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Kato K, Gan C, Rhodes A. Necessity of performing a routine chest radiograph following the insertion of tunnelled Hickman catheter under imaging guidance: A single centre experience. J Med Imaging Radiat Oncol 2023; 67:482-486. [PMID: 36161771 DOI: 10.1111/1754-9485.13479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 09/16/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION A chest radiograph has traditionally been performed following the insertion of a tunnelled Hickman catheter to immediately exclude rare but potentially serious complications such as pneumothorax and haemothorax and confirm appropriate positioning of the catheter tip. The value of completing the routine chest radiograph has been questioned when fluoroscopic image may be easily obtained in the angiography suite for the same purpose, and the rate of iatrogenic pneumothorax remains extremely low in the Medical literature. We describe our experience of performing Hickman catheter insertion under ultrasound and fluoroscopic guidance and whether routinely performing the chest radiograph is justifiable. METHODS A single centre retrospective review was performed of patients who received a tunnelled Hickman catheter and underwent postprocedural chest radiograph in the Interventional Radiology Department during a fifteen-year period from August 2007 to April 2021. Patient demographics and complications were documented. RESULTS Delayed iatrogenic pneumothorax was diagnosed in one asymptomatic patient (0.06%) on a chest radiograph out of 1735 patients, and they required chest tube insertion. Other complications included two cases of right common carotid artery puncture, one case of right internal jugular vein dissection and one case of left internal jugular perforation. Two patients required a repeat procedure within 24 h due to superior migration of the Hickman catheter on chest radiograph. CONCLUSION Given the extremely low rate of iatrogenic pneumothorax, chest radiograph following the insertion of a tunnelled Hickman catheter under ultrasound and fluoroscopic guidance may be an unnecessary investigation unless the patient is symptomatic, or there is sufficient clinical concern.
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Affiliation(s)
| | - Calvin Gan
- Department of Radiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Alexander Rhodes
- Department of Radiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Radiology, The University of Melbourne, Melbourne, Victoria, Australia
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Woodland DC, Randall Cooper C, Farzan Rashid M, Rosario VL, Weyker PD, Weintraub J, Bentley-Hibbert S, Kluger MD. Routine chest X-ray is unnecessary after ultrasound-guided central venous line placement in the operating room. J Crit Care 2018; 46:13-16. [PMID: 29627658 DOI: 10.1016/j.jcrc.2018.03.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 03/26/2018] [Accepted: 03/27/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Central venous catheters (CVC) can be useful for perioperative monitoring and insertion has low complication rates. However, routine post insertion chest X-rays have become standard of care and contribute to health care costs with limited impact on patient management. METHODS 200 patient charts who underwent pancreaticoduodenectomy with central line placement and early line removal were reviewed for clinical complications related to central line placement as well as radiographic evidence of malpositioning. A cost analysis was performed to estimate savings if CXR had not been performed across routine surgical procedures requiring central access. RESULTS In 200 central line placements for Whipple procedures, 198 lines were placed in the right internal jugular and 2 were placed in the subclavian. No cases of pneumothorax or hemothorax were identified and 30 (15.3%) of CVCs were improperly positioned. Only 1 (0.5%) of these was deemed clinically significant and repositioned after the CXR was performed. CONCLUSION Routine CXR consumes valuable time and resources (≅$155,000 annually) and rarely affects management. Selection should be guided by clinical factors.
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Affiliation(s)
| | | | | | | | - Paul David Weyker
- Kaiser Permanente South San Francisco, Department of Anesthesiology, Division of Critical Care Medicine, United States; Kaiser Permanente South San Francisco, Department of Anesthesiology, Division of Interventional Pain Management, United States
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Gambotti L, Pérol D, Frering B, Kaemmerlen P, Coronel B, Sebban H, Bulso V, Bachelot V, Chauvin F, Bachmann P. Safety of Percutaneous Internal Jugular Catheterization in Cancer Patients: Prospective Observational Study. J Vasc Access 2018; 5:161-7. [PMID: 16596560 DOI: 10.1177/112972980400500405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Purpose To determine predictors for failure and early complications of percutaneous internal jugular catheterization (IJC) in cancer patients. Methods Six hundred and thirty consecutive cancer patients who required central venous catheterization were included in a prospective observational study. The rates of failure (defined as the intervention of a second physician and/or failure at initial insertion site) and of early complications were prospectively ascertained. Logistic regression analysis estimated odds ratio (OR) and 95% confidence intervals (95% CI) for independent predictors for failure and early complications of percutaneous IJC. Results The failure rate was 6.7%, and the early complication rate was 6.7%. In multivariate analysis, left-side initial catheterization (p<0.01), prior catheterization at the same site (p=0.001) and physician inexperience (p<0.0001) were independently associated with failure. Placement requiring more than one needle pass (p<0.01 for two and p<0.0001 for three and more) and absence of fluoroscopy (p<0.0001) were independently associated with early complications. Conclusions Percutaneous IJC is a valid option in the central venous catheterization of cancer patients due to its reliability and safety. Skilled physicians must manage difficult placements. If placement requires more than one needle pass or is made without fluoroscopy, patients must be carefully followed for potential complications.
