Central vascular catheter placement evaluation using saline flush and bedside echocardiography

Central Venous Catheter Migration Into Pleura Diagnosed by Transesophageal Echocardiography

Central venous catheter (CVC) tip migration is a well reported delayed complication of these vascular access devices with left-sided internal jugular or subclavian vein placement being the primary risk factor for this complication. We report a case of left internal jugular CVC migration and its diagnosis made by the heretofore unreported use of intraoperative transesophageal echocardiography in this context. Moreover, we describe risk factors for CVC migration along with its diagnosis and management.

"Rapid Atrial Swirl Sign": A Better Tool Than the Landmark Technique for Ensuring Correct Depth of Insertion of Central Venous Catheters

INTRODUCTION

Central venous catheters (CVCs) are widely used in the management and resuscitation of critically ill patients in emergency departments and intensive care units. Correct depth of insertion of the CVC line is important to ensure uninterrupted flow, avoid complications, and monitor central venous pressure. Transthoracic echocardiography, with contrast enhancement, has been proposed as an alternative to chest X-ray in detecting central venous line positioning with high accuracy. Nevertheless, this method is not widely used due to some previous conflicting results and the cumbersomeness of the procedure.

MATERIAL AND METHODS

After approval by the Institutional Ethics Committee, this prospective observational study was carried out in patients for whom a central venous line was warranted. The study was conducted in the Intensive Care Unit of a tertiary care hospital among 150 adult patients to compare the "Rapid Atrial Swirl Sign" (RASS) technique by transthoracic echocardiography and the landmark-based technique for ensuring accurate depth of central venous line placement.

RESULTS

In this study, we found that the mean depth of insertion of the CVC for the Echocardiography RASS group (E) was 12.84 cm, while for the Landmark technique group (L), it was 12.02 cm. There was a significant difference between these groups, with a p-value of <0.05. We found that the majority of patients (98.63%) in Group E had the catheter tip in Zones 1, 2, and 3, while only 66.6% of patients in Group L had the catheter tip in similar zones. The mean standard deviation for zones on chest X-ray was 1.8 for Group E and 2.26 for Group L, with a significant difference between these groups (p-value <0.05).

CONCLUSION

The RASS technique is superior to the landmark technique in ensuring the correct depth of the tip of the CVC. When confirmed by chest X-ray, it was found that most patients had the catheter tip in Zone 1, 2, or 3 using the RASS technique. This confirms that the RASS technique can minimize the requirement of resources and hasten the initiation of patient management in a timely manner, unlike the landmark technique, which requires chest X-ray confirmation before use.

Impact of distance of the catheter tip from cavo-atrial junction on bubble test (delay) time: A prospective study

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.

Global use of ultrasound in newborn vascular access: RA. CE. VA: implantation and management of complications

The use of ultrasound is advantageous in many respects: pre-procedural vein selection, real-time venipuncture, tip navigation (to verify guidewire or catheter progression) and post-procedural tip location, detection of early (hematoma, pneumothorax, hemothorax) and late complications (cardiac tamponade, fibroblastic sleeve, thrombosis).Such assessment is best performed using a systematic and standardized approach, as the Rapid Central Vein Assessment, described in this study for neonates too.

Are routine chest radiographs still indicated after central line insertion? A scoping review

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.

Can the length of a catheter change the time to bubble at the tip performing the "Bubble Test"? A bench study

INTRODUCTION

Intraprocedural tip control techniques are critical during central venous catheter placement. According to international guidelines (INS 2021), intracavitary electrocardiography is the first method of choice to verify it; when this technique is not feasible, it is considered acceptable to use a contrast-enhanced ultrasound-based tip location method, commonly known as "bubble-test" as an effective alternative.

OBJECTIVE

To assess whether the length of the vascular catheter can alter the time between the injection of the contrast media and its appearance at the catheter tip and the injection duration. Differences between operators stratified according to experience were evaluated as secondary endpoints.

METHODS

A bench study was conducted using an extracorporeal circuit. For each catheter length (60, 40, and 20 cm), three injections were obtained by each of the five operators with different levels of experience for a total of 45 measurements. Differences among operators were evaluated using ANOVA, and the impact of catheter length and operator expertise on times was assessed using repeated measurement models.

RESULTS

Hub-to-tip times of 247.33 ms (SD 168.82), 166 ms (SD 95.46), 138 ms (SD 54.48), and injection duration of 1620 ms (SD 748.58), 1614 ms (SD 570.95), 1566 ms (SD 302.83) were observed for 60, 40, 20 cm catheter length, respectively. A significant time variability between operators was observed. Moreover, moving from 60 to 20 cm, hub-to-tip time was significantly longer for 60 cm devices (p = 0.0124), while little differences were observed for injection duration.

CONCLUSIONS

Catheter length can change both the time between the injection of the contrast media and its appearance at the catheter tip and the injection duration. Hub-to-tip times obtained with 20 and 40 cm and overall injection duration did not differ significantly; skilled personnel could substantially reduce both values analyzed in this study.

