1
|
Muacevic A, Adler JR, Almeida J, Gonçalves L, Madeira I, Costa A. "Optimal" Central Venous Catheter Tip Position Does Not Increase Catheter Duration: A Retrospective Cohort Study. Cureus 2022; 14:e32627. [PMID: 36660530 PMCID: PMC9845532 DOI: 10.7759/cureus.32627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2022] [Indexed: 12/23/2022] Open
Abstract
Background Central venous cannulation provides venous access in different settings. Multiple guidelines and checklists still recommend confirmation of central venous catheter (CVC) tip position using a chest radiograph. The rationale is to detect and prevent complications thus optimizing CVC placement. Our primary hypothesis is that confirmation of catheter tip position by chest radiograph is not associated with increased catheter duration. Methods A retrospective cohort study was conducted with 921 patients included. Demographic, procedure and catheter data was obtained from adult patients that placed a CVC in the operating room. The catheter tip was independently classified as "optimal" or "malpositioned" independently by two researchers. Results Data from 921 CVC placements was collected. Patients who had a post-procedure chest radiograph (n=682, 74.0%) differed from those who did not in terms of co-morbidities (p=0.030), indication for CVC (p=0.023), duration of placement (p<0.001), number of punctured veins (p=0.036) and use of ultrasound (p<0.001). There was substantial agreement between researchers when classifying CVC tip as "optimal" or "malpositioned" (κ=0.632, p<0.001). No statistically significant difference was found between duration or complications of "optimal" CVCs compared to unknown tip/"malpositioned" CVCs. This study showed a 99% rate of clinically redundant chest radiographs according to Pikwer's criteria for radiographic examination. Conclusion No difference was found regarding catheter duration or complications when comparing "optimal" and unknown/"malpositioned" tip. This study illustrates some consequences of post-procedure radiographs and reinforces that the risks/benefits should be weighed and that chest radiograph should not be done by routine.
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Wang M, Xu L, Feng Y, Gong S. Misplacement of a central venous catheter into azygos vein via the right internal jugular vein. J Vasc Access 2020; 22:1004-1007. [PMID: 32787623 DOI: 10.1177/1129729820950996] [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
For critically ill patients, central venous catheterization may not always be placed in a correct tip position, even when guided by ultrasound. A case of inadvertent catheterization into azygos vein is described.
Collapse
Affiliation(s)
- Minjia Wang
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, China
| | - Liang Xu
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, China
| | - Yue Feng
- Department of Radiology, Zhejiang Hospital, Hangzhou, China
| | - Shijin Gong
- Department of Critical Care Medicine, Zhejiang Hospital, Hangzhou, China
| |
Collapse
|
6
|
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.
Collapse
Affiliation(s)
- Malvinder S Parmar
- Northern Ontario School of Medicine, Timmins and District Hospital, Timmins, ON, Canada
| |
Collapse
|
7
|
Xia R, Sun X, Bai X, Zhou Y, Shi J, Jin Y, Chen Q. Efficacy and safety of ultrasound-guided cannulation via the right brachiocephalic vein in adult patients. Medicine (Baltimore) 2018; 97:e13661. [PMID: 30558066 PMCID: PMC6320174 DOI: 10.1097/md.0000000000013661] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 11/19/2018] [Indexed: 11/25/2022] Open
Abstract
Central venous catheter (CVC) insertion is difficult to perform and is a high-risk operation; ultrasound (US)-guided cannulation helps increase the odds of success while reducing the associated complications. The internal jugular vein (IJV) and subclavian vein (SCV) are the most commonly sites in US-guided CVC insertion. In the present study, we evaluated the safety and efficacy of US-guided supraclavicular right brachiocephalic vein (BCV) cannulations in adult patients.Between January 2016 and December 2017, 428 adult patients requiring 536 CVC insertions underwent ultrasound-guided right BCV cannulation. The success rate and complications related to indwelling catheters were analyzed.The technical success rate was 98.32% (527/536). The procedure was successful at the first try in 511 cases (95.34%). The mean operation time was 13.26 ± 3.34 minutes. The mean length of catheter introduction was 13.57 ± 3.53 cm. Incidence of intraoperative complications was 2.61%. For 3 patients, the procedure was terminated due to pneumothorax (PNX), and in 11 arterial punctures there were self-limiting hematomas. The incidence of postprocedure complications was 5.97% (32/536). These complications included catheter-related infections (n = 18) and thromboses (n = 14). Insertion lasted an average of 10.68 ± 8.77 days.Supraclavicular, in-plane, US-guided cannulation of the right BCV is an effective and safe method for inserting central venous catheters in adult patients. It provides another option for catheter access to boost clinical performance in central venous catheterization.
