Evaluation of the Sherlock 3CG Tip Confirmation System on peripherally inserted central catheter malposition rates

Peripherally inserted central catheters are often positioned blindly in the central circulation, and this may result in high malposition rates, especially in critically ill patients. Recently, a new technology has been introduced (Sherlock 3CG Tip Positioning System) that uses an electro‐magnetic system to guide positioning in the superior vena cava, and then intra‐cavity ECG to guide positioning at the cavo‐atrial junction. In this observational study, we investigated how the Sherlock 3CG Tip Positioning System would affect peripherally inserted central catheter malposition rates, defined using a post‐insertion chest radiograph, in critically ill patients. A total of 239 catheters positioned using the Sherlock 3CG Tip Positioning System were analysed. When an adequate position was defined as low superior vena cava or cavo‐atrial junction, 134 catheters (56.1%; 95% CI 50–62%) were malpositioned. When an adequate position was defined as mid/low superior vena cava, cavo‐atrial junction or high right atrium (≤ 2 cm from cavo‐atrial junction), 49 (20.5%; 95% CI 16–26%) catheters were malpositioned. These malposition rates are significantly lower than our own historical data, which used a ‘blind’ anthropometric technique to guide peripherally inserted central catheter insertion.     

Prevention of central venous catheter-related bloodstream infections: is it time to add simulation training to the prevention bundle?

Study ObjectiveTo study the impact of adding simulation-based education to the pre-intervention mandatory hospital efforts aimed at decreasing central venous catheter-related blood stream infections (CRBSI) in intensive care units (ICU).DesignPre- and post-intervention retrospective observational investigation.Setting24-bed ICU and a 562-bed university-affiliated, urban teaching hospital.PatientsICU patients July 2004-June 2008 were studied for the development of central venous catheter related blood stream infections (CRBSI).MeasurementsICU patients from July 2004-June 2008 were studied for the development of central venous catheter-related blood stream infections (CRBSI).Pre-Interventionmandatory staff and physician education began in 2004 to reduce CRBSI. The CRBSI-prevention program included online and didactic courses, and a pre- and post-test. Elements in the pre-intervention efforts included hand hygiene, full barrier precautions, use of Chlorhexidine skin preparation, and mask, gown, gloves, and hat protection for operators. A catheter-insertion cart containing all supplies and checklist were was a mandatory element of this program; a nurse was empowered to stop the procedure for non-performance of checklist items.InterventionAs of July 1, 2006, a mandatory simulation-based program for all intern, resident, and fellow physicians was added to teach central venous catheter (CVC) insertion.MeasurementsData collected pre- and post-intervention were CRBSI incidence, number of ICU catheter days, mortality, laboratory pathogen results, and costs.Main ResultsThe pre-intervention CRBSI incidence of 6.47/1,000 catheter days was reduced significantly to 2.44/1,000 catheter days post-intervention (58%; P < 0.05), resulting in a $539,902 savings (USD; 47%), and was attributed to shorter ICU and hospital lengths of stay.ConclusionsFollowing simulation-based CVC program implementation, CRBSI incidence and costs were significantly reduced for two years post-intervention.     

Predicting the optimal depth of left‐sided central venous catheters in children

The aim of this study was to predict the optimal depth for insertion of a left‐sided central venous catheter in children. Using 3D chest computed tomography angiography, we measured the distance from a point where the internal jugular vein is at the superior border of the clavicle, and from a point where the subclavian vein is inferior to the anterior border of the clavicle, to the junction of the superior vena cava and the right atrium in 257 children. Linear regression analysis revealed that the distances correlated with age, weight and height. Simple formulae for the depth of a central venous catheter via the left internal jugular vein (0.07 × height (cm)) and the left subclavian vein (0.08 × height (cm)) were developed to predict placement of the central venous catheter tip at the junction of the superior vena cava with the right atrium. Using these fomulae, the proportion of catheter tips predicted to be correctly located was 98.5% (95% CI 96.8–100%) and 94.0% (95% CI 90.8–97.3%), respectively.     

Delayed hydrothorax induced by a pericutaneous central venous catheter; report of a case

We report herein a case of 53-year-old woman who suffered a hydrothorax induced by a central venous catheter which had been placed to facilitate total parenteral nutrition. The central venous catheter was inserted into the superior vena cava through the right subclavian vein. Chest X-ray film after insertion revealed proper position of the tip. She suddenly developed dyspnea and tachycardia due to right-sided hydrothorax 21 days after the insertion of the catheter. Chest X-ray showed massive pleural effusion in the right thorax, and the catheter tip inadvertently turned upward. The continuous mechanical force of the catheter tip against the SVC wall was considered to be the cause of this life-threatening delayed hydrothorax.     

Late mediastinitis with bilateral hydrothorax after vessel perforation by a central venous catheter

A central venous catheter was inserted into the right internal jugular vein of a 67-year-old woman to provide parenteral nutrition on the 7th day after surgery. Five days later, mediastinitis with bilateral hydrothorax had developed and was causing respiratory failure and systemic inflammatory response syndrome secondary to documented vascular perforation by the catheter. Four factors have been associated with increased risk of perforation: catheter rigidity and diameter, the angle between the tip of the catheter and the vessel wall, and insertion from the left. Three catheter positions have been described as safe when radiologically confirmed: the superior vena cava, the point where the superior vena cava meets the atrium, and the midpoint of the innominate vein. However, it should not be forgotten that a radiograph is 2-dimensional and a single image of a catheter tip can correspond to a variety of locations (superior vena cava, vena innominata, extravascular location, and more). Even when there is clinical and radiologic evidence of catheter positioning, vascular perforation should be suspected in patients with a central venous catheter and bilateral pleural effusion who present respiratory insufficiency and hemodynamic instability.     