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Affiliation(s)
- L Gambotti
- Department of Public Health, Léon Bérard Center, Lyon, France
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Dalton BGA, Gonzalez KW, Keirsy MC, Rivard DC, St Peter SD. Chest radiograph after fluoroscopic guided line placement: No longer necessary. J Pediatr Surg 2016; 51:1490-1. [PMID: 26949145 DOI: 10.1016/j.jpedsurg.2016.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 01/26/2016] [Accepted: 02/01/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE Historically, a chest radiograph was obtained after central line placement in the operating room. Recent retrospective studies have questioned the need for this radiograph. The prevailing current practice at our center is to order chest radiograph only for symptomatic patients. This study examines the outcomes of selective chest radiography after fluoroscopic guided central line placement. METHODS After obtaining institutional review board approval, a single institution retrospective chart review of patients undergoing central venous catheter placement by the pediatric surgery or interventional radiology service between January 2010 and July 2014 was performed. Outcome measures included CXR within 24h of catheter placement, reason for chest radiograph, complication, and complication requiring intervention. RESULTS In the study population 622 catheters were placed under fluoroscopy. A chest radiograph was performed in 118 (19%) patients within 24h of the line placement with 25 (4%) of these patients being symptomatic in the recovery room. One patient required chest tube for shortness of breath and pleural effusion. Four symptomatic patients (0.6%) were found to have a pneumothorax, none of which required chest tube placement. There were no re-operations because of mal-position of the catheter. In the 504 patients with no postoperative chest x-ray, there were no adverse outcomes. At our institution the current average charge of a chest radiograph is $283, thus we produced savings of $142,632 for the study period without adverse events. CONCLUSION After placement of central venous catheter under fluoroscopic guidance, a chest radiograph is unlikely to be helpful in an asymptomatic patient.
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Affiliation(s)
- Brian G A Dalton
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO
| | | | - Michael C Keirsy
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO
| | - Douglas C Rivard
- Department of Radiology, Children's Mercy Hospital, Kansas City, MO
| | - Shawn D St Peter
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO.
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5
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Song YG, Byun JH, Hwang SY, Kim CW, Shim SG. Use of vertebral body units to locate the cavoatrial junction for optimum central venous catheter tip positioning. Br J Anaesth 2015; 115:252-7. [PMID: 26170349 DOI: 10.1093/bja/aev218] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Central venous catheter (CVC) placement plays an important role in clinical practice; however, optimal positioning of the CVC tip remains a controversial issue. The objective of this study was to evaluate the use of vertebral body unit (VBUs), to locate the cavoatrial junction (CAJ), for optimal CVC tip placement based on chest radiography (CXR) using the carina as a landmark. METHODS 524 patients who underwent coronary computed tomographic angiography (CTA) and CXR were included. The position of the CAJ was identified using VBUs, and the efficacy of VBUs for locating the CAJ with the carina as a landmark was analysed using multiple regression analysis. A VBU was defined as the distance between two adjacent vertebral bodies, including the inter-vertebral disk space. RESULTS The mean (sd) distance from the carina to the superior CAJ was 54.3 (9.7) mm on CTA; the mean distance in VBUs at the level of the carina was 21.4 (1.7) mm on CTA and 22.6 (2.1) mm on CXR. The mean CAJ position was 2.5 VBUs below the carina on CTA and 2.4 VBUs below on CXR with 95% limits of agreement between -0.6 and +0.3. CONCLUSIONS The position of the CVC tip in relation to the carina can be described using the thoracic spine as an internal ruler, and the position of the CAJ in adults was reliably estimated to be 2.4 VBUs below the carina. CLINICAL TRIAL REGISTRATION KCT0001319.
