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

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.

Ultrasonography and procedures in intensive care medicine

The use of point-of-care ultrasonography (POCUS) is not limited to the diagnosis and/or monitoring of critically ill patients. Further, ultrasound guidance is of paramount relevance to aid in successfully and safely performing several procedures in the intensive care unit (ICU). In this article, we review the role of POCUS as a procedural guidance in the ICU. Core procedures include, but are not limited to, vascular cannulation, pericardiocentesis, thoracentesis, paracentesis, aspiration of soft-tissue collections/arthrocentesis and lumbar puncture. With time, the procedures performed by intensivists may extend beyond the core competencies depicted in this review. Ultrasound guidance should be part of the intensivist's competencies, for which appropriate training should be achieved.

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.

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

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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.

Ultrasound localization of central vein catheter tip by contrast-enhanced transthoracic ultrasonography: a comparison study with trans-esophageal echocardiography

BACKGROUND

To assess the usefulness of pre-operative contrast-enhanced transthoracic echocardiography (CE-TTE) and post-operative chest-x-ray (CXR) for evaluating central venous catheter (CVC) tip placements, with trans-esophageal echocardiography (TEE) as gold standard.

METHODS

A prospective single-center, observational study was performed in 111 patients requiring CVC positioning into the internal jugular vein for elective cardiac surgery. At the end of CVC insertion by landmark technique, a contrast-enhanced TTE was performed by both the apical four-chambers and epigastric bicaval acoustic view to assess catheter tip position; then, a TEE was performed and considered as a reference technique. A postoperative CXR was obtained for all patients.

RESULTS

As per TEE, 74 (67%) catheter tips were correctly placed and 37 (33%) misplaced. Considering intravascular and intracardiac misplacements together, they were detected in 8 patients by CE-TTE via apical four-chamber view, 36 patients by CE-TTE via epigastric bicaval acoustic view, and 12 patients by CXR. For the detection of catheter tip misplacement, CE-TTE via epigastric bicaval acoustic view was the most accurate method providing 97% sensitivity, 90% specificity, and 92% diagnostic accuracy if compared with either CE-TTE via apical four-chamber view or CXR. Concordance with TEE was 79% (p < 0.001) for CE-TTE via epigastric bicaval acoustic view.

CONCLUSIONS

The concordance between CE-TTE via epigastric bicaval acoustic view and TEE suggests the use of the former as a standard technique to ensure the correct positioning of catheter tip after central venous cannulation to optimize the use of hospital resources and minimize radiation exposure.

Point-of-care ultrasound in a pandemic: Practical guidance in COVID-19 units

The coronavirus disease 2019 (COVID-19) pandemic has stretched our healthcare system to the brink, highlighting the importance of efficient resource utilization without compromising healthcare provider safety. While advanced imaging is a great resource for diagnostic purposes, the risk of contamination and infection transmission is high and requires extensive logistical planning for intrahospital patient transport, healthcare provider safety, and post-imaging decontamination. This dilemma has necessitated the transition to more bedside imaging. More so than ever, during the current pandemic, the clinical utility and importance of point-of-care ultrasound (POCUS) cannot be overstressed. It allows for safe and efficient beside procedural guidance and provides front line providers with valuable diagnostic information that can be acted upon in real-time for immediate clinical decision-making. The authors have been routinely using POCUS for the management of COVID-19 patients both in the emergency department and in intensive care units turned into “COVID-units.” In this article, we review the nuances of using POCUS in a pandemic situation and maximizing diagnostic output from this bedside technology. Additionally, we review various methods and diagnostic uses of POCUS which can replace conventional imaging and bridge current literature and common clinical practices in critically ill patients. We discuss practical guidance and pertinent review of the literature for the most relevant procedural and diagnostic guidance of respiratory illness, hemodynamic decompensation, renal failure, and gastrointestinal disorders experienced by many patients admitted to COVID-units.

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.

OBJECTIVE ASSESSMENT METRICS FOR CENTRAL LINE SIMULATORS: AN EXPLORATION OF CAUSAL FACTORS

The Dynamic Haptic Robotic Trainer (DHRT) was developed to minimize the up to 39% of adverse effects experienced by patients during Central Venous Catheterization (CVC) by standardizing CVC training, and provide automated assessments of performance. Specifically, this system was developed to replace manikin trainers that only simulate one patient anatomy and require a trained preceptor to evaluate the trainees' performance. While the DHRT system provides automated feedback, the utility of this system with real-world scenarios and expertise has yet to be thoroughly investigated. Thus, the current study was developed to determine the validity of the current objective assessment metrics incorporated in the DHRT system through expert interviews. The main findings from this study are that experts do agree on perceptions of patient case difficulty, and that characterizations of patient case difficulty is based on anatomical characteristics, multiple needle insertions, and prior catheterization.