Collapse
Affiliation(s)
- Rui Xia
- Department of Oncology
- Department of Intervention, The Second Affiliated Hospital of Soochow University
| | - Xingwei Sun
- Department of Intervention, The Second Affiliated Hospital of Soochow University
| | - Xuming Bai
- Department of Intervention, The Second Affiliated Hospital of Soochow University
| | - Yubin Zhou
- Department of Intervention, The Second Affiliated Hospital of Soochow University
| | - Jianming Shi
- Department of Oncology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, Jiangsu, PR China
| | - Yong Jin
- Department of Intervention, The Second Affiliated Hospital of Soochow University
| | - Qian Chen
- Department of Oncology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou, Jiangsu, PR China
| |
Collapse
|
8
|
Chui J, Saeed R, Jakobowski L, Wang W, Eldeyasty B, Zhu F, Fochesato L, Lavi R, Bainbridge D. Is Routine Chest X-Ray After Ultrasound-Guided Central Venous Catheter Insertion Choosing Wisely?: A Population-Based Retrospective Study of 6,875 Patients. Chest 2018; 154:148-156. [PMID: 29501497 DOI: 10.1016/j.chest.2018.02.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/23/2018] [Accepted: 02/01/2018] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND A routine chest radiograph (CXR) is recommended as a screening test after central venous catheter (CVC) insertion. The goal of this study was to assess the value of a routine postprocedural CXR in the era of ultrasound-guided CVC insertion. METHODS This population-based retrospective cohort study was performed to review the records of all adult patients who had a CVC inserted in the operating room in a tertiary institution between July 1, 2008, and December 31, 2015. We determined the incidence of pneumothorax and catheter misplacement after ultrasound-guided CVC insertion. A logistic regression analysis was performed to examine the potential risk factors associated with these complications, and a cost analysis was conducted to evaluate the economic impact. RESULTS Of 18,274 patients who had a CVC inserted, 6,875 patients were included. The overall incidence of pneumothorax and catheter misplacement was 0.33% (95% CI, 0.22-0.5) (23 patients) and 1.91% (95% CI, 1.61-2.26) (131 patients), respectively. The site of catheterization was the major determinant of pneumothorax and catheter misplacement; left subclavian vein catheterization was the site at a higher risk for pneumothorax (OR, 6.69 [95% CI, 2.45-18.28]; P < .001), and catheterization sites other than the right internal jugular vein were at a higher risk for catheter misplacement. Expenditures on routine postprocedural CXR were US $105,000 to $183,000 per year at our institution. CONCLUSIONS This study found that pneumothorax and catheter misplacement after ultrasound-guided CVC insertion were rare, and the costs of a postprocedural CXR were exceedingly high. We concluded that a routine postprocedural CXR is unnecessary and not a wise choice in our setting.
Collapse
Affiliation(s)
- Jason Chui
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, ON, Canada.
