Ultrasound-guided central venous catheterization around the neck: Systematic review and network meta-analysis

BACKGROUND

Ultrasound-guided central venous catheterization (CVC) has become the standard of care. However, providers use a variety of approaches, encompassing the internal jugular vein (IJV), supraclavicular subclavian vein (SupraSCV), infraclavicular subclavian vein (InfraSCV), proximal axillary vein (ProxiAV), distal axillary vein (DistalAV), and femoral vein.

OBJECTIVE

This review aimed to compare the first-pass success rate and arterial puncture rate for different approaches to ultrasound-guided CVC above the diaphragm.

METHODS

In May 2023, Embase, MEDLINE, CENTRAL, ClinicalTrials.gov, and World Health Organization International Clinical Trials Platform were searched for randomized controlled trials (RCTs) comparing the 5 CVC approaches. The Confidence in Network Meta-Analysis tool was used to assess confidence. Thirteen RCTs (4418 participants and 13 comparisons) were included in this review.

RESULTS

The SupraSCV approach likely increased the proportion of first-attempt successes compared to the other 4 approaches. The SupraSCV first-attempt success demonstrated risk ratios (RRs) > 1.21 with a lower 95% confidence interval (CI) exceeding 1. Compared to the IJV, the SupraSCV approach likely increased the first-attempt success proportion (RR 1.22; 95% confidence interval [CI] 1.06-1.40, moderate confidence), whereas the DistalAV approach reduced it (RR 0.72; 95% CI 0.59-0.87, high confidence). Artery puncture had little to no difference across all approaches (low to high confidence).

CONCLUSION

Considering first-attempt success and mechanical complications, the SupraSCV may emerge as the preferred approach, while DistalAV might be the least preferable approach. Nevertheless, head-to-head studies comparing the approaches with the greatest first attempt success should be undertaken.

Catheter-related complications in onco-hematologic children: A retrospective clinical study on 227 central venous access devices

BACKGROUND

The use of central venous access devices (CVADs) is of paramount importance to safely deliver antiblastic and support therapies in children with cancer. Though, in pediatric patients, as much as in adults, CVADs are potentially associated with severe complications which may result in unscheduled interruption of therapy, hospitalization, increased morbidity/mortality, and increased cost of care.

METHODS

We have reviewed retrospectively our experience with CVADs in children with solid tumors and hematologic diseases, with the purpose of verifying if the adoption of well-defined insertion and maintenance bundles might be effective in reducing catheter-related complications, and in particular catheter-related thrombosis.

RESULTS

A total of 227 CVADs were analyzed: 175 peripherally inserted central catheters (PICCs), 50 centrally inserted central catheters (CICCs), and 2 femorally inserted central catheters. All CVADs were non-valved, non-cuffed power injectable polyurethane catheters; 81% were tunneled. Median dwelling time of CVADs was 172 days, for a total number of 39,044 catheter days. A very low incidence of both symptomatic catheter-related thrombosis (0.9%) and catheter-related blood stream infection (0.56 episodes per 1000 catheter days) was found. Unscheduled removal or guidewire replacement because of mechanic complications occurred in 15.7% of CVADs. There was no difference in terms of complications between PICCs and CICCs or between tunneled and non-tunneled catheters.

CONCLUSIONS

Our experience with CVADs in oncologic and hematologic children suggests that catheter-related complications may be minimized by the adoption of appropriate insertion and maintenance bundles.

Point-of-care ultrasound for vascular access in neonates and children

Ultrasound plays a major role in neonatal/pediatric vascular access, both for venous access and for arterial access, not only just for the insertion of intravascular catheters, but also for many other issues related to this type of maneuver. This "global use of ultrasound" includes a systematic and consistent adoption of this technology for several steps of vascular access: (a) the pre-procedural assessment/evaluation of the vessels, (b) the ultrasound-guided puncture and cannulation of arteries and veins, (c) the real-time diagnosis of immediate, puncture-related complications, (d) the so-called "tip navigation" (i.e., real-time intra-procedural assessment of the direction and trajectory of the guidewire and/or of the catheter inside the vasculature), (e) the so-called "tip location" (i.e., intra-procedural or post-procedural assessment of the proper position of the tip of the catheter), and (f) the early diagnosis and/or management of most non-infective late complications.

CONCLUSION

Therefore, any vascular access expert (nurse or physicians) should have documented competency in the use of ultrasound. This knowledge should include the use of ultrasound for assessment of vessels, for catheter insertion, for proper placement of the tip, and for real-time detection of complications.

WHAT IS KNOWN

• Ultrasound is obviously useful for vascular access procedures in neonates and children.

WHAT IS NEW

• Recent evidence suggests that ultrasound is useful for many purposes in the field of vascular access (preprocedural scan, ultrasound-guided puncture, tip navigation, tip location, diagnosis of most non-infective complications). • Recent evidence also suggests that radiological methods no longer play any role in the insertion of vascular accesses in neonates and children.

Macro- and microscopic changes in veins with short-term central venous catheters: an observational autopsy study

BACKGROUND

Centrally inserted central catheters (CICCs) are indispensable in modern healthcare, but unfortunately, come with complications. Catheter-related thrombosis is a well-known complication reported to occur in 5-30% of patients with CICC. There is a paucity of studies that report the incidence of catheter-related thrombosis after the introduction of real-time ultrasound insertion guidance as clinical practice. This study aimed to demonstrate any pathological macro- or microscopic changes in the vein wall associated with CICCs.

METHODS

The study was approved by the Swedish Ethical Review Authority and was conducted at a large university hospital. The study included 12 patients with a short-term CICC who were subject to autopsies. Vessels with inserted catheters were macroscopically and microscopically examined.

RESULTS

In total, seven female and five male patients with a median age of 70 (interquartile range 63-76) were included. With one exception, all patients received routine thromboprophylaxis throughout the period with CICC. Most inserted CICCs were 9.5 French (54%) and were inserted in the internal jugular vein (92%). The median time with CICC was seven days (interquartile range 1.8-20). At autopsy, thrombi were observed in all cases (100%), macroscopically and microscopically, attached to the distal portion of the CICC and/or the adjacent vessel wall. Inflammatory changes in the vessel walls were seen in all cases, and varying degrees of fibrosis were demonstrated in eight cases (67%).

CONCLUSIONS

This autopsy study demonstrated that catheter-related thrombus formation with adjacent inflammatory and fibrotic vessel wall thickening was very common, despite a limited period of catheter use. The consequences of these findings are important, as thrombi may cause pulmonary embolism and possibly lead to catheter-related infections, and since inflammatory and fibrotic vessel wall thickening may evolve into chronic venous stenosis. Furthermore, the findings are a cause of concern, as CICCs are indispensable in modern healthcare and complications may be masked by the general disease that was the indication for CICC insertion.

The value of transthoracic echocardiography and chest X-ray in locating the tip of central venous catheter in dialysis patients: a comparative study with computed tomography imaging

To determine the tip position of the central venous catheter (CVC) in patients with dialysis, the guidelines recommend that it be determined using chest radiography (CXR) after catheterization, without fluoroscopy. However, some researchers have proposed that transthoracic echocardiography (TTE) can replace CXR, but this has not been widely adopted. This study aimed to determine which of the two aforementioned methods is more suitable for locating the tip position of the CVC. This prospective study included 160 patients who underwent hemodialysis at our hospital from March 2021 to December 2022. After inserting the CVC through the internal jugular vein, we used transthoracic echocardiography and CXR to determine the tip of the CVC and compared the results with those of computed tomography (CT). In the comparison between TTE and CXR for locating the CVC tip, we obtained three main findings. (1) TTE was associated with fewer misdiagnosed cases than CXR. (2) TTE provided higher sensitivity (similar sensitivity in position 2), specificity, positive/negative predictive values, and accuracy than CXR. (3) When comparing the receiver operating characteristic curves of TTE and CXR, the area under the curve (95% confidence interval) for the former was larger. Additionally, we made anatomical discoveries: the "hyperechoic triangle" recognized by TTE was equivalent to the entrance of the superior vena cava into the right atrium shown by transesophageal transthoracic echocardiography. TTE is more suitable than CXR as the first examination for CVC tip localization, as it improves diagnostic accuracy and reduces X-ray radiation damage.

A GAVeCeLT bundle for central venous catheterization in neonates and children: A prospective clinical study on 729 cases

BACKGROUND

In the pediatric patient, central venous catheterization may be associated with relevant complications. Though, most of them may be prevented by a wise choice of materials, methods, and techniques. Evidence-based insertion bundles for central venous catheterization have been developed in the adult patient, but not in neonates and children.

