Analysis of skew of visible laser reflections in a living sheep heart

Limited methods exist to confirm the position of cardiovascular devices in the heart. In our earlier work, an optical fiber was enclosed in a central catheter and guided to known positions in the superior vena cava and right atrium in the heart of a living sheep. The tissues were illuminated with two wavelengths of visible light and the reflections were analyzed using frequency domain techniques. In this follow-up work, the data were reanalyzed using statistical estimates of skew and kurtosis as a function of anatomic position. Skew values from a 520 nm laser were able to determine catheter tip position near the cavoatrial junction as validated against known positions previously determined with electrocardiogram and contrast-enhanced video fluoroscopy. This method successfully confirmed the location of the catheter tip at the cavoatrial junction in 84% of 840 trials. Further research with refined apparatus and algorithms on additional animal subjects is strongly suggested.

Experience in the use of midclavicular catheters: An inception cohort study

AIMS AND OBJECTIVES

To describe the outcomes of midclavicular catheters related to first insertion success rate, catheter dwell time, rate of catheter survival until the end of the treatment, and complication rates, as well as identify risk factors associated with early catheter removal.

BACKGROUND

Midclavicular catheters are peripheral venous catheters that are typically 20-25 cm in length.

DESIGN

Inception cohort study.

METHODS

We included all the midclavicular lines inserted in patients who met any of the following criteria: (a) difficult venous access; (b) administration of intravenous therapy expected to last between 6 and 30 days with non-irritant (pH=5-9) and/or non-vesicant drugs; or (c) contraindications to central venous catheter placement. The incidence of adverse events was calculated using percentages and episodes per 1,000 catheter days. Univariate and multivariate logistic regression analyses were performed to identify significant risk factors for unexpected catheter removal by calculating odds ratios. Catheter survival was assessed using Cox regression analysis. The STROBE guidelines were followed.

RESULTS

Overall, 2,275 midclavicular lines were placed in 1,841 participants. The insertion success rate was 99.4% and the mean catheter dwell time was 21.82 days. The rate of adverse events was .7 per 1,000 catheter days, the most common complications being thrombosis (.39) and catheter-associated bacteraemia (.14). No significant association was found between adverse events and the administration of irritant drugs. The incidence of unexpected removal was 6.7 per 1,000 catheter days. The multivariate analysis showed that both age ≤70 years and home therapy were associated with a lower likelihood of catheter failure.

CONCLUSIONS

Midclavicular catheters are associated with a high rate of insertion success and low rates of adverse events and unplanned removal.

RELEVANCE TO CLINICAL PRACTICE

Midclavicular lines are a safe alternative for intravenous therapy lasting more than 6 days, even with irritant drugs.

Joint time-frequency analysis of visible laser reflections in a sheep heart

Limited methods exist to confirm the position of cardiovascular devices in the superior vena cava or right atrium of the heart. The aim of this study was to design, test and validate the feasibility of whether an optical fiber-based instrument could accurately distinguish when a cardiovascular catheter was located in the superior vena cava vs in the right atrium. An optical fiber was placed in a cardiovascular catheter which was inserted into a living sheep and guided to the vicinity of the heart where diode laser-based reflection intensity data were simultaneously gathered from two visible wavelengths of light reflected from the venous and atrial tissue surfaces near the cavoatrial junction. The time series data were postoperatively analyzed using methods of joint time-frequency analysis and validated against catheter positions determined with fluoroscopy and ECG. The system was successful in distinguishing the location of the superior vena cava from the right atrium.

Chest radiography for simplified evaluation of central venous catheter tip positioning for safe and accurate haemodynamic monitoring: a retrospective observational study

OBJECTIVES

The tip-to-carina (TC) distance on a simple chest X-ray (CXR) has proven value in the determination of correct central venous catheter (CVC) positioning. However, previous studies have mostly focused on preventing the atrial insertion of the CVC tip, and not on appropriate positioning for accurate haemodynamic monitoring. We aimed to assess whether the TC distance could detect the passage of the CVC tip into the superior vena cava (SVC) and the right atrium (RA), and to accordingly suggest cut-off reference values for these two aspects.

DESIGN

Retrospective observational cohort study.

SETTING

Single urban tertiary level academic hospital.

PARTICIPANTS

479 patients who underwent CXR and chest CT scan after the insertion of a CVC with a 24-hour interval during the study period.