A randomised trial of intracavitary electrocardiography versus surface landmark measurement for central venous access device placement

BACKGROUND

Malpositioned central venous access devices (CVADs) can lead to significant patient injury including central vein thrombosis and dysrhythmias. Intra-cavitary electrocardiography (IC ECG) has been recommended by peak professional bodies as an accurate alternative for bedside CVAD insertion, to reduce risk of malposition and allowing immediate use of the device. Our objective was to compare the effect of IC ECG on CVAD malposition compared to traditional institutional practice for CVAD placement.

METHODS

Randomised controlled trial of IC ECG CVAD insertion verses traditional CVAD insertion (surface landmark measurement with post insertion x ray). Patient recruitment was from December 2016 to July 2018. The setting was a 900-bed tertiary referral hospital based in South Western Sydney, Australia. Three hundred and forty-four adult patients requiring CVAD insertion for intravenous therapy, were enrolled and randomly allocated (1:1 ratio) to either IC-ECG (n = 172) or traditional (n = 172) CVAD insertion. Our primary outcome of interest was the rate of catheters not requiring repositioning after insertion (ready for use). Secondary outcomes were comparison of procedure time and cost.

RESULTS

Of the 172 patients allocated to the IC ECG method, 170 (99%) were ready for use immediately compared to 139 of the 172 (81%) in the traditional insertion group (difference, 95% confidence interval (CI): 18%, 11.9-24.1%). The total procedure time was mean 15 min (SD 8 min) for IC ECG and mean 36 min (SD 17 min) for traditional CVAD insertion (difference-19.9 min (95% CI-14.6 to -34.4). IC ECG guided CVAD insertion had a cost reduction of AUD $62.00 per procedure.

CONCLUSIONS

Using IC-ECG resulted in nearly no requirement for post-insertion repositioning of CVADs resulting in savings in time and cost and virtually eliminating the need for radiographic confirmation.

TRIAL REGISTRATION

This trial is registered at the Australian New Zealand Clinical Trials Registry (http://www.anzctr.org.au). The registration number is ACTRN12620000919910.

Echocardiographic Evaluation of Cardiac Masses

PURPOSE OF REVIEW

Cardiac masses encompass a broad range of etiologies and are often initially revealed by echocardiography. The differential may change depending on the location of the mass and patients' medical history or presentation. It is important for clinicians to be aware of subtle visual characteristics on echocardiography in order to correctly diagnose the pathology.

METHODS

Patients who underwent transthoracic echocardiography and were found to have one or more cardiac masses between January 1, 2020, and May 15, 2023, were reviewed. Their demographic data, clinical presentation, medical history, imaging, and follow-up information were collected from hospital electronic medical records, de-identified, and used to complete this review paper. A detailed review of cardiac masses divided by cardiac chamber accompanied by real-world echocardiographic images from patients in a large inner city public hospital. We hope that this systematic review of cardiac masses with real-world echocardiographic images will help clinicians note subtle echocardiographic characteristics to aid in the diagnosis and treatment of cardiac masses.

Ultrasonography-Guided Procedures in the Intensive Care Setting

Ultrasonography guidance can help make procedures safer and more effective, particularly in the intensive care setting. This article discusses techniques to optimize periprocedural ultrasonography and reviews common intensive care procedures for which ultrasonography can be used: vascular access procedures, paracentesis, thoracentesis, and pericardiocentesis.

ECHOTIP: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in adult patients

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.

Case report: Extravascular catheter migration in a child: A rare complication of the totally implantable venous access device

BACKGROUND

Totally implantable venous access devices (TIVADs) are widely used to gain intermittent central venous access, such as in patients who need long-term chemotherapy, total parenteral nutrition, and long-term antibiotic treatment. At present, there are many complications associated with the use of these devices. Complete extravascular migration of TIVADs via the internal jugular vein is a very rare and potentially serious condition, especially in children.

CASE PRESENTATION

A 1-year-old girl needed palliative chemotherapy because of hepatoblastoma complicated by inferior vena cava thrombosis. A TIVAD was implanted through the right internal jugular vein with a routine heparin flushing tube. On the second day after the operation, a pale bloody liquid was drawn out from the device and the chest X-ray was checked to confirm that the position of the catheter was normal. On the third day after the operation, however, the patient's right respiratory sound was weakened on physical examination and auscultation. Fluoroscopy showed that the tip of the catheter was located in the right thoracic cavity, and there was a large amount of effusion in the right thoracic cavity. The pleural effusion was removed, the TIVAD was replaced again, and the child was discharged 2 days later.

CONCLUSIONS

Following TIVAD implantation, if abnormalities are found, in addition to chest X-ray, saline flush and echocardiography should be performed to determine the position of the catheter and rule out extravascular migration of the catheter to avoid irreparable consequences.