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Affiliation(s)
- Y G Song
- Department of Radiology, Samsung Changwon Hospital, Sungkyunkwan University, School of Medicine, Changwon, South Korea
| | - J H Byun
- Department of Thoracic and Cardiovascular Surgery, Samsung Changwon Hospital, Sungkyunkwan University, School of Medicine, Changwon, South Korea
| | - S Y Hwang
- Department of Emergency Medicine, Samsung Changwon Hospital, Sungkyunkwan University, School of Medicine, Changwon, South Korea
| | - C W Kim
- Department of Obstetrics and Gynecology, Samsung Changwon Hospital, Sungkyunkwan University, School of Medicine, Changwon, South Korea
| | - S G Shim
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University, School of Medicine, Changwon, South Korea
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Sousa B, Furlanetto J, Hutka M, Gouveia P, Wuerstlein R, Mariz JM, Pinto D, Cardoso F. Central venous access in oncology: ESMO Clinical Practice Guidelines. Ann Oncol 2015; 26 Suppl 5:v152-68. [PMID: 26314776 DOI: 10.1093/annonc/mdv296] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Affiliation(s)
- B Sousa
- Breast Unit, Champalimaud Clinical Center, Lisbon, Portugal
| | | | - M Hutka
- St George's University Hospitals, NHS Foundation Trust, London, UK
| | - P Gouveia
- Breast Unit, Champalimaud Clinical Center, Lisbon, Portugal
| | - R Wuerstlein
- CCC of LMU, Breast Center, University Hospital Munich, Munich, Germany
| | - J M Mariz
- Department of Haematology, Instituto Português de Oncologia do Porto- Francisco Gentil, Oporto, Portugal
| | - D Pinto
- Breast Unit, Champalimaud Clinical Center, Lisbon, Portugal
| | - F Cardoso
- Breast Unit, Champalimaud Clinical Center, Lisbon, Portugal
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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: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Chalumeau-Lemoine L, Ioos V, Galbois A, Maury E, Hejblum G, Guidet B. Peut-on réduire le nombre de radiographies de thorax en réanimation ? Réanimation 2011. [DOI: 10.1007/s13546-010-0001-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Jauch KW, Schregel W, Stanga Z, Bischoff SC, Brass P, Hartl W, Muehlebach S, Pscheidl E, Thul P, Volk O. Access technique and its problems in parenteral nutrition - Guidelines on Parenteral Nutrition, Chapter 9. Ger Med Sci 2009; 7:Doc19. [PMID: 20049083 PMCID: PMC2795383 DOI: 10.3205/000078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Indexed: 02/08/2023]
Abstract
Catheter type, access technique, and the catheter position should be selected considering to the anticipated duration of PN aiming at the lowest complication risks (infectious and non-infectious). Long-term (>7-10 days) parenteral nutrition (PN) requires central venous access whereas for PN <3 weeks percutaneously inserted catheters and for PN >3 weeks subcutaneous tunnelled catheters or port systems are appropriate. CVC (central venous catheter) should be flushed with isotonic NaCl solution before and after PN application and during CVC occlusions. Strict indications are required for central venous access placement and the catheter should be removed as soon as possible if not required any more. Blood samples should not to be taken from the CVC. If catheter infection is suspected, peripheral blood-culture samples and culture samples from each catheter lumen should be taken simultaneously. Removal of the CVC should be carried out immediately if there are pronounced signs of local infection at the insertion site and/or clinical suspicion of catheter-induced sepsis. In case PN is indicated for a short period (max. 7-10 days), a peripheral venous access can be used if no hyperosmolar solutions (>800 mosm/L) or solutions with a high titration acidity or alkalinity are used. A peripheral venous catheter (PVC) can remain in situ for as long as it is clinically required unless there are signs of inflammation at the insertion site.