METHODS

The Italian Group for Long Term Venous Access Devices (GAVeCeLT) has developed an insertion bundle for central venous catheterization in neonates, infants, and children, which includes seven evidence-based strategies: (1) preprocedural ultrasound evaluation, (2) appropriate aseptic technique, (3) ultrasound guided venipuncture, (4) intraprocedural tip location by non-radiological methods, (5) proper choice of the exit site by tunneling, (6) sutureless securement, and (7) protection of the exit site using glue and transparent membranes. The effectiveness and safety of this bundle has been tested in a prospective study.

RESULTS

All neonates, infants and children requiring a non-emergency central line (except for umbilical venous catheters and epicutaneo-cava catheters) were included in the study. Out of 729 central line insertions, there were no immediate complications (no pneumothorax, no arterial puncture, no malposition); the incidence of early and late complications (local ecchymosis, dislodgment, local pain, exit site infection) was 3.7%; in the first 2 weeks after insertion, no catheter-related bacterial infection or catheter-related thrombosis was recorded.

CONCLUSION

The results of this prospective study strongly validate the hypothesis that an insertion bundle is highly effective in optimizing the safety of the maneuver, reducing immediate, early, and late complications.

Short peripheral intravenous cannula and straight-tip guide wire in ultrasound-guided neonatal central venous catheterization

BACKGROUND

Inserting a J-tip guide-wire into a vein's lumen is often difficult when using the Seldinger or modified Seldinger technique for central venous catheterization (CVC) in newborns. This study was designed to compare the efficacy and safety of guide-wire insertion using the combination of a short peripheral intravenous cannula with a straight-tip guide-wire vs. a needle with a J-tip guide-wire for ultrasound-guided (USG) cannulation of the internal jugular vein (IJV) in newborns using an in-plane technique.

METHODS

One hundred and thirty newborn patients (weight, 1.4-5.2 kg) scheduled for selective or emergency surgery, were randomly assigned to either the needle group (combined with a J-tip guide-wire) or cannula group (combined with a straight-tip guide-wire). The primary outcome was the rate of successful guide-wire insertion on the first attempt. The puncture attempts, catheter placement attempts, and mechanical complications were also compared between the groups.

RESULTS

The rate of successful guide-wire insertion on the first attempt was higher in the cannula group (97%) than in the needle group (76%) (p < 0.05, χ2 = 11.233). Moreover, fewer insertion attempts were needed in the cannula group (1.0 ± 0.2) than in the needle group (1.7 ± 1.1) (p < 0.05, 95% CI [0.449, 1.028]). The time to successful guide-wire insertion was shorter in the cannula group (63 ± 32 s) than in the needle group (92±50 s) (p < 0.05, 95% CI [14.024, 43.063]). No differences were found about other catheterization parameters and complications between the groups.

CONCLUSION

The short peripheral cannula combined with a straight-tip guide-wire was superior to the needle combined with a J-tip guide-wire for USG newborn IJV catheterization in terms of successful guide-wire insertion on the first attempt and overall number of insertion attempts.

Single-plane versus real-time biplane approaches for ultrasound-guided central venous catheterization in critical care patients: a randomized controlled trial

BACKGROUND

Critical care patients often require central venous cannulation (CVC). We hypothesized that real-time biplane ultrasound-guided CVC would improve first-puncture success rate and reduce mechanical complications. The purpose of this study was to compare the success rate and safety of single-plane and real-time biplane approaches for ultrasound-guided CVC.

METHODS

From October 2022 to March 2023, 256 participants with critical illness requiring CVC were randomized to either the single-plane (n = 128) or biplane (n = 128) ultrasound-guided cannulation groups. The success rate, number of punctures, procedure duration, incidence of catheterization-related complications, and confidence score of operators were documented.

RESULTS

The central vein was successfully cannulated in all 256 participants (163 [64%] man and 93 [36%] women; mean age 69 ± 19 [range 13-104 years]), including 182 and 74 who underwent internal jugular vein cannulation (IJVC) and femoral vein cannulation (FVC), respectively. The incidence of successful puncture on the first attempt was higher in the biplane group than that in the single-plane group (91.6% vs. 74.7%; relative risk (RR), 1.226; 95% confidence interval (CI), 1.069-1.405; P = 0.002 for the IJVC and 90.9% vs. 68.3%; RR, 1.331; 95% CI, 1.053-1.684; P = 0.019 for the FVC). The biplane group was also associated with a higher first-puncture single-pass catheterization success rate (87.4% vs. 69.0% and 90.9% vs. 68.3%), fewer undesired punctures (1[1-1(1-2)] vs. 1[1-2(1-4)] and 1[1-1(1-3)] vs. 1[1-2(1-4)]), shorter cannulation time (205 s [162-283 (66-1,526)] vs. 311 s [243-401 (136-1,223)] and 228 s [193-306 (66-1,669)] vs. 340 s [246-499 (130-944)]), and fewer immediate complications (10.5% vs. 28.7% and 9.1% vs. 34.1%) for both IJVC and FVC (all P < 0.05).

CONCLUSION

Real-time biplane imaging of ultrasound-guided CVCs offers advantages over the single-plane approach for critically ill patients.

TRIAL REGISTRATION

This prospective RCT was registered at Chinese Clinical Trial Registry (ChiCTR2200064843). Registered 19 October 2022.

Axillary vein catheterization using ultrasound guidance: A prospective randomized cross-over controlled simulation comparing standard ultrasound and new needle-pilot device

BACKGROUND

Real-time ultrasound (US) guidance facilitates central venous catheterization in intensive care unit (ICU). New magnetic needle-pilot devices could improve efficiency and safety of central venous catheterization. This simulation trial was aimed at comparing venipuncture with a new needle-pilot device to conventional US technique.

METHODS

In a prospective, randomized, simulation trial, 51 ICU physicians and residents cannulated the right axillary vein of a human torso mannequin with standard US guidance and with a needle-pilot system, in a randomized order. The primary outcome was the time from skin puncture to successful venous cannulation. The secondary outcomes were the number of skin punctures, the number of posterior wall puncture of the axillary vein, the number of arterial punctures, the number of needle redirections, the failure rate, and the operator comfort.

RESULTS

Time to successful cannulation was shorter with needle-pilot US-guided technique (22 s (interquartile range (IQR) = 16-42) vs 25 s (IQR = 19-128); median of difference (MOD) = -9 s (95%-confidence interval (CI) -5, -22), p < 0.001). The rates of skin punctures, posterior wall puncture of axillary vein, and needle redirections were also lower (p < 0.01). Comfort was higher in needle-pilot US-guided group on a 11-points numeric scale (8 (IQR = 8-9) vs 6 (IQR = 6-8), p < 0.001).

CONCLUSIONS

In a simulation model, US-guided axillary vein catheterization with a needle-pilot device was associated with a shorter time of successful cannulation and a decrease in numbers of skin punctures and complications. The results plea for investigating clinical performance of this new device.

Establishment and implementation of a nurse-led interdisciplinary management strategy for central line maintenance: A single-center experience

Objectives

This study aimed to establish and implement an interdisciplinary management strategy led by senior nurses via a vascular access specialist team (VAST) at a teaching hospital.

Methods

In 2021, the hospital established and implemented a nurse-led VAST management strategy to improve the quality of clinical central line maintenance. The VAST comprised senior nurses specialized in intravenous therapy, ultrasound/radiology technologists, medical doctors with central venous catheterization certificates, central line maintenance nurses, and administrative coordinators. The management strategy mainly included systemic on-the-job training for VAST members, the establishment of an interdisciplinary central line emergency "green channel," the formation of a VAST-based, nurse-led standardized clinical rounding system, and the standardization of central line self-care instructions for patients. During the pre- (July 2020 to April 2021) and post- (May 2021 to May 2022) of the implementation the interdisciplinary management strategy, overall patients' self-care ability, the success rate of catheterization at first time, central line management compliance rate, and patients' satisfaction with catheter maintenance were investigated and compared.

Results

The results showed the score self-care ability was increased from 74.75 ± 18.4 (pre-VAST) to 99.10 ± 23.65 (post- VAST); the success rate for catheterization at first time was improved to 100% (225/225), compared to 92.9% (209/225) at pre-VAST; the central line management compliance rate was also increased to 99.6% (224/225) at post-VAST from 93.3% (210/225) at pre-VAST. A patient satisfaction survey on catheter maintenance showed improvements in all five indicators were compared to the pre- VAST (P < 0.05).

Conclusions

The nurse-led VAST interdisciplinary strategy can effectively improve the quality of clinical central line management and should be used to reinforce clinical catheterization and maintenance of central lines.

How to improve the efficiency and the safety of real-time ultrasound-guided central venous catheterization in 2023: a narrative review

Central venous catheterization (CVC) is a frequent procedure, practiced by intensivists, anesthesiologists and advanced practice nurses in intensive care units and operative rooms. To reduce CVC-associated morbidity, it is essential to strive for best practices, based on the latest evidence. This narrative review aims to synthesize current knowledge on evidence-based best practices for CVC that improve the use and feasibility of real-time ultrasound-guided insertion procedures. Optimization of the vein puncture technique and the development of new technologies are discussed to reinforce the use of the subclavian vein catheterization as first choice. The search for alternative site of insertions, without increasing infectious and thrombotic risks, deserves further research.