How I Teach: Ultrasound-guided Peripheral Venous Access

Ultrasound-guided peripheral intravenous (IV) placement is often required for patients with difficult IV access and is associated with a reduction in central line placement. Despite the importance, there is no standardized technical approach, and there is limited ability to attain mastery through simulation. We describe our step-by-step approach for teaching ultrasound-guided IV placement at the bedside using short-axis dynamic guidance, with emphasis on advancing the needle and catheter device almost entirely into the vessel before threading the catheter. Our teaching approach allows the opportunity for trainees to maximize the learning potential of a single insertion experience, which includes focused preprocedure hands-on practice, instruction with real-time feedback at the bedside, and a post-procedure debrief with reinforcement of concepts.

Supradiaphragmatic central venous catheter malposition detection using the parasternal long-axis echocardiographic view and dextrose 50% contrast solution: A pilot study

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.

Point-of-care ultrasound in pediatric nephrology

Point-of-care ultrasound (POCUS) has evolved in recent years in clinical practice, helping in early bedside diagnosis of important etiologies. Many medical schools and training programs are integrating POCUS into their curriculum. Especially with the technological advances of newer handheld ultrasound devices, POCUS has now become a component adjunct to clinical examination, in the clinic and bedside in critical care units. The diagnostic utility of POCUS lies both in early identification of critical kidney disease, and also extra-renal pathologies from a focused cardiac ultrasound, lung ultrasound, and integrated fluid assessment. There is a need to incorporate POCUS in training in pediatric nephrology and establish competency standard criteria. This review shall cover how POCUS helps in enhancing patient care in pediatric kidney disorders and critical children, and the recent advances.

Economic Evaluation of Ultrasound-guided Central Venous Catheter Confirmation vs Chest Radiography in Critically Ill Patients: A Labor Cost Model

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.

Intraoperative ultrasound evidence of accidental simultaneous cannulation of the common carotid artery and internal jugular vein: illustrative case

BACKGROUND

Establishing central venous access is important to provide fluid resuscitation or medications intravenously to patients.

OBSERVATIONS

Although accidental cannulation of the internal carotid artery has been reported in the literature, to our knowledge this report is the first documented intraoperative ultrasound video demonstrating accidental and simultaneous common carotid artery and internal jugular cannulation during central line placement in the internal jugular vein.

LESSONS

Ultrasound use minimizes accidental carotid cannulation during central line placement in the internal jugular vein. Carotid artery puncture can be managed by external application of pressure or surgical reexploration.

Massive hemothorax following internal jugular vein catheterization under ultrasound guidance: A case report

BACKGROUND

Hemothorax is a rare but life-threatening complication of central venous catheterization. Recent reports suggest that ultrasound guidance may reduce complications however, it does not guarantee safety

CASE SUMMARY

A 75-year-old male patient was admitted for laparoscopic radical nephrectomy. Under ultrasound guidance, right internal jugular vein catheterization was successfully achieved after failure to aspirate blood from the catheter in the first attempt. Sudden hypotension developed after surgical positioning and persisted until the end of the operation, lasting for about 4 h. In the recovery room, a massive hemothorax was identified on chest radiography and computed tomography. The patient recovered following chest tube drainage of 1.6 L blood.

CONCLUSION

Hemothorax must be suspected when unexplained hemodynamic instability develops after central venous catheterization despite ultrasound guidance. So the proper use of ultrasound is important

The Use of POCUS to Manage ICU Patients With COVID-19

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.

Central Venous Catheter Confirmation by Ultrasonography: A Novel Instructional Protocol

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.

Estimation of the head elevation angle that causes clinically important venous air embolism in a semi-sitting position for neurosurgery: a retrospective observational study

Introduction:

The benefits of a sitting position for neurosurgery involving the posterior fossa remain controversial. The main concern is the risk of venous air embolism (VAE). A recent study showed that the rate of VAE was higher when the head was elevated to 45° than when it was elevated to 30°. However, the degree of head elevation that causes clinically important VAE is unclear. The purpose of this study was to estimate the head elevation angle at which the probability of VAE is 50% by using EtCO₂ monitoring to detect of VAE.

Methods:

The anesthesia records of 23 patients who underwent neurosurgery in a sitting position were reviewed retrospectively. Intraoperative ventilation was set to maintain EtCO₂ at approximately 38-42 mmHg. The head elevation angle in each case was determined from a photograph taken by the anesthesiologist or brain surgeon. Nineteen of the 23 cases had photographs available that contained a horizontal reference in the background. Seven cases were treated as VAE during the operation. Six of these cases met the criteria for VAE in this study. Data analysis was performed on a total of 18 patients. The angle between the line connecting the hip joint and the shoulder joint and the horizontal reference was obtained by ImageJ software. Logistic regression was performed using the Python programming language to determine the head elevation angle at which the probability of air embolism was 50%.