Ultrasound to Detect Central Venous Catheter Placement Associated Complications: A Multicenter Diagnostic Accuracy Study

BACKGROUND

Mechanical complications arising after central venous catheter placement are mostly malposition or pneumothorax. To date, to confirm correct position and detect pneumothorax, chest x-ray film has been the reference standard, while ultrasound might be an accurate alternative. The aim of this study was to evaluate diagnostic accuracy of ultrasound to detect central venous catheter malposition and pneumothorax.

METHODS

This was a prospective, multicenter, diagnostic accuracy study conducted at the intensive care unit and postanesthesia care unit. Adult patients who underwent central venous catheterization of the internal jugular vein or subclavian vein were included. Index test consisted of venous, cardiac, and lung ultrasound. Standard reference test was chest x-ray film. Primary outcome was diagnostic accuracy of ultrasound to detect malposition and pneumothorax; for malposition, sensitivity, specificity, and other accuracy parameters were estimated. For pneumothorax, because chest x-ray film is an inaccurate reference standard to diagnose it, agreement and Cohen's κ-coefficient were determined. Secondary outcomes were accuracy of ultrasound to detect clinically relevant complications and feasibility of ultrasound.

RESULTS

In total, 758 central venous catheterizations were included. Malposition occurred in 23 (3.3%) out of 688 cases included in the analysis. Ultrasound sensitivity was 0.70 (95% CI, 0.49 to 0.86) and specificity 0.99 (95% CI, 0.98 to 1.00). Pneumothorax occurred in 5 (0.7%) to 11 (1.5%) out of 756 cases according to chest x-ray film and ultrasound, respectively. In 748 out of 756 cases (98.9%), there was agreement between ultrasound and chest x-ray film with a Cohen's κ-coefficient of 0.50 (95% CI, 0.19 to 0.80).

CONCLUSIONS

This multicenter study shows that the complication rate of central venous catheterization is low and that ultrasound produces a moderate sensitivity and high specificity to detect malposition. There is moderate agreement with chest x-ray film for pneumothorax. In conclusion, ultrasound is an accurate diagnostic modality to detect malposition and pneumothorax.

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.

ERS statement on chest imaging in acute respiratory failure

Chest imaging in patients with acute respiratory failure plays an important role in diagnosing, monitoring and assessing the underlying disease. The available modalities range from plain chest X-ray to computed tomography, lung ultrasound, electrical impedance tomography and positron emission tomography. Surprisingly, there are presently no clear-cut recommendations for critical care physicians regarding indications for and limitations of these different techniques.The purpose of the present European Respiratory Society (ERS) statement is to provide physicians with a comprehensive clinical review of chest imaging techniques for the assessment of patients with acute respiratory failure, based on the scientific evidence as identified by systematic searches. For each of these imaging techniques, the panel evaluated the following items: possible indications, technical aspects, qualitative and quantitative analysis of lung morphology and the potential interplay with mechanical ventilation. A systematic search of the literature was performed from inception to September 2018. A first search provided 1833 references. After evaluating the full text and discussion among the committee, 135 references were used to prepare the current statement.These chest imaging techniques allow a better assessment and understanding of the pathogenesis and pathophysiology of patients with acute respiratory failure, but have different indications and can provide additional information to each other.

Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine

PREPROCEDURE

1)We recommend that providers should be familiar with the operation of their specific ultrasound machine prior to initiation of a vascular access procedure. 2)We recommend that providers should use a high-frequency linear transducer with a sterile sheath and sterile gel to perform vascular access procedures. 3)We recommend that providers should use two-dimensional ultrasound to evaluate for anatomical variations and absence of vascular thrombosis during preprocedural site selection. 4)We recommend that providers should evaluate the target blood vessel size and depth during preprocedural ultrasound evaluation.