| | - Rasha Saeed
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, ON, Canada
| | - Luke Jakobowski
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, ON, Canada
| | - Wanyu Wang
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, ON, Canada
| | - Basem Eldeyasty
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, ON, Canada
| | - Fang Zhu
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, ON, Canada; MEDICI, University of Western Ontario, London, ON, Canada
| | - LeeAnne Fochesato
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, ON, Canada
| | - Ronit Lavi
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, ON, Canada
| | - Daniel Bainbridge
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, London, ON, Canada
| |
Collapse
|
9
|
Routine Chest Radiography Is Not Necessary After Ultrasound-Guided Right Internal Jugular Vein Catheterization. Crit Care Med 2017; 44:e804-8. [PMID: 27035241 DOI: 10.1097/ccm.0000000000001737] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
Collapse
|
10
|
Efficacy and safety of ultrasound-guided placement of central venous port systems via the right internal jugular vein in elderly oncologic patients: our single-center experience and protocol. Aging Clin Exp Res 2017; 29:127-130. [PMID: 27896794 DOI: 10.1007/s40520-016-0680-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 10/11/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Ultrasound-guidance has become the routine method for internal jugular vein (IJV) catheterization reducing dramatically failure and complication rates for central venous port (CVP) placement. AIMS The aim of this study was to determine the safety and efficacy of ultrasound-guided IJV CVP placement in elderly oncologic patients. METHODS Between January 2013 and December 2015, 101 elderly oncological patients underwent right IJV CVP placement under ultrasound-guidance. The length of catheter introduction ranged from 18 to 21 cm. Intraoperative fluoroscopy (IF) was always performed intraoperatively. Chest X-ray (CXR) was always performed 30 min after the end of the procedure. RESULTS The morbidity rate was 1.98%; two arterial punctures were reported with one self-limiting hematoma. Two patients (1.98%) had catheter misplacements, recognized by intraoperative IF. No patients (0%) experienced pneumothorax (PNX), confirmed at CXR. Patients were all discharged at maximum 6 h from the procedure. DISCUSSION The risk of catheter misplacement, PNX, and arterial/nerve puncture remains present with this technique. Lower rates of catheter misplacement have been reported after right IJV puncture, probably for its straight vertical course. Our results are in accordance with literature (1 counter-lateral subclavian vein and 1 counter-lateral internal jugular vein misplacements). All misplacements were detected intraoperatively. The PNX rates after cannulation of the IJV vary between 0.0 and 0.5%. We had no PNX occurrence. CONCLUSION Ultrasonography (US) has improved safety and effectiveness of port system placements. While routine post-procedural CXR seems avoidable, IF should be considered mandatory.
Collapse
|
11
|
|
12
|
Vinson DR, Ballard DW, Mark DG. The indications for screening chest radiography after failed thoracic central venous catheterization. Am J Emerg Med 2015; 33:970-1. [PMID: 25726064 DOI: 10.1016/j.ajem.2015.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 02/11/2015] [Indexed: 11/15/2022] Open
Affiliation(s)
- David R Vinson
- Kaiser Permanente Division of Research and The Permanente Medical Group, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente Sacramento Medical Center, Sacramento, CA, 95825.
| | - Dustin W Ballard
- Kaiser Permanente Division of Research and The Permanente Medical Group, Oakland, CA; Kaiser Permanente San Rafael Medical Center, San Rafael, CA
| | - Dustin G Mark
- The Permanente Medical Group, Oakland, CA; Kaiser Permanente Oakland Medical Center, Oakland, CA
| |
Collapse
|
13
|
Vinson DR, Ballard DW, Hance LG, Stevenson MD, Clague VA, Rauchwerger AS, Reed ME, Mark DG. Pneumothorax is a rare complication of thoracic central venous catheterization in community EDs. Am J Emerg Med 2015; 33:60-6. [DOI: 10.1016/j.ajem.2014.10.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 10/08/2014] [Accepted: 10/09/2014] [Indexed: 10/24/2022] Open
|
14
|
FRYKHOLM P, PIKWER A, HAMMARSKJÖLD F, LARSSON AT, LINDGREN S, LINDWALL R, TAXBRO K, ÖBERG F, ACOSTA S, ÅKESON J. Clinical guidelines on central venous catheterisation. Swedish Society of Anaesthesiology and Intensive Care Medicine. Acta Anaesthesiol Scand 2014; 58:508-24. [PMID: 24593804 DOI: 10.1111/aas.12295] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2014] [Indexed: 12/17/2022]
Abstract
Safe and reliable venous access is mandatory in modern health care, but central venous catheters (CVCs) are associated with significant morbidity and mortality, This paper describes current Swedish guidelines for clinical management of CVCs The guidelines supply updated recommendations that may be useful in other countries as well. Literature retrieval in the Cochrane and Pubmed databases, of papers written in English or Swedish and pertaining to CVC management, was done by members of a task force of the Swedish Society of Anaesthesiology and Intensive Care Medicine. Consensus meetings were held throughout the review process to allow all parts of the guidelines to be embraced by all contributors. All of the content was carefully scored according to criteria by the Oxford Centre for Evidence-Based Medicine. We aimed at producing useful and reliable guidelines on bleeding diathesis, vascular approach, ultrasonic guidance, catheter tip positioning, prevention and management of associated trauma and infection, and specific training and follow-up. A structured patient history focused on bleeding should be taken prior to insertion of a CVCs. The right internal jugular vein should primarily be chosen for insertion of a wide-bore CVC. Catheter tip positioning in the right atrium or lower third of the superior caval vein should be verified for long-term use. Ultrasonic guidance should be used for catheterisation by the internal jugular or femoral veins and may also be used for insertion via the subclavian veins or the veins of the upper limb. The operator inserting a CVC should wear cap, mask, and sterile gown and gloves. For long-term intravenous access, tunnelled CVC or subcutaneous venous ports are preferred. Intravenous position of the catheter tip should be verified by clinical or radiological methods after insertion and before each use. Simulator-assisted training of CVC insertion should precede bedside training in patients. Units inserting and managing CVC should have quality assertion programmes for implementation and follow-up of routines, teaching, training and clinical outcome. Clinical guidelines on a wide range of relevant topics have been introduced, based on extensive literature retrieval, to facilitate effective and safe management of CVCs.