Results:

The decision boundary in the logistic regression was 35.7°. This head elevation angle was the boundary where the probability of VAE was 50%.

Conclusion:

The angle of head elevation that caused clinically important VAE was estimated to be 35.7°.

Transthoracic echocardiography as bedside technique to verify tip location of central venous catheters in patients with atrial arrhythmia

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.

Practice Guidelines for Central Venous Access 2020

These practice guidelines update the Practice Guidelines for Central Venous Access: A Report by the American Society of Anesthesiologists Task Force on Central Venous Access, adopted by the American Society of Anesthesiologists in 2011 and published in 2012. These updated guidelines are intended for use by anesthesiologists and individuals under the supervision of an anesthesiologist and may also serve as a resource for other physicians, nurses, or healthcare providers who manage patients with central venous catheters.

Supplemental Digital Content is available in the text.

The "rapid atrial swirl sign" for assessing central venous catheters: Performance by medical residents after limited training

Rationale

Central venous catheter (CVC) placement is a standard procedure in critical care. Ultrasound guidance during placement is recommended by current guidelines, but there is no consensus on the best method for evaluating the correct CVC tip position. Recently, the “rapid atrial swirl sign” (RASS) has been investigated in a limited number of studies.

Objectives

We performed a prospective diagnostic accuracy study of focused echocardiography for the evaluation of CVC tip position in our medical ICU and IMC units.

Methods

We performed a prospective diagnostic accuracy study in 100 patients admitted to the Intensive Care Unit and Intermediate Care Unit at our center. The first 10 subjects were assessed by one staff physician investigator (reference cohort), the remaining 90 patients by different residents (test cohort). All patients received a post-procedural chest radiograph (CXR) as gold standard. CVC placement was assessed with focused echocardiography performed by residents after a short training session. A rapid opacification of the right atrium (RASS) after injection of 10 mL of normal saline was regarded as “positive”, flush after more than two seconds was defined as “delayed”, no flush was a “negative” test result.

Measurements and main results

Overall sensitivity of the RASS was 100% (95% CI 73.54–100%), specificity was 94.32% (CI 87.24–98.13%). Positive and negative predictive values were 70.59% (CI 44.04–89.09%) and 100% (CI 95.65–100%), respectively. Median time for echocardiographic testing was 5 minutes (1–28) in the whole cohort, CXRs were available after 49.5 minutes (13–254). Interrater agreement of the RASS was 0.77 (Cohen’s kappa), Measurement of CVC tip position was not different between two observers. Test characteristics were similar among differently experienced residents.

Conclusions

Presence of the RASS by focused echocardiography showed excellent sensitivity and specificity and was equally performed by residents after minimal training. In patients with a positive RASS, routine CXR can be safely omitted, reducing time, costs and radiation exposure. A negative RASS should lead to a search for misplaced catheters.

Clinical trial registration

The study was registered with www.clinicaltrials.gov (NCT02661607).

Bedside ultrasound to detect central venous catheter misplacement and associated iatrogenic complications: a systematic review and meta-analysis

Background

Insertion of a central venous catheter (CVC) is common practice in critical care medicine. Complications arising from CVC placement are mostly due to a pneumothorax or malposition. Correct position is currently confirmed by chest x-ray, while ultrasonography might be a more suitable option. We performed a meta-analysis of the available studies with the primary aim of synthesizing information regarding detection of CVC-related complications and misplacement using ultrasound (US).

Methods

This is a systematic review and meta-analysis registered at PROSPERO (CRD42016050698). PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched. Articles which reported the diagnostic accuracy of US in detecting the position of CVCs and the mechanical complications associated with insertion were included. Primary outcomes were specificity and sensitivity of US. Secondary outcomes included prevalence of malposition and pneumothorax, feasibility of US examination, and time to perform and interpret both US and chest x-ray. A qualitative assessment was performed using the QUADAS-2 tool.

Results

We included 25 studies with a total of 2548 patients and 2602 CVC placements. Analysis yielded a pooled specificity of 98.9 (95% confidence interval (CI): 97.8–99.5) and sensitivity of 68.2 (95% CI: 54.4–79.4). US examination was feasible in 96.8% of the cases. The prevalence of CVC malposition and pneumothorax was 6.8% and 1.1%, respectively. The mean time for US performance was 2.83 min (95% CI: 2.77–2.89 min) min, while chest x-ray performance took 34.7 min (95% CI: 32.6–36.7 min). US was feasible in 97%. Further analyses were performed by defining subgroups based on the different utilized US protocols and on intra-atrial and extra-atrial misplacement. Vascular US combined with transthoracic echocardiography was most accurate.

Conclusions

US is an accurate and feasible diagnostic modality to detect CVC malposition and iatrogenic pneumothorax. Advantages of US over chest x-ray are that it can be performed faster and does not subject patients to radiation. Vascular US combined with transthoracic echocardiography is advised. However, the results need to be interpreted with caution since included studies were often underpowered and had methodological limitations. A large multicenter study investigating optimal US protocol, among other things, is needed.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-1989-x) contains supplementary material, which is available to authorized users.