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Affiliation(s)
- K W Jauch
- Dept. Surgery Grosshadern, University Hospital, Munich, Germany
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Chen PT, Yen CR, Wang CC, Sung CS, Chang WK, Chan KH. A Modified Supraclavicular Approach for Central Venous Catheterization by Manipulation of Ventilation in Ventilated Patients. Semin Dial 2008; 21:469-73. [DOI: 10.1111/j.1525-139x.2008.00465.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Saad NEA, Saad WEA, Davies MG, Waldman DL. Replacement of inadvertently discontinued tunneled jugular high-flow central catheters with tract recannulation: technical results and outcome. J Vasc Interv Radiol 2008; 19:890-6. [PMID: 18503904 DOI: 10.1016/j.jvir.2008.03.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2007] [Revised: 03/04/2008] [Accepted: 03/09/2008] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To determine the technical and clinical outcomes of recannulating the tracts of inadvertently discontinued high-flow tunneled internal jugular central venous catheters. MATERIALS AND METHODS Retrospective review was performed of 49 patients who underwent 57 replacements of inadvertently discontinued catheters by recannulation from January 1997 through January 2005. The study group was divided into successful and failed recannulation groups. Technical results were evaluated for duration the catheter had been out, tract age, and laterality (ie, right vs left). Infection rate was calculated by Kaplan-Meier method and the infection rate per 100 catheter days was calculated. Intent-to-treat function rate (including failed recannulations) was calculated by the Kaplan-Meier method. RESULTS Seventy percent (n = 40) of discontinued catheters were right-sided and 30% (n = 17) were left-sided. The overall technical success rate was 86% (n = 49). The technical success rates were 100% (n = 10), 89% (32 of 36), and 64% (seven of 11) for catheters that had been outside the body for less than 12 hours, 12-24 hours, and more than 24 hours, respectively. P values for successful versus failed recannulations for tract age, the time the catheter was out, and laterality were .02, .04, and .68, respectively. The infection rate for successful recannulations at 6 months was 24% +/- 9% (0.22 infections per 100 catheter days). Functional catheter rates at 3, 6, 9, and 12 months were 55% +/- 8%, 46% +/- 8%, 29% +/- 10%, and 5% +/- 3%, respectively. CONCLUSIONS Recannulating tunneled high-flow jugular catheter tracts has a high technical success rate, particularly when they have fallen out less than 24 hours earlier and have a mature tract. The outcomes of recannulated catheters (ie, infection and function rates) are within the upper limit of results of de novo placement and over-the-wire exchange of catheters in the literature.
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Affiliation(s)
- Nael E A Saad
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Rochester Medical Center, Rochester, New York, USA.
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Abstract
PURPOSE To determine normative data for radiographic landmarks of the superior vena cava (SVC) and the location of the junction of the SVC with the right atrium for use in the placement of central venous catheters. MATERIALS AND METHODS The authors retrospectively reviewed 112 pulmonary computed tomographic (CT) angiograms obtained in seven men and seven women from each decade of life between the ages of 20 and 99 years. For each patient, the length of the SVC was measured from its origin to the cavoatrial junction. The distances from the carina and right tracheobronchial angle to the cavoatrial junction and the origin of the SVC were also measured. Interobserver variation in choosing the location of the carina and tracheobronchial angle was analyzed. RESULTS The mean length (+/-standard deviation) of the SVC was 70.7 mm +/- 14.1. The mean distance from the superior margin of the SVC to the carina was 30.4 mm +/- 11.2, from the carina to the cavoatrial junction 40.3 mm +/- 13.6, from the superior margin of the SVC to the right tracheobronchial angle 21.7 mm +/- 10.8, and from the right tracheobronchial angle to the cavoatrial junction 49.0 mm +/- 13.6. There was a statistically significant difference in interobserver variation in selecting the location of the right tracheobronchial angle as compared to choosing the carina. CONCLUSION Placement of the central venous catheter tip at or just below the level of the carina during inspiration ensures placement in the SVC. Placement of the central venous catheter tip approximately 4 cm below the carina will result in placement near the cavoatrial junction.