Massive hemothorax secondary to internal jugular vein central venous catheter placement in a patient undergoing spinal surgery complicated by chest trauma: a case report

BACKGROUND

Placement of a central venous catheter (CVC) is a common procedure for spinal surgery and is relatively safe under ultrasound guidance.

CASE PRESENTATION

We report the case of a 56-year-old female who underwent ultrasound-guided placement of an internal jugular vein CVC for fluid replacement during spinal surgery for thoracic vertebral burst compression fracture and multiple rib fractures as a result of a high-altitude fall injury. Hemothorax developed intraoperatively. During a thoracotomy, the tip of the CVC was found within the chest cavity. The presence of chest trauma may impact on clinician's appreciation of the potential complications of internal jugular vein CVC placement.

CONCLUSION

The present case demonstrates the need for clinical awareness of the potential complications of CVC placement in patients with chest trauma and the need for adequate training in this technique.

US-guided central venous catheter placement in the neonatal intensive care unit: Brachiocephalic vein or internal jugular vein?

BACKGROUND

Centrally inserted central catheters (CICCs) are commonly used to monitor venous pressure and administer parenteral nutrition and drugs in newborns. In the present study, we evaluated cannulation success rates, cannulation time, and frequency of complications in catheterization of the internal jugular vein (IJV) and brachiocephalic vein (BCV).

METHODS

The present study included patients who underwent IJV and BCV catheterization under ultrasound (US) guidance. The patients were divided into two groups, IJV and BCV, depending on the vein in which the CICC was utilized. We documented the diameters of the IJVs and BCVs, first attempt and overall success rates, mean cannulation time, and complication rates.

RESULTS

A total of 79 patients were evaluated, 37 in the BCV group and 42 in the IJV group. No significant differences were observed between the two groups in terms of sex, mean age, or weight range (p > 0.05).The mean vein diameter was significantly larger in the BCV group than in the IJV group (p < 0.001); the mean number of attempts was significantly higher in the IJV group than in the BCV group (p < 0.001); the mean cannulation time was significantly longer in the IJV group than in the BCV group (p < 0.001); and the first attempt success rate was 50% in the IJV group, versus 94.6% in the BCV group. The overall success rate was 100% in both groups. The rate of complications was 8.6% in the IJV group, while no complications developed in the BCV group.

CONCLUSIONS

Given the larger diameter of the vessel, BCV catheterization was found to result in quicker cannulation and lower complication rates. The results of the present study suggest that BCV catheterization should be the first choice for neonatal intensive care unit (NICU) patients who require parenteral support or close venous pressure monitoring.

Ultrasound versus intracavitary electrocardiography for intraprocedural tip location during central venous catheterization in infants and children: A prospective clinical study

BACKGROUND

Both intracavitary electrocardiography (IC-ECG) and ultrasound (US) have been proven to be safe and accurate for intraprocedural tip location during central venous catheterization, and both are known to be easily applicable and feasible in pediatric patients. Though, no prospective clinical study has directly compared the two methods as regards their applicability, feasibility, and procedural time.

METHODS

This study prospectively enrolled all children requiring a central venous access device in non-emergency situations, during a period of 1 year. All devices were inserted according to a well-defined insertion bundle including both IC-ECG and US-based tip location. The primary endpoint of the study was to compare the two methods in terms of applicability, feasibility and time required.

RESULTS

This study included 100 consecutive central venous catheterizations in children of age ranging from 1 month to 18 years. The applicability of IC-ECG based tip location was 98% and its feasibility 100%; the time required for IC-ECG was 1.9 ± 2 min. The applicability of US-based tip location was 96% and its feasibility was 100%; the maneuver required 2.2 ± 3 min.

CONCLUSIONS

US is an appropriate alternative method for intraprocedural tip location in children. The combined use of US and IC-ECG (both maneuvers being accurate, inexpensive, cost-effective, non-invasive, and equally fast to perform) should be recommended for tip location in pediatric patients, and it will avoid completely the use of fluoroscopy or of post-procedural x-ray.

Incidence of catheter-related bloodstream infections following ultrasound-guided central venous catheterization: a systematic review and meta-analysis

Background

Ultrasonographic guidance is widely used for central venous catheterization. Several studies have revealed that ultrasound-guided central venous catheterization increases the rate of success during the first attempt and reduces the procedural duration when compared to the anatomical landmark-guided insertion technique, which could result in protection from infectious complications. However, the effect of ultrasound-guided central venous catheterization on catheter-related bloodstream infections remains unclear. We aimed to conduct a systematic review and meta-analysis to evaluate the value of ultrasound guidance in preventing catheter-related bloodstream infections and catheter colonization associated with central venous catheterization.

Methods

The Cochrane Central Register of Controlled Trials (CENTRAL) and MEDLINE (via PubMed) were searched up to May 9, 2022 for randomized controlled trials (RCTs) comparing ultrasound-guided and anatomical landmark-guided insertion techniques for central venous catheterization. Risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool for RCTs. A meta-analysis was performed for catheter-related bloodstream infections and catheter colonization, as primary and secondary outcomes, respectively.

Results

Four RCTs involving 1268 patients met the inclusion criteria and were analyzed. Ultrasound-guided central venous catheterization was associated with a slightly lower incidence of catheter-related bloodstream infections (risk ratio, 0.46; 95% confidence interval [CI], 0.16–1.32) and was not associated with a lower incidence of catheter colonization (risk ratio, 1.36; 95% CI, 0.57–3.26).

Conclusion

Ultrasound-guided central venous catheterization might reduce the incidence of catheter-related bloodstream infections. Additional RCTs are necessary to further evaluate the value of ultrasound guidance in preventing catheter-related bloodstream infections with central venous catheterization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07760-1.

Factors influencing the optimal selection of central venous access devices: A qualitative study of health care team members' perspectives

Objective

This study aimed to explore health care team members' understanding of the factors influencing the optimal selection of central venous access devices (CVADs).

Methods

The data of the study was collected using semi-structured interviews. Twenty-six hospital medical staff (four hospital manager, 15 head nurses, 7 nurse) with experience in peripheral or central catheterization from four regions (Northern China, Southern China, Northwest China, and Qinghai-Tibet China) in China were interviewed between June and October 2021. Content analysis was used to analyze the data.

Results

The results revealed five themes and 14 sub-themes. Patients: concerns, resources, requirements, and evaluation (security concerns, support resources, life requirements, evaluation among patients); nurses: awareness, knowledge, and popularizing methods (awareness of intravenous therapy, understanding of professional knowledge, forms of popularizing methods); doctors: support and involvement (support for decision-making, involvement in intravenous work); hospital managers: authority, quality control and continuing education (management of catheterization authority, quality control of intravenous infusion, investment in continuing education) and environment: differences and commonalities (differences in social support, and current commonalities).

Conclusion

Nurses and other healthcare team members' understanding, selection, use, and recommendation of CVADs have an indirect effect on patients' decision-making. Therefore, hospital managers and government departments can indirectly strengthen medical team cooperation and improve learning education in order to improve the safety of patients receiving intravenous infusions.

Medical students’ self-assessed efficacy and satisfaction with training on endotracheal intubation and central venous catheterization with smart glasses in Taiwan: a non-equivalent control-group pre- and post-test study

PURPOSE

Endotracheal intubation and central venous catheterization are essential procedures in clinical practice. Simulation-based technology such as smart glasses has been used to facilitate medical students’ training on these procedures. We investigated medical students’ self-assessed efficacy and satisfaction regarding the practice and training of these procedures with smart glasses in Taiwan.

METHODS

This observational study enrolled 145 medical students in the 5th and 6th years participating in clerkships at Taipei Veterans General Hospital between October 2020 and December 2021. Students were divided into the smart glasses or the control group and received training at a workshop. The primary outcomes included students’ pre- and post-intervention scores for self-assessed efficacy and satisfaction with the training tool, instructor’s teaching, and the workshop.

RESULTS

The pre-intervention scores for self-assessed efficacy of 5th- and 6th-year medical students in endotracheal intubation and central venous catheterization procedures showed no significant difference. The post-intervention score of self-assessed efficacy in the smart glasses group was better than that of the control group. Moreover, 6th-year medical students in the smart glasses group showed higher satisfaction with the training tool, instructor’s teaching, and workshop than those in the control group.

CONCLUSION

Smart glasses served as a suitable simulation tool for endotracheal intubation and central venous catheterization procedures training in medical students. Medical students practicing with smart glasses showed improved self-assessed efficacy and higher satisfaction with training, especially for procedural steps in a space-limited field. Simulation training on procedural skills with smart glasses in 5th-year medical students may be adjusted to improve their satisfaction.