Use of Contrast-Enhanced Ultrasound for Confirmation of Central Venous Catheter Placement: Systematic Review and Meta-analysis

OBJECTIVES

The purpose of this meta-analysis was to determine the sensitivity, specificity, and positive and negative predictive values of contrast-enhanced ultrasound (US) for confirming the tip location and placement of central venous catheters in adult patients.

METHODS

A systematic review was performed using electronic databases, including MEDLINE, ClinicalTrials.gov, Cochrane, Embase, PubMed, and Scopus. Inclusion criteria were studies conducted on adult patients receiving an internal jugular or a subclavian central venous catheter in the emergency department or intensive care unit. Furthermore, the catheter tip location had to be checked with the use of the agitated saline contrast-enhanced US technique.

RESULTS

A total of 2245 articles were screened by title and abstract. Seventeen articles were retrieved and assessed for the predefined inclusion criteria. Four articles and 1 abstract were used in the final analysis. Contrast-enhanced US showed pooled sensitivity of 72% (95% confidence interval, 44%-91%), pooled specificity of 100% (95% confidence interval, 99%-100%), a positive predictive value of 92.1%, and a negative predictive value of 98.5% compared with chest radiography for confirming the placement of central venous catheters.

CONCLUSIONS

In the setting of central venous catheter placement, postprocedural contrast-enhanced US imaging is a safe, efficient, and highly specific confirmatory test for the catheter tip location compared with chest radiography.

Ultrasound-Guided Peripheral Intravenous Line Placement: A Narrative Review of Evidence-based Best Practices

Peripheral intravenous line placement is a common procedure in emergency medicine. Ultrasound guidance has been demonstrated to improve success rates, as well as decrease complications and pain. This paper provides a narrative review of the literature focusing on best practices and techniques to improve performance with this procedure. We provide an evidence-based discussion of preparation for the procedure, vein and catheter selection, multiple techniques for placement, and line confirmation.

A rare case of malposition of central venous catheter detected by ultrasonography-guided saline flush test

Central venous catheter (CVC) insertion is associated with many potential complications; malposition of the catheter is one of them. A chest X-ray is routinely done to detect the malposition of catheter, but sometimes it has been seen that X-ray is time-consuming and its accuracy is also low for determining the exact position of the catheter tip. In our case, an ultrasonography (USG)-guided CVC was placed into the right internal jugular vein of the patient. As there was no ECG change obtained during insertion of guidewire and catheter, malposition was suspected, which was easily detected by a novel USG-guided saline flush test. We present a case report where USG was used for detection of a misplaced CVC (from right internal jugular vein to right subclavian vein). With ultrasound, the location of the catheter tip can be confirmed in very less time compared with chest X-ray.

Routine Chest Radiography Is Not Necessary After Ultrasound-Guided Right Internal Jugular Vein Catheterization

OBJECTIVES

Central venous catheter placement is a common procedure performed on critically ill patients. Routine postprocedure chest radiographs are considered standard practice. We hypothesize that the rate of clinically relevant complications detected on chest radiographs following ultrasound-guided right internal jugular vein catheterization is exceedingly low.

DESIGN

Retrospective chart review.

SETTING

Adult ICUs, emergency departments, and general practice units at an academic tertiary care hospital system.

PATIENTS

All 1,322 ultrasound-guided right internal jugular vein central venous catheter attempts at an academic tertiary care hospital system over a 1-year period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data from standardized procedure notes and postprocedure chest radiographs were extracted and individually reviewed to verify the presence of pneumothorax or misplacement, and any intervention performed for either complication. The overall success rate of ultrasound-guided right internal jugular vein central venous catheter placement was 96.9% with an average of 1.3 attempts. There was only one pneumothorax (0.1% [95% CI, 0-0.4%]), and the rate of catheter misplacement requiring repositioning or replacement was 1.0% (95% CI, 0.6-1.7%). There were no arterial placements found on chest radiographs. Multivariate regression analysis showed no correlation between high-risk patient characteristics and composite complication rate.

CONCLUSIONS

In a large teaching hospital system, the overall rate of clinically relevant complications detected on chest radiographs following ultrasound-guided right internal jugular vein catheterization is exceedingly low. Routine chest radiograph after this common procedure is an unnecessary use of resources and may delay resuscitation of critically ill patients.

Diagnostic Accuracy of Central Venous Catheter Confirmation by Bedside Ultrasound Versus Chest Radiography in Critically Ill Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

We performed a systematic review and meta-analysis to examine the accuracy of bedside ultrasound for confirmation of central venous catheter position and exclusion of pneumothorax compared with chest radiography.

DATA SOURCES

PubMed, Embase, Cochrane Central Register of Controlled Trials, reference lists, conference proceedings and ClinicalTrials.gov.