INTERVENTION

The TC distance was measured on CXR, and the position of the CVC tip was assessed on the chest CT images. The TC distance was described as a negative or positive number if the CVC tip was above or below the carina, respectively. Receiver-operating characteristics curve analyses were conducted to ascertain the TC distance to detect SVC entrance and RA insertion of CVC tip.

RESULTS

The TC distance could significantly detect both SVC entrance and RA insertion (p<0.001 for both; area under curve 0.987 and 0.965, respectively), with a reference range of -6.69 to 15.61 mm.

CONCLUSION

The TC distance in CXR is a simple and precise method to confirm not only the safe placement of the CVC tip but also its optimal positioning for accurate haemodynamic monitoring.

Interventional management of central vein occlusion in patients with peripherally inserted central catheter placement

OBJECTIVE

This study evaluated the incidence of central vein occlusion (CVO) and analyzed the interventional management for CVO during peripherally inserted central catheter (PICC) placement to suggest an adequate management protocol to ensure the success and patency of PICCs.

METHODS

We retrospectively reviewed the records of 2568 PICCs to identify CVO in two medical centers between January 2016 and June 2017. Procedural images were reviewed for the following items: date and indication for the PICC; type of catheter; accessed vein and arm; characteristics of CVO on ascending arm venography; PICC placement technique; indwelling period of the PICC; and follow-up records. A guidewire passage trial was performed to the CVO, as follows: a trial with a 0.018-inch single or double guidewire through the pretrimmed PICC lumen; and a trial with a combination of a 0.035-inch guidewire and a curved 5F diagnostic catheter through the PICC introducer sheath.

RESULTS

The incidence of CVO was 3.2% (71/2232), and 59 patients were analyzed (23 men; mean age, 69 ± 11 years; median age, 80 years; age range, 31-92 years). Forty-four patients had thrombotic CVO, and 12 patients had acute thrombotic CVO. Thirty-six patients had occlusion of the left innominate vein, and six patients had contiguous involvement of the adjacent central vein. Forty-two patients had obtuse stump morphology of CVO, and 28 patients had grade >III collateral development. The PICC indwelling time was statistically different between the group with successful catheter advancement (n = 36, success group) and the group with failed catheter advancement (n = 18, failure group; P = .007) with ipsilateral trimmed PICCs. Eight patients had a symptomatic catheter associated with upper extremity deep venous thrombosis (UEDVT; <30 days), one in the success group and seven in the failure group. The incidence of catheter-associated UEDVT after primary PICC placement on each arm was statistically different between the success and failure groups (P = .004).

CONCLUSIONS

A PICC passage trial for ipsilateral CVO is challenging but frequently successful with a simple guidewire technique, which can preserve catheter patency, decrease contralateral arm access, and prevent the development of new catheter-associated UEDVT.

Risk factors for central venous catheter-related thrombosis in children: a retrospective analysis

Central venous catheter (CVC) placement is associated with increased risk of thrombosis in the paediatric population, particularly in relation to the type of catheter and the manner of its insertion. Here, we investigate risk factors associated with CVC-related thrombosis in children, with particular emphasis on positioning of the catheter tip. Patients aged 0-18 who underwent at least one CVC placement from 2008 to 2013 at a single centre with a subsequent follow-up echocardiogram were included for a total of 104 patients and 147 lines. Data on clinical and catheter-related risk factors were collected from patient charts. Statistical analysis using Pearson's χ tests, independent samples t-test, and odds ratios were used to assess potential risk factors for thrombosis. Neither insertion site (subclavian vein or otherwise), left- vs. right-sided insertion, nor catheter type were significant risk factors for thrombosis. There were no thrombotic events reported at the superior vena cava (SVC)-right atrium junction and no significant differences in thrombotic risk with initial tip placement in the SVC-right atrium junction vs. the SVC, right atrium, or inferior vena cava. Acute lymphoblastic leukaemia was a major clinical risk factor for thrombosis. Tip movement was common and may have been an important factor in the development of CVC-related thrombi. Prospective studies can yield insight into the role of follow-up imaging in the prevention of catheter-related thrombosis in children.

