Diagnostic Accuracy of Central Venous Catheter Confirmation by Bedside Ultrasound Versus Chest Radiography in Critically Ill Patients: A Systematic Review and Meta-Analysis. (Carroll)

Ablordeppey EA, Drewry AM, Beyer AB, et al. Diagnostic Accuracy of Central Venous Catheter Confirmation by Bedside Ultrasound Versus Chest Radiography in Critically Ill Patients: A Systematic Review and Meta-Analysis. Crit Care Med. 2017 Apr;45(4):715-724.

OBJECTIVE: We performed a systematic review and meta-analysis to examine the accuracy of bedside ultrasound for confirmation of central venous catheter position and exclusion of pneumothorax compared with chest radiography.

DATA SOURCES: PubMed, Embase, Cochrane Central Register of Controlled Trials, reference lists, conference proceedings and ClinicalTrials.gov.

STUDY SELECTION: Articles and abstracts describing the diagnostic accuracy of bedside ultrasound compared with chest radiography for confirmation of central venous catheters in sufficient detail to reconstruct 2 × 2 contingency tables were reviewed. Primary outcomes included the accuracy of confirming catheter positioning and detecting a pneumothorax. Secondary outcomes included feasibility, interrater reliability, and efficiency to complete bedside ultrasound confirmation of central venous catheter position.

DATA EXTRACTION: Investigators abstracted study details including research design and sonographic imaging technique to detect catheter malposition and procedure-related pneumothorax. Diagnostic accuracy measures included pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio.

DATA SYNTHESIS: Fifteen studies with 1,553 central venous catheter placements were identified with a pooled sensitivity and specificity of catheter malposition by ultrasound of 0.82 (0.77-0.86) and 0.98 (0.97-0.99), respectively. The pooled positive and negative likelihood ratios of catheter malposition by ultrasound were 31.12 (14.72-65.78) and 0.25 (0.13-0.47). The sensitivity and specificity of ultrasound for pneumothorax detection was nearly 100% in the participating studies. Bedside ultrasound reduced mean central venous catheter confirmation time by 58.3 minutes. Risk of bias and clinical heterogeneity in the studies were high.

CONCLUSIONS: Bedside ultrasound is faster than radiography at identifying pneumothorax after central venous catheter insertion. When a central venous catheter malposition exists, bedside ultrasound will identify four out of every five earlier than chest radiography.

Attending Physician Adherence to a 29-Component Central Venous Catheter Bundle Checklist During Simulated Procedures. (Chaudhary)

Barsuk JH, et al. Attending Physician Adherence to a 29-Component Central Venous Catheter Bundle Checklist During Simulated Procedures. Crit Care Med. 2016 Oct;44(10):1871-81.

OBJECTIVES: Central venous catheter insertions may lead to preventable adverse events. Attending physicians’ central venous catheter insertion skills are not assessed routinely. We aimed to compare attending physicians’ simulated central venous catheterinsertion performance to published competency standards.

DESIGN: Prospective cohort study of attending physicians’ simulated internal jugular and subclavian central venous catheter insertion skills versus a historical comparison group of residents who participated in simulation training.

SETTING: Fifty-eight Veterans Affairs Medical Centers from February 2014 to December 2014 during a 2-day simulation-based education curriculum and two academic medical centers in Chicago.

SUBJECTS: A total of 108 experienced attending physicians and 143 internal medicine and emergency medicine residents.

INTERVENTION: None.

MEASUREMENTS AND MAIN RESULTS: Using a previously published central venous catheter insertion skills checklist, we compared Veterans Affairs Medical Centers attending physicians’ simulated central venous catheter insertion performance to the same simulated performance by internal medicine and emergency medicine residents from two academic centers. Attending physician performance was compared to residents’ baseline and posttest (after simulation training) performance. Minimum passing scores were set previously by an expert panel. Attending physicians performed higher on the internal jugular (median, 75.86% items correct; interquartile range, 68.97-86.21) and subclavian (median, 83.00%; interquartile range, 59.00-86.21) assessments compared to residents’ internal jugular (median, 37.04% items correct; interquartile range, 22.22-68.97) and subclavian (median, 33.33%; interquartile range, 0.00-70.37; both p < 0.001) baseline assessments. Overall simulated performance was poor because only 12 of 67 attending physicians (17.9%) met or exceeded the minimum passing score for internal jugular central venous catheter insertion and only 11 of 47 (23.4%) met or exceeded the minimum passing score for subclavian central venous catheter insertion. Resident posttest performance after simulation training was significantly higher than attending physician performance (internal jugular: median, 96%; interquartile range, 93.10-100.00; subclavian: median, 100%; interquartile range, 96.00-100.00; both p < 0.001).

