Use of Contrast‐Enhanced Ultrasound for Confirmation of Central Venous Catheter Placement: Systematic Review and Meta‐analysis

Chebl, Ralph Bou; Kiblawi, Shafeek; Khuri, Christopher El; Hajj, Nadine El; Bachir, Rana; Aoun, Roni; Dagher, Gilbert Abou

doi:10.1002/jum.14296

Cited by 22 publications

(28 citation statements)

References 25 publications

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“…The bedside ultrasonography and saline flush technique have both been identified as methods to reduce PICC malpositions in settings where fluoroscopy is not available, such as in the ICU (13,14). Despite its proven usefulness, the saline flush technique requires additional heart ultrasound probes and a professional assistant to identify saline bubbles in the right atrium using ultrasonography.…”

Section: Discussionmentioning

confidence: 99%

Ipsilateral ultrasound-monitoring technique for reducing malpositions of peripherally inserted central catheters in the intensive care unit

Song¹,

Lee²,

Lee³

et al. 2021

Ann Palliat Med

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Background: We performed ultrasonographic examinations of the ipsilateral internal jugular vein after placement of peripherally inserted central catheters (PICCs) and found that more than half of malpositions of PICC went to the head through the ipsilateral internal jugular vein. We aimed to reduce malpositions of PICCs in settings where fluoroscopy is not available.Methods: This retrospective study had a case-control, single-center study design. From January to June 2018, PICCs were inserted with the patient's arm abducted without the use of ultrasonography to identify the presence of the PICC in the ipsilateral internal jugular vein (procedure A). From July to December 2018, PICCs were inserted in a similar fashion; however, ultrasonography was employed to detect the catheter tip in the ipsilateral internal jugular vein (procedure B).Results: There were 794 placements of PICCs in 650 patients. Procedures A and B were performed in 418 and 376 patients, respectively. Malpositioning of PICC tips occurred significantly less often in procedure B than in procedure A (2.4% vs. 5.7%, P=0.02). Conclusions:In a setting without fluoroscopy, insertions of PICCs can be performed with the arm abducted at 90°. Ultrasound monitoring for the presence of the catheter in the ipsilateral internal jugular vein can help with correct positioning, thereby reducing the occurrence of catheter tip malpositions.

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Section: Discussionmentioning

confidence: 99%

Ipsilateral ultrasound-monitoring technique for reducing malpositions of peripherally inserted central catheters in the intensive care unit

Song¹,

Lee²,

Lee³

et al. 2021

Ann Palliat Med

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“…Three recent meta-analyses found that POCUS for CVC position con rmation was feasible (98% adequate visualization), fast (reducing mean CVC con rmation time compared to CXR), and accurate. [7,9,11] In the RCT, POCUS-only CVC PCEP reduced the time from insertion to rst use of CVC and reduced overall CXR utilization by 56.7% (P < .0001). [9] Additionally, the annual cost to the United States healthcare system for CXRs after CVC placement exceeds $500 million.…”

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confidence: 96%

“…[7,9,11] In the RCT, POCUS-only CVC PCEP reduced the time from insertion to rst use of CVC and reduced overall CXR utilization by 56.7% (P < .0001). [9] Additionally, the annual cost to the United States healthcare system for CXRs after CVC placement exceeds $500 million. [12] Thus, CXRs represents avoidable costs and resource utilization to the health care system, results in ionizing radiation exposure, and delays in patient care.…”

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confidence: 96%

“…Observational data and a randomized controlled trial (RCT) have shown that POCUS can also provide similar yet faster diagnostic information to CXR after CVC insertion, thus demonstrating superior e ciency. [7][8][9][10] A POCUS-guided CVC PCEP protocol consists of three ultrasound imaging steps (Fig. 1).…”

mentioning

confidence: 99%

“…[12] Thus, CXRs represents avoidable costs and resource utilization to the health care system, results in ionizing radiation exposure, and delays in patient care. [9,10,[13][14][15] Despite advantages of POCUS over CXR, including that POCUS is easy to perform, faster, and is non-inferior to CXR, POCUSguided CVC PCEP has had slow rate of clinical adoption. [9,10,[13][14][15][16] Even among providers with ultrasound experience, self-reported use of POCUS for CVC PCEP and de-adoption of CXR is low (1.5%), citing various barriers to this practice.…”

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confidence: 99%

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Study Protocol for Draup: De-implementation Ofroutine Chest Radiographs After Adoption of Ultrasound Guided Insertion and Confirmation of Central Venous Catheter Protocol, A Hybrid Implementation/effectiveness Study

Ablordeppey¹,

Powell²,

McKay³

et al. 2020

Preprint

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BACKGROUNDAvoiding low value medical practices is an important focus in current healthcare utilization. Despite advantages of point of care ultrasound (POCUS) over chest x-ray (CXR), including improved workflow and timeliness of results, POCUS-guided central venous catheter (CVC) position confirmation and exclusion of pneumothorax (PCEP) has had slow rate of adoption. This demonstrates a gap that is ripe for the development and application of de-implementation strategies that support substitution of POCUS for CXR after CVC insertion.METHODSDe-implementation of routine chest radiographs after adoption of ultrasound guided insertion and confirmation of central venous catheter protocol (DRAUP) will be created to de-implement an unnecessary imaging modality in the critical care environment. Guided by the Consolidated Framework for Implementation Research constructs, we will explore barriers and facilitators of POCUS for CVC PCEP in a single center, large tertiary, academic hospital via focus groups. The focus groups will inform the development and testing of strategies that address identified determinants of implementation and de-implementation.Operational use of the de-implementation strategies will be conceptualized using Morgan’s framework for understanding and reducing medical overuse. We will locally implement these strategies and assess them using Proctor’s outcomes (adoption, de-adoption, fidelity and penetration) in an observational study to demonstrate proof of concept, gaining valuable insights on our selected implementation and de-implementation strategies. Secondary outcomes will include POCUS-guided CVC PCEP efficacy measured by time and effectiveness measured by sensitivity and specificity of POCUS detection.DISCUSSIONWith limited data available to inform interventions that use concurrent implementation and de-implementation strategies to substitute CXR for POCUS using DRAUP, we propose that this primary implementation and secondary effectiveness pilot study will provide novel data that would expand the knowledge of replacing low value or unnecessary care in critically ill patients. Trial Registration: ClinicalTrials.gov Identifier, NCT04324762, Registered on 27 March 2020

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

Ablordeppey

Drewry

Anderson

et al. 2020

AEM Education and Training

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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

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Use of Contrast‐Enhanced Ultrasound for Confirmation of Central Venous Catheter Placement: Systematic Review and Meta‐analysis

Abstract: In the setting of central venous catheter placement, postprocedural contrast-enhanced US imaging is a safe, efficient, and highly specific confirmatory test for the catheter tip location compared with chest radiography.

Cited by 22 publications

References 25 publications

Ipsilateral ultrasound-monitoring technique for reducing malpositions of peripherally inserted central catheters in the intensive care unit

Ipsilateral ultrasound-monitoring technique for reducing malpositions of peripherally inserted central catheters in the intensive care unit

Study Protocol for Draup: De-implementation Ofroutine Chest Radiographs After Adoption of Ultrasound Guided Insertion and Confirmation of Central Venous Catheter Protocol, A Hybrid Implementation/effectiveness Study

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

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