The Different Impacts on the Long-Term Survival of Tunneled Internal Jugular Hemodialysis Catheters Based on Tip Position and Laterality

Background/Aims: The aim of this study was to examine the impact of different catheter tip positions on the life of the catheter, dysfunction, infection, and quality of hemodialysis and possible differences between the access site laterality in jugular-tunneled hemodialysis catheters. Methods: Catheters were evaluated for the following parameters: place of insertion, time of insertion, duration of use, and reason for removal. In all patients, the catheter tip position was checked using an X-ray. Results: The mean duration of implanted catheters with the tip placed in the cavo-atrial junction and right atrium was significantly longer. There were no differences in catheter functionality at follow-up or complications based on catheter laterality for each catheter tip position. Conclusion: According to our results, the localization of the catheter tip in superior vena cava still remains the least preferable method. Our results showed that the main factor responsible for better catheter functionality was not laterality but the depth to which the catheter tip is inserted into the body.

Risk factors associated with catheter-related upper extremity deep vein thrombosis in patients with peripherally inserted central venous catheters: a prospective observational cohort study: part 2

This is the second part of a 2-part series that reports on the results of a prospective observational cohort study designed to examine risk factors associated with symptomatic upper extremity deep vein thrombosis (UEDVT) in patients with peripherally inserted central catheters (PICCs). Part 1, published in the May/June 2014 issue of the Journal of Infusion Nursing, provided an extensive review and critique of the literature regarding risk factors associated with catheter-related UEDVT and identified 28 suspected risk factors. A study was undertaken to examine each of the risk factors among 203 acute care patients with PICCs, 13 of whom experienced a UEDVT, yielding an incidence of 6.4%. The most common reason for admission was infection (33.5%), and the primary reason for insertion of the PICC was venous access (58.6%). Hypertension (P = .022) and obesity (P = .008), defined as a body mass index ≥30, were associated with UEDVT. The clinical symptoms of edema (P < .001) and a 3-cm or more increase in arm circumference (P < .001) in the PICC arm after PICC placement were associated with UEDVT. All other variables were not statistically significant. The results suggest that patients who are obese and hypertensive may be at greater risk for the development of UEDVT and that the physical finding of edema and increased arm circumference in the PICC arm are possibly suggestive of UEDVT.

Successfully Eliminating Chest Radiography by Replacing It With Dual Vector Technology and an Algorithm for PICC Placement

It can be difficult to get the tip of a central vascular access device to the targeted area of the caval-atrial junction accurately and precisely when placing a device at the bedside. Tip placement outside this precise location can lead to complications and poor patient outcomes. Malpositions increase patients' radiation exposure, increase costs, and delay treatment. The current standard of using chest radiography to check tip placement has demonstrated discrepancies and is subject to interpretation differences between radiologists. Chest radiography and malpositions can be eliminated with the use of technology that includes Doppler, echocardiography (ECG), and an algorithm. This technology can reduce the cost of labor and supplies in addition to allowing the use of a central vascular access device immediately after placement.

Defining Central venous Line Position in Children: Tips for the Tip

Purpose

The purpose of this study is to analyse literature related to the position of centrally inserted central venous catheters and to review topics related to assessment of tip position of those catheters in children. Applications of specific techniques to PICCs (Periferally Inserted Central Catheters) and umbilical venous catheter will also be reviewed.

Methods

Analysis of 68 original manuscripts, 42 specifically related to the paediatric population, 26 related to the adult population. The papers analysed were published between 1949 and 2014; all articles were in English except one in Italian and one in German.

Results

From the analysed literature, most of the guidelines recommend tip positioning at a level between the superior vena cava and the right atrium. Several methods have been described to evaluate tip position in the paediatric population, but none of those is considered completely reliable. The standard methods used to identify catheter tip position are radiography and fluoroscopy, but no specific landmark can be recommended in the paediatric population. The ultrasonographic approach has been investigated mainly for PICCs positioning in the neonatal population. The electrocardiographic method has been evaluated in the general paediatric population.

Conclusions

No specific recommendation can be given due to the low level of evidence. Ultrasound and ECG (electrocardiogram) techniques are a potential alternative to chest X-ray and further studies should be implemented to establish them. A wider application of these techniques may reduce neonatal and paediatric exposure to radiations and additionally reduce costs.

