Point‐of‐care Ultrasound–guided Central Venous Catheter Confirmation in Ultrasound Nonexperts

Abstract

Objective: Emerging evidence suggests that chest radiography (CXR) following central venous catheter (CVC) placement is unnecessary when point-of-care ultrasound (POCUS) is used to confirm catheter position and exclude pneumothorax. However, few providers have adopted this practice, and it is unknown what contributing factors may play a role in this lack of adoption, such as ultrasound experience. The objective of this study was to evaluate the diagnostic accuracy of POCUS to confirm CVC position and exclude a pneumothorax after brief education and training of nonexperts. Methods:We performed a prospective cohort study in a single academic medical center to determine the diagnostic characteristics of a POCUS-guided CVC confirmation protocol after brief training performed by POCUS nonexperts. POCUS nonexperts (emergency medicine senior residents and critical care fellows) independently performed a POCUS-guided CVC confirmation protocol after a 30-minute didactic training. The primary outcome was the diagnostic accuracy of the POCUS-guided CVC confirmation protocol for malposition and pneumothorax detection. Secondary outcomes were efficiency and feasibility of adequate image acquisition, adjudicated by POCUS experts.Results: Twenty-six POCUS nonexperts collected data on 190 patients in the final analysis. There were five (2.5%) CVC malpositions and six (3%) pneumothoraxes on CXR. The positive likelihood ratios of POCUS for malposition detection and pneumothorax were 12.33 (95% confidence interval [CI] = 3.26 to 46.69) and 3.41 (95% CI = 0.51 to 22.76), respectively. The accuracy of POCUS for pneumothorax detection compared to CXR was 0.93 (95% CI = 0.88 to 0.96) and the sensitivity was 0.17 (95% CI = 0.00 to 0.64). The median (interquartile range) time for CVC confirmation was lower for POCUS (9 minutes [8.5-9.5 minutes]) compared to CXR

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

“…Table 2a demonstrates probability variables based on both internal and external data. 24 , 25 , 42 We conducted one-way and two-way sensitivity analyses based on input from the literature about process steps within the protocols ( Table 2b ). 24 Salary ranges are based on 25 th and 75 th percentiles from national sources while the times are based on reported standard deviation when available and estimated based on experience of practicing clinicians.…”

Point‐of‐care ultrasound use in emergencies: what every anaesthetist should know

“…Subclavian central venous catheter insertion is more commonly placed in trauma emergencies to avoid cervical spine movement. There is evidence for use of ultrasound to both confirm catheter position and rule out pneumothorax post‐insertion [71]. There is a published three‐step POCUS approach to evaluate central venous catheter placement and rule out complications [72].…”

“…Subclavian central venous catheter insertion is more commonly placed in trauma emergencies to avoid cervical spine movement. There is evidence for use of ultrasound to both confirm catheter position and rule out pneumothorax post-insertion [71].…”

Protocol for DRAUP: a deimplementation programme to decrease routine chest radiographs after central venous catheter insertion

“…This subject group will be chosen given previous data demonstrating adequate retention of ultrasound knowledge and skill for ultrasound guided CVC Open access confirmation. 22 Recruitment will be via email request for participation in protocol education and training. They will undergo a 60-min didactic training and will demonstrate adequate ultrasound image acquisition and interpretation.…”