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Affiliation(s)
- Michael A Mahlon
- Department of Radiology, Tripler Army Medical Center, Honolulu, Hawaii, USA
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Benham JR, Culp WC, Wright LB, McCowan TC. Complication Rate of Venous Access Procedures Performed by a Radiology Practitioner Assistant Compared with Interventional Radiology Physicians and Supervised Trainees. J Vasc Interv Radiol 2007; 18:1001-4. [PMID: 17675618 DOI: 10.1016/j.jvir.2007.05.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To compare venous access complication rates associated with procedures performed by radiology practitioner assistants (RPAs) versus interventional radiology (IR) faculty members, IR fellows, and radiology residents. MATERIALS AND METHODS A retrospective review of venous access procedures in the IR department for 12 consecutive months at a single university hospital was performed. Procedural primary operators included 12 radiology residents, two IR fellows, four IR faculty members, and one board-certified RPA with 2 years of university training. Data examined included immediate and short-term complications separated into major and overall categories. RESULTS A total of 2093 venous access procedures were performed. The RPA performed 670 procedures (temporary central venous catheter placement, n = 274; peripherally inserted central catheter, n = 67; venous access catheter change, n = 99; venous port placement, n = 126; tunneled central venous catheter placement, n = 39; catheter check, n = 32; and venous explant, n = 43). Similar procedure ratios were noted with faculty members, fellows, and residents. Procedures by the RPA had a major complication rate of 0.29% and an overall complication rate of 0.89%. Four IR faculty members performed 291 procedures, with no major complications and an overall complication rate of 1.71%. Two IR fellows performed 562 procedures, with a major complication rate of 0.35% and an overall complication rate of 1.06%. Twelve residents performed 570 procedures, with a major complication rate of 0.52% (range, 0%-2.46%) and an overall complication rate of 1.39% (range, 0%-3.70%). No significant difference was found among groups (P = .7). CONCLUSION A properly trained and monitored RPA can safely perform selected venous access procedures with complication rates equal to those of IR faculty members, fellows, and residents.
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Affiliation(s)
- Joseph R Benham
- Department of Radiology, University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, Arkansas 72205, USA.
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Affiliation(s)
- Roberto E Kusminsky
- Department of Surgery, West Virginia University, Robert C Byrd Health Sciences Center, Charleston Division and Charleston Area Medical Center, Charleston, WV 25304, USA
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15
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Lanza C, Russo M, Fabrizzi G. Central venous cannulation: are routine chest radiographs necessary after B-mode and colour Doppler sonography check? Pediatr Radiol 2006; 36:1252-6. [PMID: 17016700 DOI: 10.1007/s00247-006-0307-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2006] [Revised: 07/05/2006] [Accepted: 07/09/2006] [Indexed: 11/27/2022]
Abstract
BACKGROUND After the insertion of a central venous catheter, a chest radiograph is usually obtained to ensure correct positioning of the catheter tip. OBJECTIVE To determine in a paediatric population whether B-mode and colour Doppler sonography after central venous access is useful to evaluate catheter position, thus obviating the need for a postprocedural radiograph. MATERIALS AND METHODS A prospective study of 107 consecutive central venous access procedures placed in a paediatric intensive care unit was performed. At the end of the procedure, B-mode and colour Doppler sonography were used to assess catheter position and check for complications. A postprocedural chest radiograph was obtained in all patients. RESULTS In 96 patients postprocedural B-mode and colour Doppler sonography showed colour Doppler signals within the vena cava. Among the 11 patients predicted to have a potential complication, there was one pneumothorax and ten malpositions. Chest radiography showed a total of 13 complications-1 pneumothorax and 12 malpositions. The concordance between colour Doppler sonography and chest radiography was 98.1% in the detection of catheter position; sonography had a sensitivity of 84.6% and a specificity of 100%. CONCLUSIONS The close concordance between B-mode and colour Doppler sonography and chest radiography justifies the more frequent use of sonography to evaluate catheter position because ionizing radiation is eliminated. Chest radiography may then be performed only when there is suspected inappropriate catheter tip position after sonography.
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Affiliation(s)
- Cecilia Lanza
- Azienda Ospedaliero-Universitaria Ospedali Riuniti, Pediatric Radiology Department-Presidio Salesi, Ancona, 60123, Italy.
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Joly F, Treton X, Barbero F, Pingenot I, Raskine L, Messing B. Prévention des complications liées à un dispositif intraveineux profond. NUTR CLIN METAB 2006. [DOI: 10.1016/j.nupar.2006.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
Pediatric interventional radiologists are ideally suited to provide vascular access services to children because of inherent safety advantages and higher success from using image-guided techniques. The performance of vascular access procedures has become routine at many adult interventional radiology practices, but this service is not as widely developed at pediatric institutions. Although interventional radiologists at some children's hospitals offer full-service vascular access, there is little or none at others. Developing and maintaining a pediatric vascular access service is a challenge. Interventionalists skilled in performing such procedures are limited at pediatric institutions, and institutional support from clerical staff, nursing staff, and technologists might not be sufficiently available to fulfill the needs of such a service. There must also be a strong commitment by all members of the team to support such a demanding service. There is a slippery slope of expected services that becomes steeper and steeper as the vascular access service grows. This review is intended primarily as general education for pediatric radiologists learning vascular access techniques. Additionally, the pediatric or adult interventional radiologist seeking to expand services might find helpful tips. The article also provides education for the diagnostic radiologist who routinely interprets radiographs containing vascular access devices.