Collapse
Affiliation(s)
- P. FRYKHOLM
- Department of Surgical Sciences; Anaesthesiology and Intensive Care Medicine; University Hospital; Uppsala University; Uppsala Sweden
| | - A. PIKWER
- Department of Clinical Sciences Malmö; Anaesthesiology and Intensive Care Medicine; Skåne University Hospital; Lund University; Malmö Sweden
| | - F. HAMMARSKJÖLD
- Department of Anaesthesiology and Intensive Care Medicine; Ryhov County Hospital; Jönköping Sweden
- Division of Infectious Diseases; Department of Clinical and Experimental Medicine; Faculty of Health Sciences; Linköping University; Linköping Sweden
| | - A. T. LARSSON
- Department of Anaesthesiology and Intensive Care Medicine; Gävle-Sandviken County Hospital; Gävle Sweden
| | - S. LINDGREN
- Department of Anaesthesiology and Intensive Care Medicine; Institute of Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - R. LINDWALL
- Department of Clinical Sciences; Division of Anaesthesiology and Intensive Care Medicine; Karolinska Institute; Danderyd University Hospital; Stockholm Sweden
| | - K. TAXBRO
- Department of Anaesthesiology and Intensive Care Medicine; Ryhov County Hospital; Jönköping Sweden
| | - F. ÖBERG
- Department of Anaesthesiology and Intensive Care Medicine; Karolinska University Hospital Solna; Stockholm Sweden
| | - S. ACOSTA
- Department of Clinical Sciences Malmö; Vascular Centre; Skåne University Hospital; Lund University; Malmö Sweden
| | - J. ÅKESON
- Department of Clinical Sciences Malmö; Anaesthesiology and Intensive Care Medicine; Skåne University Hospital; Lund University; Malmö Sweden
| |
Collapse
|
15
|
Weber E, Wołyniec W, Liberek T. Please, take X-ray! Hemodial Int 2014; 18:563-4. [PMID: 24698094 DOI: 10.1111/hdi.12146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Ewa Weber
- Department of Nephrology, Transplantology and Internal Medicine, Medical University of Gdansk, Poland
| | | | | |
Collapse
|
16
|
El Amrani M, El Kabbaj D, Benyahia M. [Late pneumomediastinum revealed by acute pulmonary edema in hemodialysis]. Nephrol Ther 2014; 10:118-9. [PMID: 24656891 DOI: 10.1016/j.nephro.2013.12.002] [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: 09/10/2013] [Revised: 12/02/2013] [Accepted: 12/26/2013] [Indexed: 11/15/2022]
Abstract
Central venous catheterization occupies an important place in the treatment of end stage renal disease pending the creation of an arteriovenous fistula. However, this procedure is not devoid of complications. We report a case of late pneumomediastinum revealed by an acute pulmonary edema in a young patient on hemodialysis, and we discuss its characteristics.
Collapse
Affiliation(s)
- Mohamed El Amrani
- Service de néphrologie, dialyse et transplantation rénale, unité de dialyse, hôpital militaire d'instruction Mohammed V, Hay Riad, 10100 Rabat, Maroc.