Going the (social) distance: Comparing the effectiveness of online versus in-person Internal Jugular Central Venous Catheterization procedural training

BACKGROUND

This study compares surgical residents' knowledge acquisition of ultrasound-guided Internal Jugular Central Venous Catheterization (US-IJCVC) between in-person and online procedural training cohorts before receiving independent in-person Dynamic Haptic Robotic Simulation training.

METHODS

Three surgical residency procedural training cohorts, two in-person (N = 26) and one online (N = 14), were compared based on their performance on a 24-item US-IJCVC evaluation checklist completed by an expert physician completed after training. Pre- and post-training US-IJCVC knowledge was also compared for the online cohort.

RESULTS

No significant change in the pass rates on the US-IJCVC checklist was found between in-person and online cohorts (p = 0.208). There were differences in the Economy of Time and Motion between in-person and online cohorts (p < 0.005). The online cohort had significant increases in US-IJCVC knowledge pre-to post-training (p < 0.008).

CONCLUSION

Online training with independent simulation practice was as effective as in-person training for US-IJCVC.

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

BACKGROUND

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

CASE SUMMARY

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

CONCLUSION

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

[Application of ultrasound-guided central venous catheterization at various sites in infants with shock]

OBJECTIVES

To study the clinical characteristics of ultrasound-guided central venous catheterization at various sites in infants with shock, and to explore how to quickly select the site for central venous puncture in infants with shock.

METHODS

The medical data of 112 infants who were diagnosed with shock and underwent central venous catheterization in the Pediatric Intensive Care Unit, Dongguan Children's Hospital Affiliated to Guangdong Medical University, from January 2016 to December 2020 were reviewed retrospectively. The patients were divided into an ultrasound group (n=70) and a body surface location group (n=42) according to whether the catheterization was carried out under ultrasound guidance. The application of ultrasound-guided catheterization at various sites in infants was summarized and analyzed, and the success rate of one-time puncture, overall success rate, catheterization time, and complications were compared between these sites.

RESULTS

Compared with the body surface location group, the ultrasound group had a significantly higher success rate of one-time puncture, a significantly shorter catheterization time, and a significantly reduced incidence rate of complications in internal jugular vein and femoral vein catheterizations (P<0.05). In the ultrasound group, the proportion of internal jugular vein catheterization was the highest (51%, 36/70), followed by femoral vein catheterization (33%, 23/70), and subclavian vein catheterization (16%, 11/70). For the comparison between different puncture sites under ultrasound guidance, internal jugular vein catheterization showed the shortest time of a successful catheterization [5.5 (5.0, 6.5) minutes] (P<0.05). There was no significant difference in the incidence rate of complications among the different puncture sites groups (P>0.05).

CONCLUSIONS

In infants with shock, ultrasound-guided internal jugular vein catheterization can be used as the preferred catheterization method for clinicians.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Trendelenburg (Head-Down Tilt) and Head Rotation: Ultrasonographic effects on the internal jugular vein for catheterization safety

Most guidelines fail to specify patient positioning during central venous catheterization. The objective was to determine the effects of head-down tilt (Trendelenburg position) and head rotation on the internal jugular vein (IJV). A prospective, observational, longitudinal, and descriptive study using healthy adult volunteers, of both sexes, was performed. The change in position and cross-sectional areas (CSA) of the right IJV and common carotid artery (CA) were measured by ultrasonography during Trendelenburg position (TP) (0°, 5°, 10°, and 15°) and contralateral head-rotation (HR) (0°, 45°, and 90°) for a total of 12 positions. The neutral supine position was first, randomizing the other 11 positions, with 5-minute rest intervals in between. Vital signs and symptoms were recorded. A total of 54 volunteers were recruited between the ages of 21 and 32, of which 30 were men. Any degree of TP or HR significantly increased the CSA. The largest area obtained was 1.78cm² with a TP15HR90 which did not have a statistical difference with TP10HR45 1.59cm² . A HR90 tended to displace the IJV medially, overlaying the CA. Any degree of TP or HR will significantly increase CSA or the right IJV. A 5° to 10° TP is recommended when the patient's condition allows it, with a 45° HR, without significantly displacing the IJV anterior to the CCA. This article is protected by copyright. All rights reserved.

Incidence rate and risk factors of central line-associated bloodstream infections among neonates and children admitted to a tertiary care university hospital

Central-line associated bloodstream infection (CLABSI) is a common healthcare-associated infection in patients indwelling central venous catheter (CVC). This study examined the incidence rates, risk factors, and clinical outcomes of CLABSI among neonates (aged < 1 month) and children (aged ≥ 1 month) admitted to a tertiary care university hospital. An overall CLABSI incidence rate was 3.2 per 1,000 catheter-days. Number of CVC lumen and place of catheter insertion were a significant risk factor among our neonates and children, respectively. CLABSI prolonged hospitalization and increased hospital costs.

Guidewire lost during endovenous intervention

Central venous catheterization is an important vascular access route used in many operations like open-heart surgery, hemodialysis, multiple trauma patients, total parenteral nutrition, and poor peripheral veins. During central venous catheterization, mechanical complications such as catheter thrombosis, infections, and pneumothorax can develop. In this report, we aimed to present a case of guidewire left unrecognized in venous system after central venous catheterization procedure. The guidewire has been extracted under fluoroscopy guidance. This case emphasizes maintaining and improving patient care and safety by doctor and the team.

Ultrasound to the Rescue: Management of Looped Guidewire during Hemodialysis Catheter Insertion in the Left Internal Jugular Vein

Hemodialysis catheters are commonly placed in the major central vein for the purpose of dialysis. Coiling or looping of guidewire is a rare but reported complication of a central vascular catheter insertion. We report a case in which we encountered a rare complication of looping of the guidewire used for dialysis catheter placement and how we correctly diagnosed and repositioned it under ultrasound guidance. A 68-yearold man diagnosed with Carcinoma of Pyriform Fossa admitted in our ICU had Acute Renal Failure. An attempt to insertion of hemodialysis catheter in left internal jugular vein was made. Following successful puncture, the guide wire was threaded through needle. After five centimeter length of guide wire was threaded, resistance was felt and a loop of guidewire was visualized which was abutting the posterior wall of vein in out-of-plane view, creating a dual-point echogenicity. Under ultrasound guidance, we slowly pulled out the guidewire till the loop disappeared.The catheter was then inserted without repeat puncture of the vessel, thus preventing chance of thrombosis by repeated attempts. Real time USG guidance not only improves the success rates but also decreases the number of attempts and complications related to hemodialysis catheterization. Moreover, it benefits the patients by reducing the risks and discomforts of the procedure by reducing the duration of cannulation. The intelligent use of real-time ultrasound guidance in each step of the central venous catheterization is absolutely the need of the hour to prevent catastrophic yet preventable complications.

Amidst COVID-19 pandemic: the catastrophic sequelae of an inadvertent carotid artery insertion during central venous catheter placement - a case report

Introduction: Central venous catheter (CVC) placement is one of the most commonly performed procedures in the intensive care unit for the institution of high-risk medications and nutrients. Despite the frequent use of ultrasound, inadvertent placement of CVC into the carotid artery is still possible. It carries significant morbidity due to the incidence of bleeding, arteriovenous fistula, and stroke.

Methods: We present a case of accidental placement of CVC into the right carotid artery, which led to the right-sided temporoparietal stroke.

Case Summary: A 71-year-old male was admitted to hospital with symptoms of cough, fatigue, and shortness of breath. He was diagnosed with coronavirus disease-19 and did require mechanical ventilation due to progressive hypoxic respiratory failure. The patient developed distributive shock and underwent CVC placement at the day of admission. On the 24th day of intubation, the patient was unable to move his left upper and lower extremities. Computed tomography (CT) head revealed showed a large temporoparietal stroke. CT Angiogram of head and neck revealed a misplaced CVC within the right common carotid artery . He was transferred to the Neuro ICU at our hospital where the patient underwent catheter removal and carotid artery sheath placement followed by dual antiplatelet therapy. Although the patient survived, he still required long-term facility placement due to the stroke.

Conclusion: We reiterate that an experienced clinician must perform the CVC placement with ultrasound guidance and verify its placement with multiple confirmation techniques afterwards. Providers must manage unintentional carotid artery placement promptly to prevent long-term sequelae associated with it.

Hemodynamic effects of increased intra-abdominal pressure in critically ill children

OBJECTIVE

To evaluate the influence of intra-abdominal pressure on the cardiac index (CI) at different intra-abdominal hypertension grades achieved when performing an abdominal compression maneuver (ACM). Evaluating the effectiveness of the ACM in distending the left internal jugular vein (LIJV).

METHODS

Prospective observational study conducted in the PICU of a quaternary care teaching hospital. Participants underwent the ACM and the IAP was measured with an indwelling urinary catheter. At each IAH grade reached during the ACM, the CI was measured by transthoracic echocardiography and the LIJV cross-sectional area (CSA) was determined by ultrasonography.