Defining peripherally inserted central catheter tip position and an evaluation of insertions in one unit

Peripherally inserted central catheters are increasingly used to provide access to the central venous circulation. They are commonly positioned 'blind' using a variety of anthropometric techniques and operator experience to direct insertion length. Malposition rates are poorly defined because of differing insertion techniques, difficulties defining anatomical tip position on chest radiographs, controversy over what constitutes an adequate catheter position and possible differences between patient groups. We have developed a reproducible method to define catheter positions on chest radiograph and have applied this in a retrospective analysis of 256 ICU and 243 non-ICU catheter insertions over a 6-month period. Two different definitions were used for adequate position. 'Blind' positioning of peripherally inserted central catheters was associated with a definition-dependent malposition rate of 42-76%. Malposition rates were significantly higher in ICU patients. Emerging technologies may assist in reducing these high rates.

Triple-lumen peripherally inserted central catheter in patients in the critical care unit: prospective evaluation

PURPOSE

To prospectively evaluate outcomes associated with use of a triple-lumen (TL) peripherally inserted central catheter (PICC) in the intensive care unit (ICU) setting.

MATERIALS AND METHODS

Patients were prospectively enrolled in this HIPAA-compliant, institutional review board-approved study. Informed consent was obtained. All patients were in one hospital's ICUs and needed intermediate-term central venous access requiring three lumina. A 6-F tapered TL PICC was placed by a bedside nursing-based team with backup from the Interventional Radiology department. Placement complications, as well as long-term complications, were recorded. At catheter removal, ultrasonography (US) of the veins containing the TL PICC was performed to detect occult venous thrombosis. Regardless of indication for removal, catheters were sent for culture to detect colonization.

RESULTS

The study was stopped prematurely after 50 of a planned 167 patients were enrolled when a scheduled interim analysis detected a venous thrombosis rate that was considered unacceptably high by the study oversight committee (thrombosis was symptomatic in 20% of patients [10 of 50]). Venous thrombosis (symptomatic or asymptomatic) was detected in 26 of 45 patients (58%; 95% confidence interval [CI]: 43%, 72%) examined with US. Documented catheter-related bloodstream infection did not occur (0%; 95% CI: 0%, 7%); colonization was detected in three of 29 catheter tips sent for culture (10%; 95% CI: 2%, 27%). Catheter malfunction and dislodgment occurred in one patient each.

CONCLUSION

The TL PICC design used in this study resulted in unacceptably high venous thrombosis rates. Even when used in a high-risk setting for infection (ie, the ICU), rates of clinically evident infection and colonization were absent and low, respectively.

Use of C-Arm Fluoroscopy by Nurses for Placement of PICC Lines

The Minnesota Department of Health Ionizing Radiation Rules “prohibits the use of fluoroscopy by a person other than a licensed practitioner of the healing arts... when the licensed practitioner of the healing arts is not physically present in the room” (Minnesota Administrative Rules, 2007). Getting a licensed practitioner into the room caused delays in completing PICC line insertion procedures. To minimize these delays we considered multiple options; one of the options was to have PICC nurses licensed to operate the fluoroscopy machine. This article will explain the process the Vascular Access Department at the University of Minnesota Medical Center, Fairview went through to make this option a reality.

Our team has demonstrated that with proper training, education, machine maintenance and completion of competencies, nurses can operate fluoroscopy independently and clear PICC lines for use with a high degree of safety, efficiency and accuracy.

Risk of venous thromboembolism in hospitalized patients with peripherally inserted central catheters

BACKGROUND

Peripherally inserted central catheters (PICC) are increasingly used in hospitalized patients. The benefit can be offset by complications such as upper extremity deep vein thrombosis (UEDVT).

METHODS

Retrospective study of patients who received a PICC while hospitalized at the Methodist University Hospital (MUH) in Memphis, TN. All adult consecutive patients who had PICCs inserted during the study period and who did not have a UEDVT at the time of PICC insertion were included in the study. A UEDVT was defined as a symptomatic event in the ipsilateral extremity, leading to the performance of duplex ultrasonography, which confirmed the diagnosis of UEDVT. Pulmonary embolism (PE) was defined as a symptomatic event prompting the performance of ventilation-perfusion lung scan or spiral computed tomography (CT).

RESULTS

Among 777 patients, 38 patients experienced 1 or more venous thromboembolisms (VTEs), yielding an incidence of 4.89%. A total of 7444 PICC-days were recorded for 777 patients. This yields a rate of 5.10 VTEs/1000 PICC-days. Compared to patients whose PICC was inserted in the SVC, patients whose PICC was in another location had an increased risk (odds ratio = 2.61 [95% CI = 1.28-5.35]) of VTE. PICC related VTE was significantly more common among patients with a past history of VTE (odds ratio = 10.83 [95% CI = 4.89-23.95]).