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Affiliation(s)
- James S Donaldson
- Department of Medical Imaging, Children's Memorial Hospital, Northwestern University, Feinberg School of Medicine, 2300 Children's Plaza, No. 9, Chicago, IL 60614, USA.
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Messing B, Joly F. Guidelines for management of home parenteral support in adult chronic intestinal failure patients. Gastroenterology 2006; 130:S43-51. [PMID: 16473071 DOI: 10.1053/j.gastro.2005.09.064] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2004] [Accepted: 09/07/2005] [Indexed: 02/07/2023]
Abstract
Management of home parenteral support in adult benign but chronic intestinal failure patients requires a nutrition support team using disease-specific pathways. Education of patients to ensure they self manage home parenteral nutrition (HPN) is cornerstone to obtain minimal rate of technical complications and improvement in quality of life. Nutritive mixtures, compounded by pharmacists in single "all-in-one" bags, must be tailored according to the nutritional and intestinal status of individual patients with definition of macronutrients and water-electrolyte needs, respectively. Each PN cycle should be complete in essential nutrients to be nutritionally efficient and should have sufficient amounts of amino acids, dextrose, water, minerals, and micronutrients to avoid deficiency. When the nutritional goal is achieved, a minimum number of PN cycles per week should be implemented, guided ideally by digestive balance(s) (In-Out) of macronutrients and minerals of individual patients. Indeed, HPN is, in most cases, a complementary nonexclusive mode of nutritional support. In short gut patients--who represent 75% of chronic intestinal failure patients--encouraging enteral feeding decrease PN delivery and the risk of metabolic liver disease associated with HPN. In short gut patients with no severe renal impairment, blood citrulline dosage, in association with the remnant anatomy, is a tool to delineate transient from permanent intestinal failure. The latter group includes candidates for trophic gut factors and rehabilitative or reconstructive surgery, including intestinal transplantation. Thus, outcome improvement for intestinal failure patients needs intestinal failure teams having expertise in all medical and surgical aspects of this field.
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Affiliation(s)
- Bernard Messing
- Service d'Hépatogastroenterologie et d'Assistance Nutritive, Hôpital Lariboisière, Paris, France.
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Lessnau KD. Is Chest Radiography Necessary After Uncomplicated Insertion of a Triple-Lumen Catheter in the Right Internal Jugular Vein, Using the Anterior Approach? Chest 2005; 127:220-3. [PMID: 15653987 DOI: 10.1378/chest.127.1.220] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES Chest radiographs are required in many institutions by protocol after the insertion of a right internal jugular vein triple-lumen catheter (TLC), even if the anterior approach is used. This study investigates whether correct placement can be predicted during insertion and whether a "routine" postprocedural chest radiograph can be safely omitted. DESIGN The operators included 18 first-, second-, or third-year medical residents, 3 pulmonary fellows, and a board-certified pulmonary medicine and critical care attending, with at least 1 certified physician present during the procedure. All operators were trained in the "seven number rule." PATIENTS One hundred consecutive patients who required central venous access. Patients with left internal jugular vein or subclavian catheters were excluded. SETTING Single institution, medical ICU, step-down unit, and floors. INTERVENTIONS Right internal jugular vein TLC insertion, anterior approach, with subsequent chest radiograph. MEASUREMENTS AND RESULTS Eighty-eight patients had uncomplicated insertions, as defined by fewer than four sticks with a 22-gauge pathfinder needle and fewer than four slides with the 18-gauge introducer needle. Ninety-eight catheters were in accurate position, 1 catheter was in the distal superior cava vein, and 1 catheter was in an S-shaped position. CONCLUSIONS It is safe to omit the routine chest radiograph after uncomplicated insertion of a TLC. i.v. treatment can be initiated early. However, if there is any doubt about the correct position, a chest radiograph should be obtained.
