Precordial Doppler to assess vascular access in children: A preliminary report

Abstract

Background Delayed identification and dysfunction of peripheral intravenous (PIV) infiltration can lead to serious injury in children. This preliminary study aimed to describe the application of precordial Doppler ultrasound to detect and confirm the correct PIV access in children with congenital heart disease (CHD). Methods This study was conducted on children (<18 years) diagnosed with CHD and admitted to the pediatric intensive care unit (PICU) of a single center after cardiac surgery or cardiac catheterization between February 2020 and May 2021. Three raters judged the precordial Doppler sound change (S test) after injection of 0.5 mL/kg of normal saline (NS) through the PIV access. Blood‐flow velocities before and after the NS injection were recorded and the accuracy of detecting PIV catheter infiltration and dysfunction was analyzed (V test). Results The overall incidence of PIV infiltration and dysfunction was in 3 out of 103 patients (2.9%). The sensitivity, specificity, positive and negative likelihood ratios, and area under the receiver operating characteristic curve were 3 out of 3 [100%, 95% confidence interval (CI): 29.2–100], 86 out of 100 (86%, 95% CI: 77.6%–92.1), 7.1, 0.0, and 0.93, respectively, in the S test and they were 2 out of 3 (66.7%, 95% CI: 9.4%–99.2), 94 out of 100 (94.0%, 95% CI: 87.4%–7.8%), 11.1, 0.36, and 0.80, respectively in the V test. Conclusions Precordial Doppler ultrasound was a feasible and accurate technique for confirming correct PIV access in children with CHD; however, a larger, prospective investigation is necessary to examine its diagnostic accuracy.

Optimal probe position for precordial Doppler ultrasound in children

“…Second, the Doppler sound may be attributed to the turbulence ejected from the left ventricle into the aorta rather than that from the right ventricle into the pulmonary artery. Our previous study demonstrated that the Doppler sound was audible even in patients with bidirectional Glenn or Fontan shunts who had a direct connection between the superior vena cava and pulmonary artery 5,10 . In these cases, the administered NS did not enter the right cardiac chamber; however, microbubbles would enter from the pulmonary arteries into the left cardiac chambers because of the presence of right to left intracardiac or intrapulmonary shunts.…”

“…Our previous study demonstrated that the Doppler sound was audible even in patients with bidirectional Glenn or Fontan shunts who had a direct connection between the superior vena cava and pulmonary artery. 5,10 In these cases, the administered NS did not enter the right cardiac chamber; however, microbubbles would enter from the pulmonary arteries into the left cardiac chambers because of the presence of right to left intracardiac or intrapulmonary shunts. In these patients, the insonating Doppler beam could be changed by the turbulence in the left ventricle due to the injected NS, resulting in changes in the pitch of the heartbeat.…”

Optimal dose of normal saline for confirming correct peripheral venous access with precordial Doppler ultrasonography in children

“…The monitor detects the Doppler signals derived from the patient’s intracardiac blood flow. A small amount of normal saline (NS) is then administered via a PIV line to induce changes in the Doppler signals 5 , 6 . The precordial Doppler can be attached during the induction of anesthesia and potentially be used throughout the surgery.…”

“…We previously used an NS injection dose of 0.5 mL/kg, based on findings obtained from a small, exploratory data set 5 , 6 . Therefore, the minimally required dose of NS for confirming correct PIV placement remains unknown.…”