STUDY SELECTION

Articles and abstracts describing the diagnostic accuracy of bedside ultrasound compared with chest radiography for confirmation of central venous catheters in sufficient detail to reconstruct 2 × 2 contingency tables were reviewed. Primary outcomes included the accuracy of confirming catheter positioning and detecting a pneumothorax. Secondary outcomes included feasibility, interrater reliability, and efficiency to complete bedside ultrasound confirmation of central venous catheter position.

DATA EXTRACTION

Investigators abstracted study details including research design and sonographic imaging technique to detect catheter malposition and procedure-related pneumothorax. Diagnostic accuracy measures included pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio.

DATA SYNTHESIS

Fifteen studies with 1,553 central venous catheter placements were identified with a pooled sensitivity and specificity of catheter malposition by ultrasound of 0.82 (0.77-0.86) and 0.98 (0.97-0.99), respectively. The pooled positive and negative likelihood ratios of catheter malposition by ultrasound were 31.12 (14.72-65.78) and 0.25 (0.13-0.47). The sensitivity and specificity of ultrasound for pneumothorax detection was nearly 100% in the participating studies. Bedside ultrasound reduced mean central venous catheter confirmation time by 58.3 minutes. Risk of bias and clinical heterogeneity in the studies were high.

CONCLUSIONS

Bedside ultrasound is faster than radiography at identifying pneumothorax after central venous catheter insertion. When a central venous catheter malposition exists, bedside ultrasound will identify four out of every five earlier than chest radiography.

Utilization of Thoracic Ultrasound for Confirmation of Central Venous Catheter Placement and Exclusion of Pneumothorax: A Novel Technique in Real-Time Application

AIM

To evaluate the safety and utility of ultrasonography as a tool to confirm central venous catheter (CVC) position and to exclude insertion-related pneumothorax in place of chest radiography (CXR) in a tertiary medical intensive care unit (ICU).

METHODS

We randomized 60 consecutive medical ICU patients to conventional or ultrasound groups for CVC placement. Both groups had CVCs inserted under ultrasound guidance. The intervention group underwent real-time transthoracic echocardiography to assist in catheter positioning and chest ultrasonography for exclusion of pneumothorax. Our primary end point was reduction in CXR use. The secondary end point was time elapsed from the end of procedure to the availability of CVC for use. χ² test was used to compare the 2 groups for the primary end point. T test was used to compare the 2 groups for the secondary end point.

RESULTS

Thirty patients were randomized to the conventional group and 30 were randomized to the ultrasound group. One patient was excluded in the control group since the procedure needed to be aborted. Patient characteristics were well matched for age, body mass index, and acute physiologic assessment and chronic health evaluation (APACHE III) scores. There was a 56.7% ( P < .0001) reduction in CXR use in the ultrasound arm. Mean time to use was 53.6 minutes in the control group and 25 minutes in the ultrasound arm ( P = .0015). Mean time required to complete the procedure was 27.7 minutes in the control group and 24.1 minutes in the ultrasound group ( P = .2053). No pneumothorax was detected in either arm.

CONCLUSION

Ultrasound-guided CVC placement and positioning with a minor modification in technique reduced the use of bedside CXR and reduced the time to use of the CVC.

Advantages and pitfalls of pocket ultrasound vs daily chest radiography in the coronary care unit: A single-user experience

BACKGROUND

Pocket ultrasonography may enhance patient diagnosis and care. We sought to assess pocket ultrasound in detecting common conditions in the coronary care unit (CCU) compared to portable daily chest radiography (CXR) and conventional transthoracic echocardiography (TTE).

METHODS

An experienced pocket ultrasound user performed a pocket ultrasound examination for interstitial edema, pneumonia, central line seen in the right ventricle, pleural and pericardial effusions, left atrial enlargement, and cardiomegaly. Data were blindly compared to the radiologist CXR interpretation and cardiologist TTE interpretation.

RESULTS

A total of 102 CXR and pocket ultrasound examinations were performed in 66 patients. The most common CXR indication was "interval change" (37%) and finding central line (65%). Pocket ultrasound demonstrated overall good concordance with CXR ranging from 77% for pleural effusion to 92% for pneumonia. Additionally, the pocket ultrasound examination appeared to anticipate resolution of pulmonary edema prior to the CXR. Compared to TTE, pocket ultrasound had excellent sensitivity for cardiac findings with values ranging from 85% for left atrial enlargement to 100% for cardiomegaly, but limited specificity of cardiomegaly at just 51%.

CONCLUSION

In the CCU, bedside pocket ultrasound reliably diagnoses common conditions identified by CXR with the advantage of lack of ionizing radiation and the suggestion of detecting the resolution of pulmonary edema prior to CXR. Pitfalls include only modest concordance for pleural effusions and limited specificity for cardiomegaly. Larger, multicenter studies are needed to determine whether pocket ultrasound can reduce routine daily CXR in the CCU and other intensive care settings.

