmed blood stream infection; M/R: Minocycline/rifampicin; MBI-LCBI: Mucosal barrier injury laboratory-confirmed bloodstream infection; MRSA: Methicillin-resistant Staphylococcus aureus; NHS: National Health Service (UK); NHSN: National Healthcare Safety Network (USA); OT: Operation Theater; PICC: Peripherally-inserted central catheter; PIV: Peripheral intravenous line; PL: Peripheral line; PVI: Povidone-iodine; RA: Right atrium; RCT: Randomized controlled trial; RR: Relative risk; SCV/SV: Subclavian vein; ScVO2: Central venous oxygen saturation; Sn: Sensitivity; SOP: Standard operating procedure; SVC: Superior vena cava; TEE: Transesophageal echocardiography; UPP: Useful Practice Points; USG: Ultrasonography; WHO: World Health Organization How to cite this article Javeri Y, Jagathkar G, Dixit S, Chaudhary D, Zirpe KG, Mehta Y, et al. Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020. Indian J Crit Care Med 2020;24(Suppl 1):S6–S30.
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Affiliation(s)
- Yash Javeri
- Department of Critical Care, Anesthesia and Emergency Medicine, Regency Health, Lucknow, Uttar Pradesh, India, , e-mail:
| | - Ganshyam Jagathkar
- Department of Critical Care Medicine, Medicover Hospital, Hyderabad, Telangana, India, e-mail:
| | - Subhal Dixit
- Department of Critical Care Medicine, Sanjeevan & MJM Hospital, Pune, Maharashtra, India, e-mail:
| | - Dhruva Chaudhary
- Department of Pulmonary and Critical Care, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, , e-mail:
| | - Kapil Gangadhar Zirpe
- Department of Neuro Trauma Unit, Grant Medical Foundation, Pune, Maharashtra, India, , e-mail:
| | - Yatin Mehta
- Department of Critical Care and Anesthesiology, Medanta The Medicity, Sector-38, Gurgaon, Haryana, India, Extn. 3335, e-mail:
| | - Deepak Govil
- Department of Critical Care, Medanta Hospital, The Medicity, Gurugram, Haryana, India, , e-mail:
| | - Rajesh C Mishra
- Department of Critical Care, Saneejivini Hospital, Vastrapur, Ahmedabad, Gujarat, India, , e-mail:
| | - Srinivas Samavedam
- Department of Critical Care, Virinchi Hospital, Hyderabad, Telangana, India, , e-mail:
| | - Rahul Anil Pandit
- Department of Intensive Care Unit, Fortis Hospital, Mumbai, Maharashtra, India, , e-mail:
| | - Raymond Dominic Savio
- Department of Critical Care Medicine, Apollo Hospital, Chennai, Tamil Nadu, India, e-mail:
| | - Anuj M Clerk
- Department of Intensive Care, Services Sunshine Global Hospital, Surat, Gujarat, India, e-mail:
| | - Shrikanth Srinivasan
- Department of Critical Care Medicine, Manipal Hospital, New Delhi, India, , e-mail:
| | - Deven Juneja
- Department of Critical Care Medicine, Max Superspecialty Hospital, New Delhi, India, , e-mail:
| | - Sumit Ray
- Department of Critical Care, Artemis Hospital, Gurugram, Haryana, India, e-mail:
| | - Tapas Kumar Sahoo
- Department of Critical Care, Medanta Hospital, Ranchi, Jharkhand, India, , e-mail:
| | - Srinivas Jakkinaboina
- Department of Critical Care Medicine, Citizens Specialty Hospital, Hyderabad, Telangana, India, , e-mail:
| | - Nandhakishore Jampala
- Department of Critical Care, Medicover Hospital, Hyderabad, Telangana, India, , e-mail:
| | - Ravi Jain
- Department of Critical Care Medicine, Nayati Medicity, Mathura, Uttar Pradesh, India, , e-mail:
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Spencer TR, Bardin-Spencer A. Ultrasound Guidance for Vascular Access Procedures by Qualified Vascular Access Specialists or Other Applicable Healthcare Clinicians. ACTA ACUST UNITED AC 2019. [DOI: 10.2309/j.java.2019.004.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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49
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A Randomized Trial of Ultrasound- versus. Fluoroscopy-Guided Subclavian Vein Catheterization in Children with Hematologic Disease. Indian J Pediatr 2019; 86:1021-1027. [PMID: 31332603 DOI: 10.1007/s12098-019-03021-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 06/13/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To compare the ultrasound- and fluoroscopy-guided subclavian vein catheterization in pediatric population with hematologic diseases. METHODS A randomized prospective study of subclavian vein catheterization in pediatric population with hematologic diseases was performed. After randomization, the patients were assigned to either ultrasound- or fluoroscopy-guided subclavian vein catheterization. The primary outcome was number of attempts at venous cannulation. Secondary outcomes included: catheterization success rate, fluoroscopy time, operation time, and surgical complications. RESULTS There were 170 children enrolled between February 2017 and July 2018. There was no difference between the two groups with regard to the demographic data. Success within 3 attempts was achieved in 82 cases (82/87, 92.0%) in the ultrasound (US) group vs. 65 cases (65/83, 78.3%) in the fluoroscopy group (P = 0.002). The average operation time was 10(7) min in US group vs. 10(6) min in fluoroscopy group (P = 0.722). There were 3 complications in the US group, while there were 6 complications in the fluoroscopy group (P = 0.321). There were 4 catheter-related thrombosis (CRTs) found in the US group during follow-up, however there was no CRT in the fluoroscopy group (P = 0.121). CONCLUSIONS Ultrasound-guided venous puncture is a more accurate method of subclavian vein catheterization. However, the catheter tip can be placed more precisely by fluoroscopy. Thus, combined ultrasound-and fluoroscopy-guided technology is more efficient in subclavian vein catheterization of children with hematologic disease.
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50
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Franco-Sadud R, Schnobrich D, Mathews BK, Candotti C, Abdel-Ghani S, Perez MG, Rodgers SC, Mader MJ, Haro EK, Dancel R, Cho J, Grikis L, Lucas BP, Soni NJ. Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine. J Hosp Med 2019; 14:E1-E22. [PMID: 31561287 DOI: 10.12788/jhm.3287] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 02/02/2023]
Abstract
PREPROCEDURE 1)We recommend that providers should be familiar with the operation of their specific ultrasound machine prior to initiation of a vascular access procedure. 2)We recommend that providers should use a high-frequency linear transducer with a sterile sheath and sterile gel to perform vascular access procedures. 3)We recommend that providers should use two-dimensional ultrasound to evaluate for anatomical variations and absence of vascular thrombosis during preprocedural site selection. 4)We recommend that providers should evaluate the target blood vessel size and depth during preprocedural ultrasound evaluation. TECHNIQUES General Techniques 5) We recommend that providers should avoid using static ultrasound alone to mark the needle insertion site for vascular access procedures. 6)We recommend that providers should use real-time (dynamic), two-dimensional ultrasound guidance with a high-frequency linear transducer for central venous catheter (CVC) insertion, regardless of the provider's level of experience. 7)We suggest using either a transverse (short-axis) or longitudinal (long-axis) approach when performing real-time ultrasound-guided vascular access procedures. 8)We recommend that providers should visualize the needle tip and guidewire in the target vein prior to vessel dilatation. 9)To increase the success rate of ultrasound-guided vascular access procedures, we recommend that providers should utilize echogenic needles, plastic needle guides, and/or ultrasound beam steering when available. Central Venous Access Techniques 10) We recommend that providers should use a standardized procedure checklist that includes the use of real-time ultrasound guidance to reduce the risk of central line-associated bloodstream infection (CLABSI) from CVC insertion. 11)We recommend that providers should use real-time ultrasound guidance, combined with aseptic technique and maximal sterile barrier precautions, to reduce the incidence of infectious complications from CVC insertion. 12)We recommend that providers should use real-time ultrasound guidance for internal jugular vein catheterization, which reduces the risk of mechanical and infectious complications, the number of needle passes, and time to cannulation and increases overall procedure success rates. 13)We recommend that providers who routinely insert subclavian vein CVCs should use real-time ultrasound guidance, which has been shown to reduce the risk of mechanical complications and number of needle passes and increase overall procedure success rates compared with landmark-based techniques. 14)We recommend that providers should use real-time ultrasound guidance for femoral venous access, which has been shown to reduce the risk of arterial punctures and total procedure time and increase overall procedure success rates. Peripheral Venous Access Techniques 15) We recommend that providers should use real-time ultrasound guidance for the insertion of peripherally inserted central catheters (PICCs), which is associated with higher procedure success rates and may be more cost effective compared with landmark-based techniques. 16)We recommend that providers should use real-time ultrasound guidance for the placement of peripheral intravenous lines (PIV) in patients with difficult peripheral venous access to reduce the total procedure time, needle insertion attempts, and needle redirections. Ultrasound-guided PIV insertion is also an effective alternative to CVC insertion in patients with difficult venous access. 