CONCLUSIONS

About 5% of patients undergoing PICC placement in acute care hospitals will develop thromboembolic complications. Thromboembolic complications were especially common among persons with a past history of VTE. Catheter tip location at the time of insertion may be an important modifiable risk factor.

The EKG Method for Positioning the Tips of PICCs: Results from Two Preliminary Studies

Two preliminary studies were conducted to determine feasibility of using the electrocardiography (EKG) method to determine terminal tip location when inserting a peripherally inserted central catheter (PICC). This method uses the guidewire inside the catheter (or a column of saline contained in the catheter) as an intracavitary electrode. The EKG monitor is then connected to the intracavitary electrode. The reading on the EKG monitor reflects the closeness of the intracavitary electrode (the catheter tip) to the superior vena cava (SVC). The studies revealed that the EKG method was extremely precise; all tips placed using the EKG method and confirmed using x-ray were located in the superior vena cava. In conclusion, the EKG method has clear advantages in terms of accuracy, cost-effectiveness, and feasibility in conditions where x-ray control may be difficult or expensive to obtain. The method is quite simple, easy to learn and to teach, non-invasive, easy to reproduce, safe, and apt to minimize malpositions due to failure of entering the SVC.

Percutaneously inserted central catheter for total parenteral nutrition in neonates: complications rates related to upper versus lower extremity insertion

OBJECTIVE

The objective of this study was to compare the complication rates of upper versus lower extremity percutaneously inserted central catheters used for total parenteral nutrition in neonates.

METHODS

During a 48-month study period, 396 neonates were identified as having had percutaneously inserted central venous catheters. A total of 370 catheters were inserted from the upper and 107 from the lower extremity. Data retrieved and analyzed were birth weight, gestational age, age at placement, duration in place, duration of total parenteral nutrition, type of infusates, catheter-related bloodstream infection, phlebitis, leakage, occlusion, necrotizing enterocolitis, intraventricular hemorrhage, serum creatinine, liver function tests, and length of hospitalization.

RESULTS

The median birth weight and gestational age were 940 g and 28 weeks. The rate of catheter-related bloodstream infection was 11.6% for the upper and 9.3% in the lower extremity catheters. The most common organism was coagulase-negative Staphylococcus for both upper and lower extremity catheters and significantly higher with catheters from the upper extremity. Lower extremity catheters were in place longer, and the time from insertion to complication was also longer. The rate of cholestasis was higher for the upper extremity catheters. Multiple regression analysis showed that the most significant contributor to cholestasis was duration of time the catheters were in place and the duration of total parenteral nutrition administration. Receiver operating characteristics curve demonstrated higher sensitivity for duration of catheters in predicting cholestasis with duration of total parenteral nutrition being more specific.

CONCLUSION

Lower extremity percutaneously inserted central venous catheters had lower rates of catheter-related bloodstream infection, longer time to first complication, and lower cholestasis despite longer duration of total parenteral nutrition. When possible, lower extremity inserted catheters should be used for the administration of total parenteral nutrition.

Continuing Controversy of Midclavicular Catheters

A review of 50 years of research on catheter tip placement indicates an overwhelming preference for the lower third of the superior vena cava as the appropriate tip location. Despite this evidence, there are still practitioners, physicians, and nurses who advocate tip placement within the axillo-subclavian-innominate vein (also referred to as the midclavicular). This article looks at the arguments presented by practitioners who support midclavicular tip placement. It also reviews some of the research from which the recommendations for superior vena cava placement are derived.

Taking the Leap From PICC Placement to Tip Placement

Nurses who place peripherally inserted central catheters (PICCs) obtain x-rays after placement to determine tip placement. Radiologists read and interpret the x-ray to verify tip placement. It is then the primary physician or the radiologist who releases the PICC line for use. Until 2002, there were few institutions across the United States that empowered the vascular access nurse to take on this responsibility. This article discusses how to advance practice at the state-board-of-nursing level and discusses strategies to implement the change in scope of practice.

Analysis of Tip Malposition and Correction in Peripherally Inserted Central Catheters Placed at Bedside by a Dedicated Nursing Team

PURPOSE

To analyze the patterns of postplacement tip malposition in peripherally inserted central catheters (PICCs) placed at bedside, and to describe results of bedside and imaging-guided correction of tip malposition.