Ultrasound Guidance for Central Venous Catheterization: A Step Further to Prevent Malposition of Central Venous Catheter before Radiographic Confirmation

Ultrasound (USG) guidance has long been used for guiding central venous catheterization. USG provides direct visualization of needle puncture through the skin into the vein. Most of the time USG guidance is just limited to puncturing of the vein and seeing guidewire entering the vein while malpositioning of catheter occurs after that which is seen later on while checking chest radiograph. Repositioning of catheter after that becomes not only difficult requiring repeated chest radiograph to reconfirm position of catheter but also increases chances of infection with repeated manipulations. USG guidance can be used for tracing both guidewire and catheter during the procedure to prevent malpositioning of catheter, thus when done at the right time can prevent complication related to malpositioning and repeated manipulations. We used linear USG probe to check malposition of guidewire and microconvex probe to confirm position of central venous catheter.

Simplified point-of-care ultrasound protocol to confirm central venous catheter placement: A prospective study

BACKGROUND

The current standard for confirmation of correct supra-diaphragmatic central venous catheter (CVC) placement is with plain film chest radiography (CXR). We hypothesized that a simple point-of-care ultrasound (POCUS) protocol could effectively confirm placement and reduce time to confirmation.

METHODS

We prospectively enrolled a convenience sample of patients in the emergency department and intensive care unit who required CVC placement. Correct positioning was considered if turbulent flow was visualized in the right atrium on sub-xiphoid, parasternal or apical cardiac ultrasound after injecting 5 cc of sterile, non-agitated, normal saline through the CVC.

RESULTS

Seventy-eight patients were enrolled. POCUS had a sensitivity of 86.8% (95%CI 77.1%-93.5%) and specificity of 100% (95%CI 15.8%-100.0%) for identifying correct central venous catheter placement. Median POCUS and CXR completion were 16 minutes (IQR 10-29) and 32 minutes (IQR 19-45), respectively.

CONCLUSION

Ultrasound may be an effective tool to confirm central venous catheter placement in instances where there is a delay in obtaining a confirmatory CXR.

Diagnostic Accuracy of Central Venous Catheter Confirmation by Bedside Ultrasound Versus Chest Radiography in Critically Ill Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

We performed a systematic review and meta-analysis to examine the accuracy of bedside ultrasound for confirmation of central venous catheter position and exclusion of pneumothorax compared with chest radiography.

DATA SOURCES

PubMed, Embase, Cochrane Central Register of Controlled Trials, reference lists, conference proceedings and ClinicalTrials.gov.

STUDY SELECTION

Articles and abstracts describing the diagnostic accuracy of bedside ultrasound compared with chest radiography for confirmation of central venous catheters in sufficient detail to reconstruct 2 × 2 contingency tables were reviewed. Primary outcomes included the accuracy of confirming catheter positioning and detecting a pneumothorax. Secondary outcomes included feasibility, interrater reliability, and efficiency to complete bedside ultrasound confirmation of central venous catheter position.

DATA EXTRACTION

Investigators abstracted study details including research design and sonographic imaging technique to detect catheter malposition and procedure-related pneumothorax. Diagnostic accuracy measures included pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio.

DATA SYNTHESIS

Fifteen studies with 1,553 central venous catheter placements were identified with a pooled sensitivity and specificity of catheter malposition by ultrasound of 0.82 (0.77-0.86) and 0.98 (0.97-0.99), respectively. The pooled positive and negative likelihood ratios of catheter malposition by ultrasound were 31.12 (14.72-65.78) and 0.25 (0.13-0.47). The sensitivity and specificity of ultrasound for pneumothorax detection was nearly 100% in the participating studies. Bedside ultrasound reduced mean central venous catheter confirmation time by 58.3 minutes. Risk of bias and clinical heterogeneity in the studies were high.

CONCLUSIONS

Bedside ultrasound is faster than radiography at identifying pneumothorax after central venous catheter insertion. When a central venous catheter malposition exists, bedside ultrasound will identify four out of every five earlier than chest radiography.

Internal jugular vein versus subclavian vein as the percutaneous insertion site for totally implantable venous access devices: a meta-analysis of comparative studies

Background

A totally implantable venous access device (TIVAD) provides reliable, long-term vascular access and improves patients’ quality of life. The wide use of TIVADs is associated with important complications. A meta-analysis was undertaken to compare the internal jugular vein (IJV) with the subclavian vein (SCV) as the percutaneous access site for TIVAD to determine whether IJV has any advantages.

Methods

All randomized controlled trials (RCTs) and cohort studies assessing the two access sites, IJV and SCV, were retrieved from PubMed, Web of Science, Embase, and OVID EMB Reviews from their inception to December 2015. Random-effects models were used in all analyses. The endpoints evaluated included TIVAD-related infections, catheter-related thrombotic complications, and major mechanical complications.