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20
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Abstract
Vascular access is the cornerstone of medical therapy in the pediatric population and presents unique challenges. The vessels are small, often exceedingly so, and gaining access may require considerable patience and skill. Peripheral IVs are difficult to place in children, both because of lack of patient cooperation and because of the very small size of many veins. In addition, repeated venipuncture has been identified as one of the greatest stresses in hospitalized children. In the recent past, all forms of central venous access were the preserve of surgeons and were placed in the operating room under general anesthesia. In recent years, pediatric interventional radiologists have described placing peripherally inserted central catheters (PICCs), subcutaneous venous access ports, hemodialysis catheters, and a variety of temporary and permanent central lines even in the smallest children. This has been achieved safely, reliably, and, by dispensing with general anesthesia and operating room time in most cases, at considerable cost savings to the entire health care system. In addition, new forms of reliable, stable access such as the PICC line have made possible outpatient treatment of a wide variety of conditions, particularly infectious, which previously necessitated hospital admission. This has resulted not only in considerable cost saving for the health care system but also improved quality of life for the patient and their family. In this section, I review the current state of pediatric vascular access with emphasis on those areas where pediatric differs from adult practice.
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Affiliation(s)
- John J Crowley
- Department of Pediatric Imaging, Children's Hospital of Michigan, Detroit, Michigan 48201, USA.
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Schutz JCL, Patel AA, Clark TWI, Solomon JA, Freiman DB, Tuite CM, Mondschein JI, Soulen MC, Shlansky-Goldberg RD, Stavropoulos SW, Kwak A, Chittams JL, Trerotola SO. Relationship between Chest Port Catheter Tip Position and Port Malfunction after Interventional Radiologic Placement. J Vasc Interv Radiol 2004; 15:581-7. [PMID: 15178718 DOI: 10.1097/01.rvi.0000127890.47187.91] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Jakob C L Schutz
- Department of Radiology, University of Pennsylvania Medical Center, 1 Silverstein, 3400 Spruce Street, Philadelphia, Pennsylvania 19104, USA
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Kaufman LJ, Clark TWI, Roberts DA, Freiman DB, Shlansky-Goldberg RD, Patel AA, Mondschein JI, Stavropoulos SW, Soulen MC, Solomon JA, Tuite CM, Cope C, Porter DL, Stadtmauer EA, Cunningham KA, Trerotola SO. Do Simultaneous Bilateral Tunneled Infusion Catheters in Patients Undergoing Bone Marrow Transplantation Increase Catheter-related Complications? J Vasc Interv Radiol 2004; 15:57-61. [PMID: 14709689 DOI: 10.1097/01.rvi.0000106383.63463.6b] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Secure venous access with multiple lumens is necessary for the care of allogeneic hematopoietic stem cell transplant (HSCT) recipients. The outcomes associated with simultaneous bilateral tunneled internal jugular infusion catheter placement in the HSCT recipient population were investigated in an attempt to determine whether simultaneous introduction of these catheters compounds or magnifies the risks (infection, venous thrombosis) associated with tunneled catheters. MATERIALS AND METHODS Patients undergoing HSCT and receiving bilateral tunneled infusion catheters in a single procedure were identified using a quality assurance data base. Medical records for the duration of catheterization were reviewed; 43 patients were included in the study (mean age, 42 years; range, 22-56). Diagnoses included acute lymphocytic leukemia (n = 4), acute myelogenous leukemia (n = 8), aplastic anemia (n = 2), chronic myelogenous leukemia (n = 17), chronic lymphocytic leukemia (n = 1), Hodgkin lymphoma (n = 1), myelodysplasia (n = 4), myelofibrosis (n = 2), and non-Hodgkin lymphoma (n = 4). Cox proportional hazards regression analysis was performed to determine differences in infection rates between dual- and triple-lumen catheters. RESULTS Forty-three pairs of catheters were placed. All met venous access needs for HSCT recipient care. Complete follow-up was achieved for 77 of 87 (89%) catheters. The overall infection rate was 0.25 per 100 catheter-days. The rate was 0.19 and 0.33 for dual- and triple-lumen catheters, respectively (P =.15). Mechanical failure did not differ between catheter types (dual: 0.14 episodes per 100 days, triple: 0.05 per 100 days, P =.2). CONCLUSIONS Bilateral multilumen tunneled infusion catheter placement in a single procedure using imaging guidance is safe with acceptable outcomes and meets venous access needs for HSCT. There is a trend toward higher infection rates, with more lumens and more mechanical failure with dual-lumen catheters.