RESULTS

Twenty-four children were included (median age and weight of 3.5 months and 6.37kg, respectively). The median CI observed at baseline and during IAH grades I, II, III, and IV were 3.65L/min/m² (IQR 3.12-4.03), 3.38L/min/m² (IQR 3.04-3.73), 3.16L/min/m² (IQR 2.70-3.53), 2.89L/min/m² (IQR 2.38-3.22), and 2.42L/min/m² (IQR 1.91-2.79), respectively. A 25% increase in the LIJV CSA area was achieved in 14 participants (58%) during the ACM.

CONCLUSION

The ACM significantly increases IAP, causing severe reversible impairment in the cardiovascular system and is effective in distending the LIJV in just over half of the subjects. Even low levels of HIA can result in significant cardiac dysfunction in children. Therefore, health professionals should be aware of the negative hemodynamic repercussions caused by the increased IAP.

A retrospective comparison for prediction of optimal length of right subclavian vein catheterization in infants: landmark-based estimation vs. linear regression model

Background

The optimal insertion length for right subclavian vein catheterization in infants has not been determined. This study retrospectively compared landmark-based and linear regression model-based estimation of optimal insertion length for right subclavian vein catheterization in pediatric patients of corrected age < 1 year.

Methods

Fifty catheterizations of the right subclavian vein were analyzed. The landmark related distances were: from the needle insertion point (I) to the tip of the sternal head of the right clavicle (A) and from A to the midpoint (B) of the perpendicular line drawn from the sternal head of the right clavicle to the line connecting the nipples. The optimal length of insertion was retrospectively determined by reviewing post-procedural chest radiographs. Estimates using a landmark-based equation (IA + AB – intercept) and a linear regression model were compared with the optimal length of insertion.

Results

A landmark-based equation was determined as IA + AB – 5. The mean difference between the landmark-based estimate and the optimal insertion length was 1.0 mm (95% limits of agreement –18.2 to 20.3 mm). The mean difference between the linear regression model (26.681 – 4.014 × weight + 0.576 × IA + 0.537 × AB – 0.482 × postmenstrual age) and the optimal insertion length was 0 mm (95% limits of agreement –16.7 to 16.7 mm). The difference between the estimates using these two methods was not significant.

Conclusions

A simple landmark-based equation may be useful for estimating optimal insertion length in pediatric patients of corrected age < 1 year undergoing right subclavian vein catheterization.

Ultrasound-guided insertion of peripherally inserted central catheter after anesthetic induction in children undergoing surgery for moyamoya disease - Thirty cases report

Background

Pediatric patients with moyamoya disease are vulnerable to ischemic attacks following physical or emotional stress, such as those experienced during blood sampling. A central venous catheter might be beneficial for blood sampling, and a peripherally inserted central catheter (PICC) is a considerable option for central venous access. However, PICC insertion during anesthetic management is relatively rare.

Case

Thirty cases of ultrasound-guided PICC insertion were performed in children undergoing surgery for moyamoya disease after anesthetic induction. Positioning was successful in 22 cases, and 5 were malpositioned. In three cases, the peripheral insertion failed. Adjustment of the insertion depth was performed in nine cases. No complications related to catheterization were observed during the procedure or the catheter indwelling period.

Conclusions

We report the successful use of PICC in children undergoing surgery for moyamoya disease with a considerable success rate and low incidence of malpositioning or complications.

Placement of hemodialysis catheters with the help of the micropuncture technique in patients with central venous occlusion and limited access

Background/aim

This study aims to describe the technical success of the micropuncture technique, which is performed in placement of tunneled hemodialysis catheters in patients with central venous occlusion and limited access.

Materials and methods

A total of 25 patients with central venous occlusion and in need of catheter placement for hemodialysis between 2012 and 2018 were included in this study and analyzed retrospectively. Technical success was defined as the placement of tunneled dialysis catheters with optimal position and function.

Results

Internal jugular vein access in 16 patients (14 right and 2 left) and right subclavian vein access in 3 patients were successfully performed in placement of the tunneled dialysis catheter. Although internal jugular and subclavian vein access was attempted bilaterally, the procedure failed in 6 patients. The overall technical success of recanalization of the occluded central veins was 76% (19/25). No minor or major complications were encountered.

Conclusion

Tunneled dialysis catheter placement through the occluded internal jugular and subclavian veins with the micropuncture technique is effective and safe in patients with limited vascular access. The recanalization of the occluded conventional access routes should always be kept in mind to allow for the preservation of vascular accesses for future requirements.

Comparison of intraosseous access and central venous catheterization in Chinese adult emergency patients: A prospective, multicenter, and randomized study

BACKGROUND

It is challenging to establish peripheral intravenous access in adult critically patients. This study aims to compare the success rate of the first attempt, procedure time, operator satisfaction with the used devices, pain score, and complications between intraosseous (IO) access and central venous catheterization (CVC) in critically ill Chinese patients.

METHODS

In this prospective clustered randomized controlled trial, eight hospitals were randomly divided into either the IO group or the CVC group. Patients who needed emergency vascular access were included. From April 1, 2017 to December 31, 2018, each center included 12 patients. We recorded the data mentioned above.

RESULTS

A total of 96 patients were enrolled in the study. There were no statistically significant differences between the two groups regarding sex, age, body mass index, or operator satisfaction with the used devices. The success rates of the first attempt and the procedure time were statistically significant between the IO group and the CVC group (91.7% vs. 50.0%, P<0.001; 52.0 seconds vs. 900.0 seconds, P<0.001). During the study, 32 patients were conscious. There was no statistically significant difference between the two groups regarding the pain score associated with insertion. There were statistically significant differences between the two groups regarding the pain score associated with IO or CVC infusion (1.5 vs. 0.0, P=0.044). Complications were not observed in the two groups.

CONCLUSIONS

IO access is a safe, rapid, and effective technique for gaining vascular access in critically ill adults with inaccessible peripheral veins in the emergency departments.

Effects of a Quality Improvement Program to Reduce Central Venous Catheter-Related Infections in Hemodialysis Patients

BACKGROUND

Central catheter infections are of concern in patients on hemodialysis because of the high risk of catheter-related bloodstream infections, sepsis, and death. Adequate nursing is critical for the prevention of such infections. This study aimed to use the PDCA (plan-do-check-act) method to reduce the incidence of central venous catheter infection using management in the maintenance of central venous catheter in patients on hemodialysis, compared with routine care.

METHODS

This pilot study recruited patients on hemodialysis via central venous catheterization at the Blood Purification Center of Ruijin Hospital between November 2017 and November 2018. The patients were randomized to the routine and PDCA groups. All participants received routine nursing. The PDCA group received central venous catheter management by PDCA. The incidence of central venous catheterization-related infections, nursing satisfaction, and quality of life were compared between the two groups.

RESULTS

A total of 122 participants were enrolled in each group. The incidence of central catheter-related bloodstream infection, as the primary outcome, was 0.8 and 8.8 cases per 1000 catheter days in the PDCA and routine groups, respectively (P < 0.001). In addition, as the secondary outcomes, the scores of nursing satisfaction (health guidance, nursing technology, and therapeutic effects) score and quality of life (physiological, psychological, social, and environmental status) were better in the PDCA group than in the routine group (all P < 0.01).

CONCLUSIONS

This pilot study suggests that the PDCA cycle model can effectively reduce the incidence of central venous catheter-related infections and improve satisfaction and quality of life in patients on hemodialysis.

Complicated central catheterization in atypical celphos poisoning simulating throttling homicide: Review of neck resuscitation artefacts

Therapeutic artefacts are a challenge for forensic pathologists for correct interpretation at autopsy. A 23-year-old female was found unconscious at home and immediately admitted to an emergency of a tertiary care hospital where resuscitative measures were taken. However, she died after 4 h of hospitalization. The injuries (abrasions, subcutaneous bruising and haemorrhage in the deep structures of the neck) discovered at autopsy simulated the findings of throttling and aroused the suspicion of homicide. Later, enquiry revealed that it happened due to mal-positioned central line in the carotid artery during internal jugular vein access to provide fluid as the patient was in shock due to aluminium phosphide (Celphos)poisoning. The bleeding diatheses in Celphos poisoning might have precipitated the extensive neck haemorrhage in this case.

Magnetic Tracking and Electrocardiography-Guided Tip Confirmation System Versus Fluoroscopy for Placement of Peripherally Inserted Central Catheters: A Randomized, Noninferiority Comparison

PURPOSE

To determine whether the use of a magnetic tracking and electrocardiography-guided catheter tip confirmation system (TCS) is safe and noninferior to fluoroscopy concerning positioning accuracy of a peripheral inserted central catheter (PICC).