TECHNIQUES

General Techniques 5) We recommend that providers should avoid using static ultrasound alone to mark the needle insertion site for vascular access procedures. 6)We recommend that providers should use real-time (dynamic), two-dimensional ultrasound guidance with a high-frequency linear transducer for central venous catheter (CVC) insertion, regardless of the provider's level of experience. 7)We suggest using either a transverse (short-axis) or longitudinal (long-axis) approach when performing real-time ultrasound-guided vascular access procedures. 8)We recommend that providers should visualize the needle tip and guidewire in the target vein prior to vessel dilatation. 9)To increase the success rate of ultrasound-guided vascular access procedures, we recommend that providers should utilize echogenic needles, plastic needle guides, and/or ultrasound beam steering when available. Central Venous Access Techniques 10) We recommend that providers should use a standardized procedure checklist that includes the use of real-time ultrasound guidance to reduce the risk of central line-associated bloodstream infection (CLABSI) from CVC insertion. 11)We recommend that providers should use real-time ultrasound guidance, combined with aseptic technique and maximal sterile barrier precautions, to reduce the incidence of infectious complications from CVC insertion. 12)We recommend that providers should use real-time ultrasound guidance for internal jugular vein catheterization, which reduces the risk of mechanical and infectious complications, the number of needle passes, and time to cannulation and increases overall procedure success rates. 13)We recommend that providers who routinely insert subclavian vein CVCs should use real-time ultrasound guidance, which has been shown to reduce the risk of mechanical complications and number of needle passes and increase overall procedure success rates compared with landmark-based techniques. 14)We recommend that providers should use real-time ultrasound guidance for femoral venous access, which has been shown to reduce the risk of arterial punctures and total procedure time and increase overall procedure success rates. Peripheral Venous Access Techniques 15) We recommend that providers should use real-time ultrasound guidance for the insertion of peripherally inserted central catheters (PICCs), which is associated with higher procedure success rates and may be more cost effective compared with landmark-based techniques. 16)We recommend that providers should use real-time ultrasound guidance for the placement of peripheral intravenous lines (PIV) in patients with difficult peripheral venous access to reduce the total procedure time, needle insertion attempts, and needle redirections. Ultrasound-guided PIV insertion is also an effective alternative to CVC insertion in patients with difficult venous access. 17)We suggest using real-time ultrasound guidance to reduce the risk of vascular, infectious, and neurological complications during PIV insertion, particularly in patients with difficult venous access. Arterial Access Techniques 18)We recommend that providers should use real-time ultrasound guidance for arterial access, which has been shown to increase first-pass success rates, reduce the time to cannulation, and reduce the risk of hematoma development compared with landmark-based techniques. 19)We recommend that providers should use real-time ultrasound guidance for femoral arterial access, which has been shown to increase first-pass success rates and reduce the risk of vascular complications. 20)We recommend that providers should use real-time ultrasound guidance for radial arterial access, which has been shown to increase first-pass success rates, reduce the time to successful cannulation, and reduce the risk of complications compared with landmark-based techniques.

POSTPROCEDURE

21) We recommend that post-procedure pneumothorax should be ruled out by the detection of bilateral lung sliding using a high-frequency linear transducer before and after insertion of internal jugular and subclavian vein CVCs. 22)We recommend that providers should use ultrasound with rapid infusion of agitated saline to visualize a right atrial swirl sign (RASS) for detecting catheter tip misplacement during CVC insertion. The use of RASS to detect the catheter tip may be considered an advanced skill that requires specific training and expertise.

TRAINING

23) To reduce the risk of mechanical and infectious complications, we recommend that novice providers should complete a systematic training program that includes a combination of simulation-based practice, supervised insertion on patients, and evaluation by an expert operator before attempting ultrasound-guided CVC insertion independently on patients. 24)We recommend that cognitive training in ultrasound-guided CVC insertion should include basic anatomy, ultrasound physics, ultrasound machine knobology, fundamentals of image acquisition and interpretation, detection and management of procedural complications, infection prevention strategies, and pathways to attain competency. 25)We recommend that trainees should demonstrate minimal competence before placing ultrasound-guided CVCs independently. A minimum number of CVC insertions may inform this determination, but a proctored assessment of competence is most important. 26)We recommend that didactic and hands-on training for trainees should coincide with anticipated times of increased performance of vascular access procedures. Refresher training sessions should be offered periodically. 27)We recommend that competency assessments should include formal evaluation of knowledge and technical skills using standardized assessment tools. 28)We recommend that competency assessments should evaluate for proficiency in the following knowledge and skills of CVC insertion: (a) Knowledge of the target vein anatomy, proper vessel identification, and recognition of anatomical variants; (b) Demonstration of CVC insertion with no technical errors based on a procedural checklist; (c) Recognition and management of acute complications, including emergency management of life-threatening complications; (d) Real-time needle tip tracking with ultrasound and cannulation on the first attempt in at least five consecutive simulation. 29)We recommend a periodic proficiency assessment of all operators should be conducted to ensure maintenance of competency.