| | - Driss El Kabbaj
- Service de néphrologie, dialyse et transplantation rénale, unité de dialyse, hôpital militaire d'instruction Mohammed V, Hay Riad, 10100 Rabat, Maroc
| | - Mohammed Benyahia
- Service de néphrologie, dialyse et transplantation rénale, unité de dialyse, hôpital militaire d'instruction Mohammed V, Hay Riad, 10100 Rabat, Maroc
| |
Collapse
|
17
|
LINDGREN S, PIKWER A, RICKSTEN SE, ÅKESON J. Survey of central venous catheterisation practice in Sweden. Acta Anaesthesiol Scand 2013; 57:1237-44. [PMID: 24102163 DOI: 10.1111/aas.12190] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clinical guidelines on central venous catheterisation were introduced by the Swedish Society of Anaesthesiology and Intensive Care Medicine in 2011. The purpose of this study was to investigate current national practice and assess to what extent these guidelines influence clinical routines in Swedish operating wards and intensive care units. METHODS An invitation to participate in an online survey regarding central venous catheterisation was sent to 65 departments of anaesthesiology and intensive care medicine in Sweden. The survey aimed at investigating routine standards (part 1) and 24-h clinical practice (part 2). RESULTS Forty-seven (72%) and 49 (75%) of 65 departments took part in parts 1 and 2, respectively, and 73% adhered to the national guidelines. Many units monitored mechanical (42%) and infectious (69%) complications. Ultrasound was used by more than 50%. Checklists for insertion were used by 22%. Physicians inserted most catheters. No serious complications were reported during the 24-h study period. Ninety-seven non-tunnelled, 17 venous ports, 9 tunnelled and 8 peripheral central venous catheters were inserted. Ninety-three (71%) catheters were inserted in operating rooms, and 31 (24%) in intensive care units. Catheterisations were followed up by chest X-ray in most departments. CONCLUSION Knowledge of the Swedish guidelines was adequate, and most participating departments had local catheterisation routines. We could identify some variation in practice, but overall adherence to the guidelines was good. Nevertheless, monitoring of procedures and complications of cannulation and maintenance could be in need of improvement.
Collapse
Affiliation(s)
- S. LINDGREN
- Department of Anaesthesiology and Intensive Care; Institution of Clinical Sciences; Sahlgrenska Academy, Gothenburg University; Gothenburg Sweden
| | - A. PIKWER
- Department of Anaesthesiology and Intensive Care Medicine; Institution of Clinical Sciences Malmö; Skåne University Hospital, Lund University; Malmö Sweden
| | - S.-E. RICKSTEN
- Department of Anaesthesiology and Intensive Care; Institution of Clinical Sciences; Sahlgrenska Academy, Gothenburg University; Gothenburg Sweden
| | - J. ÅKESON
- Department of Anaesthesiology and Intensive Care Medicine; Institution of Clinical Sciences Malmö; Skåne University Hospital, Lund University; Malmö Sweden
| |
Collapse
|
18
|
El Hammoumi MM, Drissi G, Achir A, Benchekroun A, Benosman A, Kabiri EH. Iatrogenic pneumothorax: experience of a Moroccan Emergency Center. REVISTA PORTUGUESA DE PNEUMOLOGIA 2012. [PMID: 23200118 DOI: 10.1016/j.rppneu.2012.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The incidence of iatrogenic pneumothorax (IPx) will increase with invasive procedures particularly at training hospitals, that is why we have made a retrospective study of the common diagnostic or therapeutic causes of IPx and its impact on morbidity. From January 2011 to December 2011, 36 patients developed IPx as emergencies, after an invasive procedure. Their mean age was 38 years (range: 19-69 years). Of the patients, 21 (58%) were male and 15 (42%) were female. The purpose was diagnostic in 6 cases and therapeutic in 30 cases. In 8 patients (22%) the procedure was performed due to underlying lung diseases and in 28 patients (78%) for other diseases. The procedure most frequently causing IPnx was central venous catheterization, with 20 patients (55%), other frequent causes were mechanical ventilation in 8 cases (22%) (of whom we reported 3 cases of bilateral pneumothorax), 6 cases of thoracentesis (16%) and 2 patients had life-saving percutaneous tracheotomy. The majority of our patients were managed by a small chest tube placement (unilateral n=30, bilateral n=3). The average duration of drainage was 3 days (range: 1-15 days), sadly one of our patients died of ischemic brain damage 15 days after tracheotomy. At training hospitals the incidence of IPnx will increase with the increase in invasive procedures, which should only be performed by experienced personnel or under their supervision.