METHODS

In this prospective, randomized, single-center study, adult patients scheduled for PICC insertion were assigned 1:1 either to TCS or fluoroscopy. The primary objective was a noninferiority comparison of correct PICC tip position confirmed by X-ray obtained immediately after catheter insertion. Time needed for PICC insertion and insertion-related complications up to 14 days after the procedure were secondary outcomes to be assessed for superiority.

RESULTS

A total of 210 patients (62.3 ± 14.4 years, 63.8% male) were included at a single German center between June 2016 and October 2017. Correct PICC tip position was achieved in 84 of 103 TCS (82.4%) and 103 of 104 fluoroscopy patients (99.0%). One-sided 95% lower confidence limit on the difference between proportions was -23.1%. Thus, noninferiority of TCS was not established (p > 0.99). Insertion of PICC took longer with TCS compared to fluoroscopy (8.4 ± 3.7 min vs. 5.0 ± 2.7 min, p < 0.001). Incidence of complications within a mean follow-up of 5.0 ± 2.3 days did not differ significantly between groups.

CONCLUSION

Noninferiority of TCS to fluoroscopy in the incidence of correct PICC tip position was not reached. Ancillary benefit of TCS over fluoroscopy including less radiation exposure and lower resource requirements may nonetheless justify the use of TCS. The study is registered with Clinical.Trials.gov (Identifier: NCT02929368).

PIÑATA: Pinpoint insertion of intravenous needles via augmented reality training assistance

Conventional needle insertion training relies on medical dummies that simulate surface anatomy and internal structures such as veins or arteries. These dummies offer an interesting space to augment with useful information to assist training practices, namely, internal anatomical structures (subclavian artery and vein, internal jugular vein and carotid artery) along with target point, desired inclination, position and orientation of the needle. However, limited research has been conducted on Optical See-Through Augmented Reality (OST-AR) interfaces for training needle insertion, especially for central venous catheterization (CVC). In this work we introduce PIÑATA, an interactive tool to explore the benefits of OST-AR in CVC training using a dummy of the upper torso and neck; andexplore if PIÑATA complements conventional training practices.. Our design contribution also describes the observation and co-design sessions used to collect user requirements, usability aspects and user preferences. This was followed by a comparative study with 18 participants - attending specialists and medical residents - that performed needle insertion tasks for CVC with PIÑATAand the conventional training system. The performance was objectively measured by task completion time and number of needle insertion errors. A correlation was found between the task completion time in the two training methods, suggesting the concurrent validity of our OST-AR tool. An inherent difference in the task completion time (p =0.040) and in the number of errors (p = 0.036) between novices and experts proved the construct validity of the new tool. The qualitative answers of the participants also suggest its face and content validity, a high acceptability rate and a medium perceived workload. Finally, the result of semi-structured interviews with these 18 participants revealed that 14 of them considered that PIÑATA can complement the conventional training system, especially due to the visibility of the vessels inside the simulator. 13 agreed that OST-AR adoption in these scenarios is likely, particularly during early stages of training. Integration with ultrasound information was highlighted as necessary future work. In sum, the overall results show that the OST-AR tool proposed can complement the conventional training of CVC.

Lateral oblique approach for internal jugular vein catheterization: Randomized comparison of oblique and short-axis view of ultrasound-guided technique

OBJECTIVE:

The lateral oblique approach is a novel needle-in-plane technique for ultrasound-guided catheterization of the internal jugular vein. In this study, we aimed to compare the oblique approach with the classical short-axis technique for facilitating the procedure and reduction of mechanical complications.

METHODS:

This research was planned as a prospective study. Eighty-four open-heart surgery patients requiring a central venous catheter were randomly allocated into two groups: Oblique approach group (n=42) and short-axis group (n=42). Time to cannulate, the number of necessary puncture attempts, and frequency of carotid artery puncture, hematoma, puncture site bleeding, pneumothorax, and hemothorax in each group were recorded. Visualization of the vein and the needle using ultrasound were also evaluated by a subjective scale.

RESULTS:

The patient’s characteristics were comparable between the two groups. The mean time of catheterization was 52.00±70.18 seconds in the oblique approach group and 40.76±49.30 seconds in short-axis group. The mean number of needle puncture attempts was 1.21±0.61 in oblique approach and 1.12±0.50 in short-axis group. The results did not differ significantly. There was an improved visualization of the needle in the oblique approach group, but this was not proved as statistically significant.

CONCLUSION:

The results of our study suggest that the lateral oblique approach is a safe and effective technique, which can be a strong alternative to the classical short-axis technique for ultrasound-guided catheterization of the internal jugular vein.

Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020

Background and Purpose

Short-term central venous catheterization (CVC) is one of the commonly used invasive interventions in ICU and other patient-care areas. Practice and management of CVC is not standardized, varies widely, and need appropriate guidance. Purpose of this document is to provide a comprehensive, evidence-based and up-to-date, one document source for practice and management of central venous catheterization. These recommendations are intended to be used by critical care physicians and allied professionals involved in care of patients with central venous lines.

Methods

This position statement for central venous catheterization is framed by expert committee members under the aegis of Indian Society of Critical Care Medicine (ISCCM). Experts group exchanged and reviewed the relevant literature. During the final meeting of the experts held at the ISCCM Head Office, a consensus on all the topics was made and the recommendations for final document draft were prepared. The final document was reviewed and accepted by all expert committee members and after a process of peer-review this document is finally accepted as an official ISCCM position paper.

Modified grade system was utilized to classify the quality of evidence and the strength of recommendations. The draft document thus formulated was reviewed by all committee members; further comments and suggestions were incorporated after discussion, and a final document was prepared.

Results

This document makes recommendations about various aspects of resource preparation, infection control, prevention of mechanical complication and surveillance related to short-term central venous catheterization. This document also provides four appendices for ready reference and use at institutional level.

Conclusion

In this document, committee is able to make 54 different recommendations for various aspects of care, out of which 40 are strong and 14 weak recommendations. Among all of them, 42 recommendations are backed by any level of evidence, however due to paucity of data on 12 clinical questions, a consensus was reached by working committee and practice recommendations given on these topics are based on vast clinical experience of the members of this committee, which makes a useful practice point. Committee recognizes the fact that in event of new emerging evidences this document will require update, and that shall be provided in due time.

Abbreviations list

ABHR: Alcohol-based hand rub; AICD: Automated implantable cardioverter defibrillator; BSI: Blood stream infection; C/SS: CHG/silver sulfadiazine; Cath Lab: Catheterization laboratory (Cardiac Cath Lab); CDC: Centers for Disease Control and Prevention; CFU: Colony forming unit; CHG: Chlorhexidine gluconate; CL: Central line; COMBUX: Comparison of Bedside Ultrasound with Chest X-ray (COMBUX study); CQI: Continuous quality improvement; CRBSI: Catheter-related blood stream infection; CUS: Chest ultrasonography; CVC: Central Venous Catheter; CXR: Chest X-ray; DTTP: Differential time to positivity; DVT: Deep venous thrombosis; ECG: Electrocardiography; ELVIS: Ethanol lock and risk of hemodialysis catheter infection in critically ill patients; ER: Emergency room; FDA: Food and Drug Administration; FV: Femoral vein; GWE: Guidewire exchange; HD catheter: Hemodialysis catheter; HTS: Hypertonic saline; ICP: Intracranial pressure; ICU: Intensive Care Unit; IDSA: Infectious Disease Society of America; IJV: Internal jugular vein; IPC: Indian penal code; IRR: Incidence rate ratio; ISCCM: Indian Society of Critical Care Medicine; IV: Intravenous; LCBI: Laboratory confirmed blood stream infection; M/R: Minocycline/rifampicin; MBI-LCBI: Mucosal barrier injury laboratory-confirmed bloodstream infection; MRSA: Methicillin-resistant Staphylococcus aureus; NHS: National Health Service (UK); NHSN: National Healthcare Safety Network (USA); OT: Operation Theater; PICC: Peripherally-inserted central catheter; PIV: Peripheral intravenous line; PL: Peripheral line; PVI: Povidone-iodine; RA: Right atrium; RCT: Randomized controlled trial; RR: Relative risk; SCV/SV: Subclavian vein; ScVO₂: Central venous oxygen saturation; Sn: Sensitivity; SOP: Standard operating procedure; SVC: Superior vena cava; TEE: Transesophageal echocardiography; UPP: Useful Practice Points; USG: Ultrasonography; WHO: World Health Organization

How to cite this article

Javeri Y, Jagathkar G, Dixit S, Chaudhary D, Zirpe KG, Mehta Y, et al. Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020. Indian J Crit Care Med 2020;24(Suppl 1):S6–S30.

From the simulation center to the bedside: Validating the efficacy of a dynamic haptic robotic trainer in internal jugular central venous catheter placement

BACKGROUND

The objective of this study was to validate the transfer of ultrasound-guided Internal Jugular Central Venous Catheterization (US-IJCVC) placement skills from training on a Dynamic Haptic Robotic Trainer (DHRT), to placing US-IJCVCs in clinical environments. DHRT training greatly reduces preceptor time by providing automated feedback, standardizes learning experiences, and quantifies skill improvements.