CONCLUSIONS: This study demonstrates highly variable simulated central venous catheter insertion performance among a national cohort of experienced attending physicians. Hospitals, healthcare systems, and governing bodies should recognize that even experienced physicians require periodic clinical skill assessment and retraining.

Early goal-directed therapy in pediatric septic shock: comparison of outcomes “with” and “without” intermittent superior venacaval oxygen saturation monitoring: a prospective cohort study. (Tarquinio)

Sankar J, Sankar MJ, Suresh CP, et al. Early goal-directed therapy in pediatric septic shock: comparison of outcomes “with” and “without” intermittent superior venacaval oxygen saturation monitoring: a prospective cohort study*. Pediatr Crit Care Med. 2014 May;15(4):e157-67.

Full-text for Children’s and Emory users.

OBJECTIVE: To evaluate the effect of intermittent central venous oxygen saturation monitoring (ScvO(2)) on critical outcomes in children with septic shock, as continuous monitoring may not be feasible in most resource-restricted settings.

Continue reading

Simulation training for pediatric residents on central venous catheter placement: a pilot study. (Fellow #1 with PCCM)

Thomas SM, Burch W, Kuehnle SE, Flood RG, Scalzo AJ, Gerard JM. Simulation training for pediatric residents on central venous catheter placement: a pilot study. Pediatr Crit Care Med. 2013 Nov;14(9):e416-23.

OBJECTIVE: To assess the effect of simulation training on pediatric residents’ acquisition and retention of central venous catheter insertion skills. A secondary objective was to assess the effect of simulation training on self-confidence to perform the procedure.

DESIGN: Prospective observational pilot study.

SETTING: Single university clinical simulation center.

SUBJECTS: Pediatric residents, postgraduate years 1-3.

INTERVENTIONS: Residents participated in a 60- to 90-minute ultrasound-guided central venous catheter simulation training session. Video recordings of residents performing simulated femoral central venous catheter insertions were made before (baseline), after, and at 3-month following training. Three blinded expert raters independently scored the performances using a 24-item checklist and 100-mm global rating scale. At each time point, residents rated their confidence to perform the procedure on a 100-mm scale.

MEASUREMENTS AND MAIN RESULTS: Twenty-six residents completed the study. Compared with baseline, immediately following training, median checklist score (54.2% [interquartile range, 40.8-68.8%] vs 83.3% [interquartile range, 70.0-91.7%]), global rating score (8.0 mm [interquartile range, 0.0-64.3 mm] vs 79.5 mm [interquartile range, 16.3-91.7 mm]), success rate (38.5% vs 80.8%), and self-confidence (8.0 mm [interquartile range, 3.8-19.0 mm] vs 52.0 mm [interquartile range, 43.5-66.5 mm]) all improved (p < 0.05 for all variables). Compared with baseline, median checklist score (54.2% [interquartile range, 40.8-68.8%] vs 54.2% [interquartile range, 45.8-80.4%], p = 0.47), global rating score (8.0 mm [interquartile range, 0.0-64.3 mm] vs 35.5 mm [interquartile range, 5.3-77.0], p = 0.62), and success rate (38.5% vs 65.4%, p = 0.35) were similar at 3-month follow-up. Self-confidence, however, remained above baseline at 3-month follow-up (8.0 mm [interquartile range, 3.8-19.0 mm] vs 61.0 mm [interquartile range, 31.5-71.8 mm], p < 0.01).

CONCLUSIONS: Simulation training improved pediatric residents’ central venous catheter insertion procedural skills. Decay in skills was found at 3-month follow-up. This suggests that simulation training for this procedure should occur in close temporal proximity to times when these skills would most likely be used clinically and that frequent refresher training might be beneficial to prevent skills decay.

Full-text for Children’s and Emory users.