Results

Twelve studies including 3905 patients published between 2008 and 2015, were included. Our meta-analysis showed that incidences of TIVAD-related infections (odds ratio [OR] 0.71, 95 % confidence interval [CI] 0.48–1.04, P = 0.081) and catheter-related thrombotic complications (OR 0.76, 95 % CI 0.38–1.51, P = 0.433) were not significantly different between the two groups. However, compared with SCV, IJV was associated with reduced risks of total major mechanical complications (OR 0.38, 95 % CI 0.24–0.61, P < 0.001). More specifically, catheter dislocation (OR 0.43, 95 % CI 0.22–0.84, P = 0.013) and malfunction (OR 0.42, 95 % CI 0.28–0.62, P < 0.001) were more prevalent in the SCV than in the IJV group; however, the risk of catheter fracture (OR 0.47, 95 % CI 0.21–1.05, P = 0.065) were not significantly different between the two groups. Sensitivity analyses using fixed-effects models showed a decreased risk of catheter fracture in the IJV group.

Conclusion

The IJV seems to be a safer alternative to the SCV with lower risks of total major mechanical complications, catheter dislocation, and malfunction. However, a large-scale and well-designed RCT comparing the complications of each access site is warranted before the IJV site can be unequivocally recommended as a first choice for percutaneous implantation of a TIVAD.

Ultrasound-guided central vascular interventions, comments on the European Federation of Societies for Ultrasound in Medicine and Biology guidelines on interventional ultrasound

Central venous access has traditionally been performed on the basis of designated anatomical landmarks. However, due to patients' individual anatomy and vessel pathology and depending on individual operators' skill, this landmark approach is associated with a significant failure rate and complication risk. There is substantial evidence demonstrating significant improvement in effectiveness and safety of vascular access by realtime ultrasound (US)-guidance, as compared to the anatomical landmark-guided approach. This review comments on the evidence-based recommendations on US-guided vascular access which have been published recently within the framework of Guidelines on Interventional Ultrasound (InVUS) of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) from a clinical practice point of view.

The role of ultrasound guidance for vascular access

PURPOSE OF REVIEW

Ultrasound-guided cannulation of the internal jugular vein has become a standard practice over recent years. Despite known benefits, ultrasound is less frequently used for other vascular applications probably because these are technically demanding and require more experience. The authors of this review focus on pitfalls of ultrasound guidance: most important practical aspects as well as nonroutine vascular applications are discussed.

RECENT FINDINGS

Ultrasound guidance increases the first-pass and overall success rates and reduces the risk of complications of central venous catheterization through the subclavian and femoral routes, as well as arterial and difficult peripheral venous access. Ultrasound is also useful to detect catheter malposition and complications. Technical improvements and new modifications of old ultrasound-guided techniques may result in better outcomes.

SUMMARY

Growing evidence suggests that routine utilization of ultrasound guidance is beneficial for all types of vascular access. The presence of a skilled operator and proper technique are, however, required to achieve success and avoid complications.

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

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

Prospective comparison of ultrasound and CXR for confirmation of central vascular catheter placement

OBJECTIVE

To prospectively compare ultrasound (US) versus CXR for confirmation of central vascular catheter (CVC) placement. Secondary objective was to determine the incidence of pneumothorax (PTX) and compare US with CXR completion times.

METHODS

Investigators performed the US saline flush echo test, and evaluated each anterior hemithorax for pleural sliding with US after subclavian or internal jugular CVC placement.

MEASUREMENTS AND MAIN RESULTS

151 total (135 in the emergency department, 16 in the intensive care unit) patients after CVC placement, mean age 62.1±15.6 years and 83 (55%) female patients. The rapid atrial swirl sign ( RASS) was ultrasound finding of an immediate appearance of turbulence entering the right atrium via superior vena cava after a rapid saline flush of the distal CVC port. RASS was considered 'negative' for CVC malposition. US identified all correct CVC placements. Four suboptimal CVC tip placements were detected by CXR. US identified three of these misplacements (McNemar exact p value >0.99). There were no cases of PTX or abnormal pleural sliding by either CXR or US. Median times for US and CXR completion were 1.1 (IQR 0.7) minutes and 20 (IQR: 30) minutes, respectively, median difference 23.8 (95% CI 19.6 to 29.3) minutes, p<0.0001.

CONCLUSIONS

PTX and CVC tip malposition were rare after US-guided CVC placement. There was no significant difference between saline flush echo and CXR for the identification of catheter tip malposition. Benefits of US assessment for complications include reduced radiation exposure and time delays associated with CXR.

Saline Contrast Echocardiography in the Era of Multimodality Imaging--Importance of "Bubbling It Right"

Saline contrast echocardiography is an established imaging modality. Logical interpretation of a carefully performed study is vital to realize its diagnostic potential. In this review, we discuss utility of saline contrast echocardiography in evaluation of various pathologies within and outside the heart other than a patent foramen ovale.