METHODS

Expert observers evaluated DHRT-trained (N = 21) and manikin-trained (N = 36) surgical residents on US-IJCVC placement in the operating suite using a US-IJCVC evaluation form. Performance and errors by DHRT-trained residents were compared to traditional manikin-trained residents.

RESULTS

There were no significant training group differences between unsuccessful insertions (p = 0.404), assistance on procedure (p = 0.102), arterial puncture (p = 0.998), and average number of insertion attempts (p = 0.878). Regardless of training group, previous central line experience significantly predicted whether residents needed assistance on the procedure (p = 0.033).

CONCLUSION

The results failed to show a statistical difference between DHRT- and manikin-trained residents. This study validates the transfer of skills from training on the DHRT system to performing US-IJCVC in clinical environments.

Guidewire Mishap: An Avoidable Iatrogenic Complication

Central vein catheterization is a commonly used technique in indoor patients. It is mainly used for venous access, allowing administration of drugs, fluids, chemotherapy, blood components. Central vein catheterisation may lead to many complication which includes bleeding, perforation of veins and hematoma formation, thrombosis, infections, bleeding, needle stick injury, air embolism, kinking or looping of the wire tip, breakage of a guidewire, etc. We, hereby, report a case where the guidewire was lost during femoral venous catherisation. A whole guidewire embolization is completely preventable complication. It may not necessarily produce any symptoms and may remain unnoticed for long time.

How to cite this article

Rani A, Malik PK. Guidewire Mishap: An Avoidable Iatrogenic Complication. Indian J Crit Care Med 2019;23(8):382-383.

Does pre-procedure ultrasound increase the success and safety of right internal jugular venous catheterization? An intervention study

Background

Real-time ultrasound (US) in central venous catheterization is superior to pre-procedure US. However, ensuring real-time US into routine practice is impeded by its perceived expense and difficulty. This expertise requires hand-eye coordination and learning curve. Moreover, availability of multiple US machines and probes for multiple operation theatres may not be possible even at the tertiary level care set-up. Currently, pre-procedure US and landmark methods are most widely used. We investigated both the techniques with application of skin markings in the pre-procedure group to ascertain efficacy and safety with a view to incorporate pre-procedure US in our practice.

Methods

In this randomized study, we investigated 66 patients. Thirty-three patients in the pre-procedure ultrasound group and 33 patients in the landmark group were included for right internal jugular vein (RIJV) cannulation. We recorded the first needle pass success rate, cannulation time and complications.

Results

Pre-procedure US was associated with more successful attempts, shorter cannulation times and less complications. Under pre-procedure US, 75.76% of first attempts were successful with a cannulation time of 50 (25-180) seconds. Under landmark technique, 27.27% of first attempts were successful with a cannulation time of 85 (20-200) seconds. First puncture success rates were higher in pre-procedure US than landmark technique, 66.67% vs 27.27%, respectively.

Conclusion

Pre-procedure US for RIJV catheterization is safer, quicker and superior to landmark technique.

A Comparison of Internal Jugular Vein Cannulation by Ultrasound-Guided and Anatomical Landmark Technique in Resource-Limited Emergency Department Setting

Background and Objectives:

Central venous catheter placement is a frequently performed procedure in emergency medicine as well as critical care unit. We aimed to compare real-time ultrasonography (USG)-guided and the traditional anatomical landmark (AL) technique for the insertion of internal jugular vein (IJV) catheters in an emergency department (ED) setting.

Materials and Methods:

Patients requiring IJV catheterization were prospectively recruited over a period of 1 year at a single center. Cannulation was done either by the AL or USG technique, according to ED physician's discretion. A preset pro forma was completed for each central line placed. Variables were compared using the independent t-test, Fisher's exact test, and the nonparametric Mann–Whitney U-test.

Results and Discussion:

Seventy patients were enrolled, of which 35 patients underwent IJV cannulation by USG-guided technique (USG group) and 35 patients by the AL technique (AL group). There were a 100% success rate (35/35) for cannulation in the USG group and a 91.4% success rate (32/35) in the AL group. The catheter was placed on the first attempt in 17 (48.6%) patients in the AL group and 32 (91.4%) patients in the USG group. In th AL group, there were three failed cannulation attempts in comparison to the USG group. The mean start to flash time for the AL technique was 16.59 s (±10.67) and 4.86 s (±2.18) in the USG group. The mean cannulation time was 305.88 s (±66.84) in the AL group and 293.03 s (±71.15) in the USG group. A total of seven acute complications were noted, of which 2 (5.7%) in the USG group and 5 (14.3%) in the AL group.

Conclusion:

The real-time USG guided technique significantly reduces the number of attempts to cannulate, has a higher first-pass success rate, a quicker flash time, and fewer complications when compared to the AL technique. In EDs equipped with USG, insertion of IJV catheters under real-time USG guidance should become the standard of care.

Cost-effectiveness-analysis of ultrasound guidance for central venous catheterization compared with landmark method: a decision-analytic model

BACKGROUND

Ultrasound guidance for central venous catheterization is a commonly used alternative to the conventional landmark method. Because from the German perspective, the cost-effectiveness of ultrasound guidance is unclear, this study examined the cost-effectiveness of ultrasound guidance versus the landmark method for adults undergoing a central venous catheterization.

METHODS

A decision-tree based model was built to estimate the costs of averted catheter-related complications. Clinical data (e.g. arterial puncture, failed attempts) were obtained from a Cochrane review and a randomized controlled trial, whilst information about cost parameters were taken from a German hospital of maximum care. The analysis was conducted from the perspective of the German Statutory Health Insurance. Results were presented as incremental cost-effectiveness ratios. To assess the parameter uncertainty, several sensitivity analyses were performed (deterministic, probabilistic and with regard to the model structure).

RESULTS

Our analysis revealed that ultrasound guidance resulted in fewer complications per person (0.04 versus 0.17 for the landmark method) and was less expensive (€51 versus €230 for the landmark method). Results were robust to changes in the model parameters and in the model structure. Whilst our model population reflected approximately 49% of adults undergoing a central venous catheterization cannulation per year, structural sensitivity analyses (e.g. extending the study cohort to patients at higher baseline risk of complications, pediatric patients, or using real-time/indirect catheterization) indicated the cost-effectiveness of ultrasound guidance for a broader spectrum of patients. The results should be interpreted by considering the assumptions (e.g. target population) and approximations (e.g. cost parameters) underpinning the model.

CONCLUSIONS

Ultrasound guidance for central venous catheterization averts more catheter-related complications and may save the resources of the German Statutory Health Insurance compared with landmark method.

Point-of-care ultrasound evaluation and puncture simulation of the internal jugular vein by medical students

Objectives

To show that medical students can evaluate the internal jugular vein (IJV) and its anatomical variations after rapid and focused training. We also aimed to evaluate the success rate of IJV puncture in simulation following traditional techniques (TTs) and monitored via ultrasound (US).

Materials and methods

Six medical students without experience with US were given 4 h of theoretical–practical training in US, and then evaluated the IJV and common carotid artery (CCA) of 105 patients. They also simulated a puncture of the IJV at a demarcated point, where a TT was theoretically performed.

Results

Adequate images were obtained from 95% of the patients; the IJV, on the right side, was more commonly found in the anterolateral position in relation to the CCA (38%). On the left side, the most commonly position observed was the anterior (36%). The caliber of the IJV relative to the CCA greatly varied. The success rate in the IJV puncture simulation, observed with US, by the TTs was 55%.

Conclusion

The training of medical students to recognize large neck vessels is a simple, quick, and feasible task and that can be integrated into the undergraduate medical curriculum.

Folded large-bore central catheter in the right internal jugular vein as shown by ultrasound: a case report

Central venous catheters are used for various purposes in the operating room. Generally, the use of ultrasound to insert a central venous catheter is rapid and minimally complicated. An advanced venous access (AVA) catheter is used to gain access to the pulmonary artery and facilitate fluid resuscitation through the internal jugular vein. The present report describes a case in which ultrasound was used in a 43-year-old man to avoid complications during insertion of an AVA catheter with a relatively large diameter. The sheath of the catheter was so thin that a dilator was essential to prevent it from folding upon insertion. Despite the use of ultrasound guidance, the AVA catheter sheath became folded within the patient’s internal jugular vein. Mechanical complications of central venous catheter insertion are well known, but folding of a large-bore catheter in the internal jugular vein has rarely been reported.

Looks can be deceiving: Gaze pattern differences between novices and experts during placement of central lines

BACKGROUND

The objective of this study was to determine whether gaze patterns could differentiate expertise during simulated ultrasound-guided Internal Jugular Central Venous Catheterization (US-IJCVC) and if expert gazes were different between simulators of varying functional and structural fidelity.