17)We suggest using real-time ultrasound guidance to reduce the risk of vascular, infectious, and neurological complications during PIV insertion, particularly in patients with difficult venous access. Arterial Access Techniques 18)We recommend that providers should use real-time ultrasound guidance for arterial access, which has been shown to increase first-pass success rates, reduce the time to cannulation, and reduce the risk of hematoma development compared with landmark-based techniques. 19)We recommend that providers should use real-time ultrasound guidance for femoral arterial access, which has been shown to increase first-pass success rates and reduce the risk of vascular complications. 20)We recommend that providers should use real-time ultrasound guidance for radial arterial access, which has been shown to increase first-pass success rates, reduce the time to successful cannulation, and reduce the risk of complications compared with landmark-based techniques. POSTPROCEDURE 21) We recommend that post-procedure pneumothorax should be ruled out by the detection of bilateral lung sliding using a high-frequency linear transducer before and after insertion of internal jugular and subclavian vein CVCs. 22)We recommend that providers should use ultrasound with rapid infusion of agitated saline to visualize a right atrial swirl sign (RASS) for detecting catheter tip misplacement during CVC insertion. The use of RASS to detect the catheter tip may be considered an advanced skill that requires specific training and expertise. TRAINING 23) To reduce the risk of mechanical and infectious complications, we recommend that novice providers should complete a systematic training program that includes a combination of simulation-based practice, supervised insertion on patients, and evaluation by an expert operator before attempting ultrasound-guided CVC insertion independently on patients. 24)We recommend that cognitive training in ultrasound-guided CVC insertion should include basic anatomy, ultrasound physics, ultrasound machine knobology, fundamentals of image acquisition and interpretation, detection and management of procedural complications, infection prevention strategies, and pathways to attain competency. 25)We recommend that trainees should demonstrate minimal competence before placing ultrasound-guided CVCs independently. A minimum number of CVC insertions may inform this determination, but a proctored assessment of competence is most important. 26)We recommend that didactic and hands-on training for trainees should coincide with anticipated times of increased performance of vascular access procedures. Refresher training sessions should be offered periodically. 27)We recommend that competency assessments should include formal evaluation of knowledge and technical skills using standardized assessment tools. 28)We recommend that competency assessments should evaluate for proficiency in the following knowledge and skills of CVC insertion: (a) Knowledge of the target vein anatomy, proper vessel identification, and recognition of anatomical variants; (b) Demonstration of CVC insertion with no technical errors based on a procedural checklist; (c) Recognition and management of acute complications, including emergency management of life-threatening complications; (d) Real-time needle tip tracking with ultrasound and cannulation on the first attempt in at least five consecutive simulation. 29)We recommend a periodic proficiency assessment of all operators should be conducted to ensure maintenance of competency.
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Affiliation(s)
| | - Daniel Schnobrich
- Divisions of General Internal Medicine and Hospital Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Benji K Mathews
- Department of Hospital Medicine, Regions Hospital, Health Partners, St. Paul, Minnesota
| | - Carolina Candotti
- Division of Hospital Medicine, University of California Davis, Davis, California
| | - Saaid Abdel-Ghani
- Department of Hospital Medicine, Medical Subspecialties Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Martin G Perez
- Department of Hospital Medicine, Memorial Hermann Northeast Hospital, Humble, Texas
| | - Sophia Chu Rodgers
- Division of Pulmonary Critical Care Medicine, Lovelace Health Systems, Albuquerque, New Mexico
| | - Michael J Mader
- Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
| | - Elizabeth K Haro
- Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
| | - Ria Dancel
- Division of Hospital Medicine, University of North Carolina, Chapel Hill, North Carolina
- Division of General Pediatrics and Adolescent Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Joel Cho
- Department of Hospital Medicine, Kaiser Permanente Medical Center, San Francisco, California
| | - Loretta Grikis
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
| | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | | | - Nilam J Soni
- Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
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