MATERIALS AND METHODS

With use of a quality assurance database, all episodes of tip malposition in PICCs placed at bedside were reviewed. Catheter tip location, success or failure of bedside repositioning (in a subset of patients, by using over-the-wire techniques), findings in the interventional radiology (IR) division, and tip correction method used in the IR suite (repositioning vs replacement) were determined with a review of medical records.

RESULTS

During the 18-month study period, 2,367 attempts were made to place a PICC at bedside; 1,654 attempts (70%) were initially successful. Of these, 163 tips (10%) were malpositioned. Complete records for 132 malpositioned tips were available for analysis. Malpositioned tips were located in the ipsilateral internal jugular vein in 45 of the 132 cases (36%), axillary vein in 36 cases (27%), ipsilateral subclavian vein in 25 cases (19%), ipsilateral brachiocephalic vein in 15 cases (11%), contralateral subclavian vein in four cases (3%), contralateral brachiocephalic vein in two cases (2%), contralateral internal jugular vein in one case (1%), and subclavian tributary in one case (1%). In three cases (2%), the tip was coiled in the superior vena cava. Malposition was corrected with catheter exchange in 76 of the 132 cases (58%), repositioning in 48 cases (36%), or removal in one case (1%). Spontaneous correction occurred in seven of the 132 malpositioned tips (5%). One hundred nine tips (83%) were repositioned in the IR division with use of imaging guidance, with 100% success. Twenty-five attempts were made to correct malposition at bedside; 16 of those attempts (64%) were successful.

CONCLUSION

Tip malposition is relatively frequent with bedside placement of PICCs. Preliminary data suggest that most malpositions can be corrected with bedside techniques. Spontaneous correction may occur but is relatively uncommon.

Complications of Vascular Access Device Terminal Tip Placement: A Case Study and Review of Subsequent Legal Action

A patient experienced complications following insertion and use of 2 similar vascular access devices with tip termination apparently in the subclavian veins. The thrombotic complications that developed were identified and reported in the first incident (a) as an occluded catheter, and then (b) as bleeding complications with delayed reporting for 8 days with the second catheter. The result was symptomatic deep vein thrombosis, thoracic outlet syndrome, and permanent nerve damage in both right and left extremities used for the venous catheter. The patient brought charges of malpractice against the hospital, the home care company, one nurse, and the manufacturer, alleging permanent nerve damage, venous occlusion, and chronic pain syndromes associated with both upper extremities. During the subsequent trial, evidence of permanent loss of function to the patient's left arm and chronic pain to both arms was presented through documentation of loss of fitness and inability to perform actions necessary to his chosen career as a pilot. The pain and loss of function were directly related to terminal tip placement of the catheter and care provided in conjunction with the venous catheter. The jury trial awarded the patient a final judgment of $7.15 million, with the hospital 55% liable and 45% liability among the other defendants. The jury also added some hospital physicians to the liability of the treatment and resulting patient harm. Nurses caring for patients have a duty to assess and evaluate the patient for complications on an ongoing basis, administer the prescribed therapy, and consistently provide communication with the primary physician specific to the assessment findings. A specialized nurse or certified intravenous nurse (CRNI) is held to a higher level of knowledge, understanding, and function. In this case, a CRNI was providing care for the patient both through hospital and outpatient home care services. Medical professionals and hospitals can reduce the likelihood of liability related to adverse events with venous catheters by acquisition of current education on the devices they insert and maintain; by updating and adhering to policies and procedures based on Standards of Practice and manufacturer instructions for use; by thorough documentation of care; and by conscientious reporting of patient clinical signs and symptoms. The goal of achieving safe patient care with vascular access devices is only possible through consistent education processes with all associated clinical staff.

Depth of a central venous catheter tip: length of insertion guideline for pediatric patients

BACKGROUND

In pediatric patients, several studies have been undertaken to establish central venous catheter (CVC) tip optimal depth. Assessments of catheter tip position using chest radiographs may be misleading, whereas transesophageal echocardiography (TEE) has been shown to accurately monitor catheter tip placement at the superior vena cava-right atrial (SVC-RA) junction. The aim of this study was to issue a guideline for ideal catheter insertion depth, from the right internal jugular vein (IJV) using TEE to confirm the position of the catheter tip at the SVC-RA junction.