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Affiliation(s)
- Lauren J Kaufman
- Department of Radiology, Division of Interventional Radiology and Medicine, University of Pennsylvania Medical Center, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Wald M, Kirchner L, Lawrenz K, Amann G. Fatal air embolism in an extremely low birth weight infant: can it be caused by intravenous injections during resuscitation? Intensive Care Med 2003; 29:630-3. [PMID: 12579421 DOI: 10.1007/s00134-003-1681-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2002] [Accepted: 01/17/2003] [Indexed: 10/22/2022]
Abstract
OBJECTIVE A preterm infant with a birth weight of 384 g who succumbed to vigorous resuscitation for sudden respiratory failure on the third day of life is presented. Postmortem examination revealed, apart from extensive pulmonary hemorrhage, a fatal amount of air mainly in the right ventricle. We believe that this air had been introduced via peripheral venous cannulas due to inadvertent and unavoidable air admixture to each injection volume administered with a syringe, and we develop an experimental model to confirm that fatal amounts of air can indeed accumulate with frequent change over of syringes within a short period of time. DESIGN An empty 50-ml syringe was connected to a 15-cm-long connection line via a three-way tap. With a 1 ml syringe 100 doses of 0.5 ml aqua were injected into the connection line. The amount of air which had collected in the 50 ml syringe after the 100 injection cycles was measured. This process was repeated three times each by three of the authors and the average air volume introduced with 100 injections calculated for each investigator. RESULTS The average amounts of air which had entered the closed system after 100 acts of syringe assembly and aqua administration were 1.84, 1.95, and 2.0 ml. This corresponds to an average volume of almost 0.02 ml per injection.
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Affiliation(s)
- Martin Wald
- University Children's Hospital, General Hospital of Vienna, University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
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Abstract
Venous access for therapy in sick children is very important, but sometimes also extremely challenging. With several advances in imaging modalities, the interventional radiologist can certainly help in these situations. This article reviews the indications, technique, and complications related to short- (peripherally inserted central catheter) and long-term (central venous lines, Port-a-catheters) venous accesses in children. A brief commentary is also made about retrieval of fragmented lines.
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Affiliation(s)
- Peter G Chait
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada
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Abstract
Percutaneous placement of cuffed tunneled catheters for hemodialysis access has become a firmly established method of providing vascular access to patients with end-stage renal disease. Considerable evidence supports the right internal jugular vein as the preferred site for catheter insertion. The use of real-time imaging using both ultrasound and fluoroscopy permits simple, safe, and effective placement of the catheter for hemodialysis. The use of these imaging techniques has significantly reduced the number of and severity of complications associated with catheter placement. A specific method of placement is described including variations for specific catheter types. The new subcutaneous port as an alternative to the cuffed tunneled catheter appears to provide another option for vascular access; preliminary data suggests higher flow rates and lower infection rates compared with externalized cuffed tunneled catheters. Finally, the criteria for obtaining training and proficiency in placement of cuffed tunneled catheters are outlined.
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Affiliation(s)
- Jack Work
- Renal Division, Emory University, Atlanta, GA 30322, USA.
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ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. 2002;26:1SA-138SA. [PMID: 11841046 DOI: 10.1177/0148607102026001011] [Citation(s) in RCA: 468] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Abstract
Since the 1997 publication of the Disease Outcomes Quality Initiative (DOQI) vascular access guidelines for cuffed, tunneled catheter placement, additional evidence supporting these recommendations has been published, including additional documentation supporting the right internal jugular vein as the preferred site for insertion. Placing the catheter tip in the right atrium rather than in the superior vena cava will provide adequate blood flow to support effective hemodialysis. The right atrial positioning of the catheter tip will also accommodate catheter tip retraction and decrease the likelihood of malfunction. Overwhelming evidence now supports the use of ultrasound guidance to assist cannulation of the internal jugular vein. This evidence is based on several studies documenting anatomical variations of the internal jugular vein. Ultrasound guidance has significantly decreased the incidence of serious complications of jugular vein cannulation. Finally, a specific technique of catheter placement with variations for catheter types is described.
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Affiliation(s)
- J Work
- Department of Medicine, Nephrology Division, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
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Affiliation(s)
- L Berlin
- Department of Radiology, Rush Medical College, Chicago, IL, USA
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