Collapse
Affiliation(s)
- M M El Hammoumi
- Department of Thoracic Surgery Mohammed V Military Teaching Hospital, Faculté de médecine et de pharmacie Université Mohamed V Souissi, Rabat, Morocco.
| | | | | | | | | | | |
Collapse
|
19
|
Calviño J, Bravo J, Martínez L, Millán B, Pulpeiro JR. Recognizing misplacement of a dialysis catheter in the azygos vein. Hemodial Int 2012; 17:455-7. [DOI: 10.1111/j.1542-4758.2012.00758.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jesús Calviño
- Department of NephrologyHospital Lucus Augusti Lugo Spain
| | - Juan Bravo
- Department of NephrologyHospital Lucus Augusti Lugo Spain
| | - Lucía Martínez
- Department of Vascular SurgeryHospital Lucus Augusti Lugo Spain
| | - Beatriz Millán
- Department of NephrologyHospital Lucus Augusti Lugo Spain
| | | |
Collapse
|
20
|
Oner B, Karam AR, Surapaneni P, Phillips DA. Pneumothorax Following Ultrasound-Guided Jugular Vein Puncture for Central Venous Access in Interventional Radiology. J Intensive Care Med 2011; 27:370-2. [DOI: 10.1177/0885066611415494] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: The purpose of our study was to review the rate of pneumothorax following central venous access, using real-time ultrasound guidance. Materials and methods: Data related to ultrasound-guided venous puncture, for central venous access, performed between July 1, 2004 and June 30, 2008 was retrospectively and prospectively collected. Access route, needle gauge, catheter type, and diagnosis of pneumothorax on the intraprocedure spot radiographs and or the postprocedure chest radiographs, were recorded. Results: A total of 1262 ultrasound-guided jugular venous puncture for central venous access were performed on a total of 1066 patients between July 1, 2004 and June 30, 2008. Access vessels included 983 right internal jugular veins, 275 left internal jugular veins, and 4 right external jugular veins. No pneumothorax (0%) was identified. Conclusion: Due to an extremely low rate of pneumothorax following ultrasound-guided central venous access, 0% in our study and other published studies, we suggest that routine postprocedure chest radiograph to exclude pneumothorax may be dispensed unless it is suspected by the operator or if the patient becomes symptomatic.
Collapse
Affiliation(s)
- Banu Oner
- Radiology Department, University of Massachusetts Medical School, Worcester, MA, USA
| | - Adib R. Karam
- Radiology Department, Abdominal Imaging Division, University of Massachusetts Medical School, Worcester, MA, USA
| | - Padmaja Surapaneni
- Radiology Department, Vascular and Interventional Radiology Division, University of Massachusetts Medical School, Worcester, MA, USA
| | - David A. Phillips
- Radiology Department, Vascular and Interventional Radiology Division, University of Massachusetts Medical School, Worcester, MA, USA
| |
Collapse
|
21
|
Chalumeau-Lemoine L, Ioos V, Galbois A, Maury E, Hejblum G, Guidet B. Peut-on réduire le nombre de radiographies de thorax en réanimation ? MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-010-0001-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
22
|
Endovascular Intervention for Central Venous Cannulation in Patients with Vascular Occlusion after Previous Catheterization. J Vasc Access 2010; 11:323-8. [DOI: 10.5301/jva.2010.5813] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2010] [Indexed: 11/20/2022] Open
Abstract
Objectives This study was designed to assess endovascular intervention for central venous cannulation in patients with vascular occlusion after previous catheterization. Methods Patients referred for endovascular management of central venous occlusion during a 42-month period were identified from a regional endovascular database, providing prospective information on techniques and clinical outcome. Corresponding patient records, angiograms, and radiographic reports were analyzed retrospectively. Results Sixteen patients aged 48 years (range 0.5–76), including 11 females, were included. All patients but 1 had had multiple central venous catheters with a median total indwelling time of 37 months. Eleven patients cannulated for hemodialysis had had significantly fewer individual catheters inserted compared with 5 patients cannulated for nutritional support (mean 3.6 vs. 10.2, p<0.001) before endovascular intervention. Preoperative imaging by magnetic resonance tomography (MRT) in 8 patients, computed tomography (CT) venography in 3, conventional angiography in 6, and/or ultrasonography in 8, verified 15 brachiocephalic, 13 internal jugular, 3 superior caval, and/or 3 subclavian venous occlusions. Patients were subjected to recanalization (n=2), recanalization and percutaneous transluminal angioplasty (n=5), or stenting for vena cava superior syndrome (n=1) prior to catheter insertion. The remaining 8 patients were cannulated by avoiding the occluded route. Conclusions Central venous occlusion occurs particularly in patients under hemodialysis and with a history of multiple central venous catheterizations with large-diameter catheters and/or long total indwelling time periods. Patients with central venous occlusion verified by CT or MRT venography and need for central venous access should be referred for endovascular intervention.
Collapse
|