METHODS

Over a 6-month period, we studied 60 right internal jugular vein catheterizations in infants and children undergoing surgery for congenital heart disease. Positions of CVC tips were confirmed to be at the SVC-RA junction by TEE. Distance from the skin puncture site to the SVC-RA junction, height, weight, and age were recorded.

RESULTS

Distances measured were found to be highly correlated with patient height. The following guideline allows the CVC tip to be positioned above the RA in 97.5% of patients with an accuracy of 95%: optimal depth of insertion (cm) = 1.7 + (0.07 x height) in patients whose height is between 40 and 140 cm.

CONCLUSION

The model proposed for the insertion of the CVC tip in pediatric patients could be used to prevent inadvertent catheter tip placement into the atrium.

Central venous catheter thrombosis as a cause of SVC obstruction and cardiac tamponade in a patient with Diamond-Blackfan anemia and iron overload

Cardiac tamponade is an infrequent but potentially lethal complication related to use of central venous catheters (CVC). We present the case of a 16-year-old female with Diamond-Blackfan anemia (DBA) who developed pericardial tamponade secondary to superior venous caval obstruction caused by CVC thrombosis. The patient presented 3 months after line placement with vomiting, abdominal pain, and cardiomegaly on chest X-ray (CXR). Her condition quickly decompensated with cardiac arrest and subsequent death despite immediate pericardiocentesis. As a result of this case, our center has developed a protocol for the management of CVC problems as a means of facilitating rapid recognition of central line clots.

Placement of Peripherally Inserted Central Catheters without Fluoroscopy in Children: Initial Catheter Tip Position

PURPOSE

To determine how often placement of peripherally inserted central catheters (PICCs) without imaging guidance results in an initially correct central venous catheter tip location.

MATERIALS AND METHODS

This study was approved by the hospital's institutional review board, which waived the requirement for informed consent. In a children's hospital, 843 PICCs were placed in 698 patients (age range, 0 days to 26 years; mean, 6.9 years) during a 14-month study period. All PICCs were placed by a specialized team of PICC nurses and interventional radiology technologists in an angiography suite with the supervision of pediatric interventional radiologists. All catheters were threaded blindly to a previously estimated length by either a PICC nurse or a pediatric interventional radiologist, according to National Association of Vascular Access Networks guidelines, and the initial PICC tip location was then determined by means of spot fluoroscopy. PICC tips were regarded as central if they resided anywhere within the superior vena cava (SVC). All catheters were then manipulated with intermittent fluoroscopic guidance to achieve a final central position in the distal third of the SVC. A chi2 test was used to compare initial and final PICC tip locations according to patient age, catheter size, accessed vein, and need for radiologist assistance. A t test was used to compare procedure time with and without radiologist assistance.

RESULTS

Analysis included 843 consecutively placed pediatric PICCs, of which 723 (85.8%) had a noncentral initial PICC tip position and required additional manipulation. After catheter repositioning performed with intermittent fluoroscopic guidance, a final central PICC tip location was achieved in 760 PICCs (90.2%).

CONCLUSION

Pediatric PICC placement without fluoroscopic guidance required catheter manipulation of initial PICC tip position in 723 cases (85.8%). PICC placement with fluoroscopic guidance is highly successful, and the authors believe it is best performed in an angiography suite.

Relationship between Chest Port Catheter Tip Position and Port Malfunction after Interventional Radiologic Placement

PURPOSE

The relationship between catheter tip position of implanted subcutaneous chest ports and subsequent port malfunction was investigated. Tip movement from initial supine position to subsequent erect position was also evaluated.

MATERIALS AND METHODS

Patients who underwent imaging-guided internal jugular chest port placement between July 2001 and May 2003 were identified with use of a quality-assurance database. Sixty-two patients were included in the study (22 men and 40 women), with a mean age of 58 years (range, 27-81 years). Catheter tip location on the intraprocedural chest radiograph was determined with use of two methods. First, the distance from the right tracheobronchial angle (TBA) was recorded (TBA distance). Second, tip location was classified into six anatomic regions: 1, internal jugular veins; 2, brachiocephalic veins; 3, superior vena cava (SVC; n = 11); 4, SVC/right atrial junction (n = 22); 5, upper half of right atrium (n = 25); and 6, lower half of right atrium (n = 4). For the duration of follow-up, catheter tip location was documented, as were all episodes of catheter malfunction.