METHODS

A 2017 study compared eye gaze patterns of expert surgeons (n = 11), senior residents (n = 4), and novices (n = 7) during CVC needle insertions using the dynamic haptic robotic trainer (DHRT), a system which simulates US-IJCVC. Expert gaze patterns were also compared between a manikin and the DHRT.

RESULTS

Expert gaze patterns were consistent between the manikin and DHRT environments (p = 0.401). On the DHRT system, CVC experience significantly impacted the percent of time participants spent gazing at the ultrasound screen (p < 0.0005) and the needle and ultrasound probe (p < 0.0005).

CONCLUSION

Gaze patterns differentiate expertise during ultrasound-guided IJCVC placement and the fidelity of the simulator does not impact gaze patterns.

Evaluating Surgical Resident Needle Insertion Skill Gains in Central Venous Catheterization Training

BACKGROUND

Training for ultrasound-guided central venous catheterization (CVC) is typically conducted on static manikin simulators with real-time feedback from a skilled observer. Dynamic haptic robotic trainers (DHRTs) are an alternative method that simulates various patient anatomies and provides consistent feedback for each insertion. This study evaluates CVC needle insertion efficiency and skill gains of both methods.

MATERIALS AND METHODS

Fifty-two first-year surgical residents were trained by placing internal jugular (IJ) CVC needles in manikins (n = 26) or robots (n = 26). Manikin-trained participants received verbal feedback from an experienced observer, whereas robotically trained participants received quantitative feedback from the personalized DHRT learning interface. All participants were pretested on a Blue Phantom manikin; participants completed posttesting on a Blue Phantom manikin (n = 26) or a novel manikin (n = 26) with different vessel depth and position. During pretests and posttests residents were timed, motion-tracked, and scored on an IJ CVC checklist.

RESULTS

(1) All skills on the IJ CVC checklist showed significant (P < 0.014) improvements from pretests to posttest; (2) Average angle of insertion, path length, and jerk improved significantly (P < 0.005); (3) Average procedural completion time, with standard error (SE) reported, decreased significantly from pretest (M = 3.516 min, SE = 0.277) to posttest (M = 1.997, SE = 0.409).

CONCLUSIONS

No significant group differences were observed in overall skill gains, but residents' average procedural completion time decreased significantly from pretests to posttest. Overall results support DHRT as an effective method for training IJ CVC skills.

The effects of ipsilateral tilt position on right subclavian venous catheterization: study protocol for a prospective randomized trial

Background

The cross-sectional area of the subclavian vein (csSCV) is an important factor determining the success rate of SCV catheterization. The head-down position increases the csSCV. However, the effects of lateral tilting on subclavian venous cross-sectional area have not yet been explored. In this trial, we test our hypothesis that ipsilateral tilt during right SCV catheterization may significantly increase the csSCV by impeding blood flow to the heart, thereby increasing the primary venipuncture success rate and reducing the complication rate and procedure time.

Methods/design

This is a two-staged, prospective, randomized, controlled trial conducted on 237 neurosurgical patients requiring SCV catheterization. Seventeen patients in stage I will be placed in supine, 20° ipsilateral tilt, and 20° contralateral tilt positions in random order. The right csSCV will be measured using ultrasonography at each position. In stage II, 220 patients will be randomly assigned to the ipsilateral tilt group (n = 110) and supine group (n = 110) according to the position for right SCV catheterization. Data on catheterization-related characteristics and complications will be collected during and after catheterization. The primary outcome measures are the right csSCV for stage I and primary venipuncture success rate for stage II. The secondary outcome measures for stage II are time to venipuncture, total catheterization time, first-pass success rate, and complications, such as arterial puncture, hematoma, pneumothorax, air embolism, and catheter misplacement.

Discussion

This is the first trial to investigate the effects of the ipsilateral tilt position on right SCV catheterization. We will attest the beneficial effects of the ipsilateral tilt position on the csSCV and the primary venipuncture success rate during right SCV catheterization. Furthermore, comparisons of the first-pass success rate, complications, and total catheterization time during SCV catheterization in the ipsilateral tilt position vs. the supine position will help us determine which position is better for safe and easy SCV catheterization.

Trial registration

ClinicalTrials.gov, ID: NCT03296735. Registered on 25 September 2017 for stage I; NCT03303274 Registered on 6 October 2017 for stage II.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2666-8) contains supplementary material, which is available to authorized users.

Risk factors for central venous catheter-related infections in a neonatal population - systematic review

OBJECTIVE

This was a systematic review of the incidence density and risk factors for central venous catheter-related infections in a neonatal population.

DATA SOURCE

The MEDLINE, Embase, Cochrane, BDENF, SciELO, and LILACS databases were used without date or language restriction. Studies that analyzed risk factors for bloodstream infections in newborns were identified.

DATA SYNTHESIS

A total of 134 articles were found that met the eligibility criteria. Of these articles, 14 were selected that addressed risk factors for central venous catheter-related infection in neonates. Catheter-related bloodstream infections remain an important complication, as shown by the incidence rates reported in the studies included in this review. The observed risk factors indicate that low birth weight, prematurity, and longer catheter permanence are related to a higher incidence of bloodstream infections. It has been observed that low rates of catheter-related infections, i.e., close to zero, are already a reality in health institutions in developed countries, since they use infection surveillance and control programs.

CONCLUSION

Catheter-related bloodstream infections still show high incidence density rates in developing countries. The authors emphasize the need for further longitudinal studies and the need for better strategies to prevent risk factors, aiming at the reduction of catheter-related infections.

Anatomical variations of the left anonymous trunk are associated with central venous catheter dysfunction

BACKGROUND

Internal jugular vein cannulation has become increasingly widespread. Compared to the left internal jugular vein (LIJV), the right internal jugular vein (RIJV) is the preferred choice for the placement of central venous catheter (CVC) for hemodialysis, mostly due to the major technical difficulties and higher rate of complications of the LIJV approach. We aimed to investigate whether variability in the direction of the LIJV/brachiocephalic vein (BV) axis on the frontal plane could be a decisive factor in determining CVC dysfunctions.

METHODS

Retrospective cohort study. From our Register, a total of 1489 consecutive patients (age 69 ± 9 years, males 60%) in whom a CVC for hemodialysis was placed from January 2012 to June 2014 were selected.

RESULTS

LIJV cannulation, compared with RIJV, was associated with a higher rate of catheter dysfunction during an observational period of 2 weeks after catheter placement (16 vs.12%; p = 0.005). This complication was strongly correlated with the amplitude of the angle between the LIJV and the ipsilateral BV axis on the frontal plane; an angle ≤ 110° was associated with a higher rate of catheter dysfunction (78 vs.16%; p < 0.001).

CONCLUSIONS

The anatomical clarification presented in our study provides useful data that could explain the dysfunction rate of CVC inserted in the LIJV. Clinicians who insert high-flow catheters (such as hemodialysis catheters) should be aware of LIJV/BV axis variability and of the possible risks of CVC dysfunction when the angle between the LIJV and ipsilateral BV is ≤ 110°.

Ultrasound-guided or landmark techniques for central venous catheter placement in critically ill children

PURPOSE

To assess whether ultrasound guidance improves central venous catheter placement outcomes compared to the landmark technique in critically ill children.

METHODS

A prospective multicentre observational study was carried out in 26 paediatric intensive care units over 6 months. Children 0-18 years old who received a temporary central venous catheter, inserted using either ultrasound or landmark techniques, were eligible. The primary outcome was the first-attempt success rate. Secondary outcomes included overall placement success, number of puncture attempts, number of procedures requiring multiple punctures (> 3 punctures), number of procedures requiring punctures at more than one vein site and immediate mechanical complications. To account for potential confounding factors, we used propensity scores. Our primary analysis was based on 1:1 propensity score matching. The association between cannulation technique and outcomes in the matched cohort was estimated using generalized estimating equations and mixed-effects models to account for patient-level and hospital-level confounders.

RESULTS

Five hundred central venous catheter-placement procedures involving 354 patients were included. Ultrasound was used for 323 procedures, and the landmark technique was used for 177. Two hundred and sixty-six procedures were matched (133 in the ultrasound group and 133 in the landmark group). Ultrasound was associated with an increase in the first-attempt success rate [46.6 vs. 30%, odds ratio 2.09 (1.26-3.46); p < 0.001], a reduced number of puncture attempts [2 (1-3) vs. 2 (1-4), B coefficient - 0.51 (95% confidence interval - 1.01 to - 0.03), p = 0.035], and fewer overall mechanical complications [12 vs. 22.5%, odds ratio 0.47 (95% confidence interval 0.24-0.91), p = 0.025] in the matched cohort. The number of puncture attempts was the main factor associated with overall complications.

CONCLUSIONS

Compared with the landmark technique, ultrasound guidance was associated with an increased first-attempt success rate, a reduced number of puncture attempts, and fewer complications during central venous catheter placement in critically ill children.