The microbiological and clinical outcome of guide wire exchanged versus newly inserted antimicrobial surface treated central venous catheters. (Kamat)

Parbat N, Sherry N, Bellomo R, Schneider AG, Glassford NJ, Johnson PD, Bailey M. The microbiological and clinical outcome of guide wire exchanged versus newly inserted antimicrobial surface treated central venous catheters. Crit Care. 2013 Sep 3;17(5):R184.

INTRODUCTION: The management of suspected central venous catheter (CVC)-related sepsis by guide wire exchange (GWX) is not recommended. However, GWX for new antimicrobial surface treated (AST) triple lumen CVC’s has never been studied. We aimed to compare the microbiological outcome of triple lumen AST CVC’s inserted by GWX (GWX-CVC’s) with newly inserted triple lumen AST CVC’s (NI-CVC’s).

METHODS: We studied a cohort of 145 consecutive patients with GWX-CVC’s and contemporaneous site-matched control cohort of 163 patients with a NI-CVC’s in a tertiary intensive care unit (ICU).

RESULTS: GWX-CVC and NI-CVC patients were similar for mean age (58.7 vs. 62.2 years), gender (88 (60.7%) vs. 98 (60.5%) male) and illness severity on admission (mean APACHE III: 71.3 vs. 72.2). However, GWX patients had longer median ICU length of stay (12.2 vs. 4.4 days; P<0.001) and median hospital length of stay (30.7 vs. 18.0 days; P <0.001). There was no significant difference with regard to the number of CVC tips with bacterial or fungal pathogen colonization among GWX-CVC’s vs. NI-CVC’s [5 (2.5%) vs. 6 (7.4%); P = 0.90]. Catheter-associated blood stream infection (CA-BSI) occurred in 2 (1.4%) GWX patients compared with 3 (1.8%) NI-CVC patients (p=0.75). There was no significant difference in hospital mortality [35 (24.1%) vs. 48 (29.4%); P= 0.29].

CONCLUSIONS: GWX-CVC’s and NI-CVC’s had similar rates of tip colonization at removal, CA-BSI and mortality. If the CVC removed by GWX is colonized, a new CVC must then be inserted at another site. In selected ICU patients at higher central vein puncture risk receiving AST CVC’s GWX may be an acceptable initial approach to line insertion.

Children’s and Emory users, request article from Emily Lawson.

A review of 5434 percutaneous pediatric central venous catheters inserted by anesthesiologists. (Kamat)

Malbezin S, Gauss T, Smith I, Bruneau B, Mangalsuren N, Diallo T, Skhiri A, Nivoche Y, Dahmani S, Brasher C. A review of 5434 percutaneous pediatric central venous catheters inserted by anesthesiologists. Paediatr Anaesth. 2013 Nov;23(11):974-979.

OBJECTIVE: To review the results of an anesthesiologist led pediatric percutaneous central venous access service.

METHODS: Prospective data on percutaneous pediatric central venous catheter (CVC) insertions were collected over 22 years. Data included age, gender, weight, previous central CVCs, venous thromboses, investigations for great vein patency, type of CVC, external diameter, previous CVC insertions, intended use, operator identity, and the vein into which the CVC was inserted. The default technique was internal jugular vein cannulation using landmark technique (LT). Complication was defined as the following: failure to cannulate any vein, hemothorax, pneumothorax, right atrial perforation, extravenous wire positioning or CVC position and whether the patient was taken back to theater for CVC repositioning.

RESULTS: Five thousand four hundred and thirty-four percutaneous CVC insertion procedures were performed on 3954 patients. One-third involved children <1 year of age (n = 1823: 34%). Five thousand one hundred and twenty-five CVCs (95.3%) were inserted into internal jugular veins. The majority were tunneled CVCs (n = 5190: 96.2%). The perioperative complication rate was 1.3%. Successful cannulation occurred in 99.5% of patients. Failure was more likely in children ❤ kg, during large bore hemodialysis CVC insertions and during the first 4 years of the service – the latter suggesting a learning curve. Ninety-nine percent of CVCs were inserted using LTs.

CONCLUSION: This study demonstrates a high success rate and low complication rate during pediatric percutaneous internal jugular vein CVC insertions by trained anesthesiologists using LTs. Smaller children, hemodialysis CVCs, and the team’s learning curve were identified as risk factors for insertion failure.

Children’s and Emory users, please request article from Emily Lawson.