RESULTS

Patients with catheter tips initially placed in position 3 had a higher risk of port malfunction (four of 11; 36%) than patients with catheter tips located in position 5 (two of 25; 8%). This difference narrowly fell short of statistical significance (P =.057). When comparing intraprocedural chest radiographs to the first erect chest radiographs, significant upward tip movement was noted. The tips migrated cephalad an average of 20 mm (P =.003) and 1.0 position units (P =.001).

DISCUSSION

Catheter tips placed in the SVC tended to have a greater risk of port malfunction compared with those positioned in the right atrium. Chest ports migrated cephalad between the supine and erect positions.

Assessment of infants with peripherally inserted central catheters: Part 2. Detecting less frequently occurring complications

Peripherally inserted central catheters (PICCs) are frequently placed in neonates to optimize nutrition and provide stable infusions of critical medications into the central vascular system. PICCs have been associated with a number of device-specific complications that can manifest during insertion, while the line is indwelling, and/or after the removal of the line. The first article of this series in Focus on the Physical, titled "Assessment of Infants With Peripherally Inserted Central Catheters: Part I. Detecting the Most Frequently Occurring Complications," presented assessment strategies to detect common complications such as catheter occlusions and catheter-related bloodstream infections. Part 2 of this series emphasizes the importance of ongoing systematic assessment of PICCs for device-specific complications such as catheter migration, dislodgement, breakage, phlebitis, and thrombosis, as well as the life-threatening complications of pleural and pericardial effusion and tamponade. Each complication is described, along with a review of the etiology, a description of presenting signs and symptoms, and key clinical interventions.

Assessment of infants with peripherally inserted central catheters: Part 1. Detecting the most frequently occurring complications

Inserting, maintaining, and monitoring vascular access are integral components of neonatal care. Advances in vascular access technology have led to the insertion of peripherally inserted central catheters (PICC) to provide stable venous access for early and aggressive parenteral nutrition. Medications that are irritating or damaging, or those with a high osmolality or a nonphysiologic pH, can also be safely administered into the central venous system. The need for repeated peripheral intravenous attempts, as well as the associated pain and physiologic instability, are virtually eliminated once a PICC line is placed. Complications related to PICCs may occur at any phase of therapy: during insertion, while indwelling, or after discontinuing the line. The risk factors associated with PICCs are distinctly different from peripheral intravenous lines because of their long dwell time, central placement, and potential to migrate. Part 1 of Focus on the Physical offers a review of the relevant anatomy of the vascular system and a discussion of the appropriate sites for catheter tip placement. Guidelines for a systematic physical assessment, along with recommendations for standardized PICC documentation, are provided. A review of the signs and symptoms of more frequently occurring complications, such as catheter occlusion and bloodstream infections, is presented to enhance awareness of PICC-specific complications in the neonate and to expedite early detection and treatment. Part 2 of this series will focus on systematic assessment for less common complications such as catheter migration, dislodgement, breakage, and thrombosis, as well as the life-threatening complications of pleural and pericardial effusion.

Pediatric peripherally inserted central catheters: complication rates related to catheter tip location

OBJECTIVE

To compare complication rates between central venous catheter tip location and noncentral tip location after peripherally inserted central catheter (PICC) placement in children.

METHODS

Between 1994 and 1998, data from all children who underwent PICC placement were analyzed. Patient demographics, catheter characteristics, catheter duration, infusate composition, and catheter complications were entered prospectively into a computerized database. Catheter tip locations were determined by fluoroscopy and were defined as central if they resided in the superior vena cava, right atrium, or high inferior vena cava at or above the level of the diaphragm, and as noncentral if located elsewhere. Differences in complication rates between the central and noncentral groups were analyzed.

RESULTS

Data from a total of 1266 PICCs were analyzed from 1053 patients with a mean age of 6.49 +/-.2 years (range: 0-45.0 years). Of the 1266 PICCs, 1096 (87%) were central in tip location, and 170 (13%) were noncentral in tip location. The central group had 42 complications of 1096 catheters (3.8%), while the noncentral group had 49 complications of 170 catheters (28.8%). Controlling for patient age, catheter size, gender, and catheter duration with a logistic regression model, there remained a statistically significant increased likelihood of complication in the noncentral group versus the central group (adjusted odds ratio: 8.28; 95% confidence interval: 5.11-13.43).

CONCLUSIONS

Centrally placed catheter tips are associated with fewer complications than are noncentrally placed catheter tips. Clinicians should ensure that catheter tips reside centrally after PICC placement in infants and children.