Fluoroscopy-guided subclavian vein catheterization in 203 children with hematologic disease

Subclavian vein catheterization plays an important role in the treatment of children with hematologic disease. However, catheter placement is a difficult and high-risk procedure in children.Fluoroscopy-guided subclavian vein catheterization was used in 203 children (mean age, 6.99 years ± 3.722 years; range, 1-16 years) with hematologic disease. The number of vein punctures, catheterization success rate, fluoroscopy time, operation time, and surgical complications were recorded.There was a 100% success rate for fluoroscopy-guided subclavian vein catheterization. A total of 124 cases (61.1%) were successful on the first venipuncture attempt; 171 cases (84.2%) achieved success within 3 attempts. Twenty-five cases had 4 to 6 time venipunctures and the remaining 7 cases underwent ≥7 time venipunctures. All catheter tips were successfully placed at the junction of the superior vena cava and the right atrium. Fluoroscopy times ranged from 16 to 607 seconds (mean, 65.46 ± 85.864 seconds). Operation time ranged between 5 and 25 minutes (mean, 10.38 ± 4.036 minutes). Arterial punctured was happened during surgery in 2 cases. There were 2 cases of catheter-related infection, but no other complications. The mean follow-up time was 35 days; range 20 to 50 days.Fluoroscopy-guided subclavian vein catheterization in children is a safe procedure, with a high success rate, resulting in a reduced number of venipunctures, optimal catheter placement, and reduced complications.

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).

Effectiveness of an Early Ultrasound Training Curriculum for General Surgery Residents

Ultrasound (US) is fast becoming an extension of the physical examination in most surgical settings. Unfortunately, few residency programs offer a formal US training curriculum to their general surgical residents. This study aimed to assess the efficacy of a formal US training module for general surgery residents. We studied the degree of improvement observed between junior and senior residents. A training-based study was conducted to evaluate baseline knowledge and skills. Subsequently, a formal didactic and practical training program for our surgery residents was instituted. Residents were then scored in various categories. A total of 18 surgical residents comprising 10 junior and 8 senior residents completed our US training module. There was no significant improvement in the scores of the senior resident group. In the junior group, the written test, image detection, optimization, and interpretation categories improved significantly after completion of the training module. Comparison of improvement in scores between junior and senior residents revealed a significantly better improvement in the junior group than in the senior group. Early training of surgical residents can significantly improve US performance in junior residents. This early training has the benefit of increased utilization of bedside US for diagnostic and procedural purposes. Interestingly, even without formal training, skill acquisition of senior residents is noted to occur during modern surgical training.

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.

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.

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.

Ultrasound for Localization of Central Venous Catheter: A Good Alternative to Chest X-Ray?

Background

Chest radiography after central venous catheter (CVC) insertion is the main method of verifying the catheter location. Despite the widespread use of radiography for detecting catheter position, x-ray may not always be readily available, especially in the operating room.

Objectives

We aimed to compare contrast-enhanced ultrasonography (CEUS) and chest radiography for detecting the correct location of CVCs.

Methods

One hundred sixteen consecutive patients with indications for CVC before cardiac surgery were enrolled in this observational study. After catheter insertion, CEUS was performed. Portable radiography was obtained postoperatively in the intensive care unit. Sensitivity, specificity, and predictive values were determined by comparing the ultrasonography results with radiographic findings as a reference standard.

Results

Chest radiography revealed 16 CVC misplacements: two cases of intravascular and 14 cases of right atrium (RA) misplacement. CEUS detected 11 true catheter malpositionings in the RA, while it could not recognize seven catheter placements correctly. CEUS showed two false RA misplacements and five falsely correct CVC positions. A sensitivity of 98% and specificity of 69% were achieved for CEUS in detecting CVC misplacements. Positive and negative predictive values were 95% and 85%, respectively. The interrater agreement (kappa) between CEUS and radiography was 0.72 (P < 0.001).

Conclusions

Despite close concordance between ultrasonography and chest radiography, CEUS is not a suitable alternative for standard chest radiography in detecting CVC location; however, considering its high sensitivity and acceptable specificity in our study, its usefulness as a triage method for detecting CVC location on a real-time basis in the operating room cannot be ignored.