超声引导经锁骨下静脉置入植入式输液港的效果

目的 探讨应用超声引导定位在经锁骨下静脉人路置入植入式输液港的效果.方法 选择乳腺癌患者60例,年龄28～63岁,体重41～70 kg,身高150～168 cm,ASA Ⅰ或Ⅱ级,拟经锁骨下静脉穿刺置入植入式输液港行长期输液及化疗,输液港导管尖端位置应在上腔静脉和右心房交界处.随机分为2组(n=30):对照组(C组)经锁骨下静脉穿刺,采用脉冲注射冰盐水实验的方法引导定位植入式输液港导管尖端位置.超声组(U组)经锁骨下静脉穿刺,采用超声引导定位植入式输液港导管尖端位置.所有患者术后均经过X线摄片进行导管定位.计算两组患者首次置入成功率.结果 U组患者术后X线摄片显示输液港导管尖端均在上腔静脉和右心房交界处,未发生导管偏离进入颈内静脉的现象,首次置入成功率100%.C组术后X线摄片显示有6例患者的输液港导管发生了偏离,进入颈内静脉,需回手术室在超声引导定位下重新穿刺置管,首次置入成功率80%.U组首次置入成功率高于C组(P<0.05).结论 超声引导定位是经锁骨下静脉正确放置植入式输液港的有效手段.     

超声引导经锁骨下静脉置入植入式输液港的效果

目的 探讨应用超声引导定位在经锁骨下静脉人路置入植入式输液港的效果.方法 选择乳腺癌患者60例,年龄28～63岁,体重41～70 kg,身高150～168 cm,ASA Ⅰ或Ⅱ级,拟经锁骨下静脉穿刺置入植入式输液港行长期输液及化疗,输液港导管尖端位置应在上腔静脉和右心房交界处.随机分为2组(n=30):对照组(C组)经锁骨下静脉穿刺,采用脉冲注射冰盐水实验的方法引导定位植入式输液港导管尖端位置.超声组(U组)经锁骨下静脉穿刺,采用超声引导定位植入式输液港导管尖端位置.所有患者术后均经过X线摄片进行导管定位.计算两组患者首次置入成功率.结果 U组患者术后X线摄片显示输液港导管尖端均在上腔静脉和右心房交界处,未发生导管偏离进入颈内静脉的现象,首次置入成功率100%.C组术后X线摄片显示有6例患者的输液港导管发生了偏离,进入颈内静脉,需回手术室在超声引导定位下重新穿刺置管,首次置入成功率80%.U组首次置入成功率高于C组(P<0.05).结论 超声引导定位是经锁骨下静脉正确放置植入式输液港的有效手段.     

超声引导经锁骨下静脉置入植入式输液港的效果

目的 探讨应用超声引导定位在经锁骨下静脉人路置入植入式输液港的效果.方法 选择乳腺癌患者60例,年龄28～63岁,体重41～70 kg,身高150～168 cm,ASA Ⅰ或Ⅱ级,拟经锁骨下静脉穿刺置入植入式输液港行长期输液及化疗,输液港导管尖端位置应在上腔静脉和右心房交界处.随机分为2组(n=30):对照组(C组)经锁骨下静脉穿刺,采用脉冲注射冰盐水实验的方法引导定位植入式输液港导管尖端位置.超声组(U组)经锁骨下静脉穿刺,采用超声引导定位植入式输液港导管尖端位置.所有患者术后均经过X线摄片进行导管定位.计算两组患者首次置入成功率.结果 U组患者术后X线摄片显示输液港导管尖端均在上腔静脉和右心房交界处,未发生导管偏离进入颈内静脉的现象,首次置入成功率100%.C组术后X线摄片显示有6例患者的输液港导管发生了偏离,进入颈内静脉,需回手术室在超声引导定位下重新穿刺置管,首次置入成功率80%.U组首次置入成功率高于C组(P<0.05).结论 超声引导定位是经锁骨下静脉正确放置植入式输液港的有效手段.     

Intra- and extra-pericardial lengths of the superior vena cava in vivo: implication for the positioning of central venous catheters

To reduce the possibility of cardiac tamponade, a rare but lethal complication of central venous catheters, the tip of the central venous catheter should be located above the cephalic limit of the pericardial reflection, not only above the superior vena cava-right atrium junction. This study was performed to measure the superior vena cava lengths above and below the pericardial reflection in cardiac surgical patients. Cardiac surgical patients (n = 61; 27 male), whose age [mean +/- SD (range)] was 47 +/- 15 (15-75) years, were studied. The intrapericardial and extrapericardial lengths, and the length of the medial duplicated part were measured separately. The whole vertical lengths of the superior vena cava on either side were calculated respectively by adding the intra-and extrapericardial and medial duplication lengths. The lateral extrapericardial was 29.1 +/- 6.5 (Mean +/- SD) (9-49) mm (range), and lateral extrapericardial length was 32.6 +/- 6.9 (20-53) mm. The medial extrapericardial length was 23.3 +/- 5.0 (11-39) mm, medical duplicated length was 7.2 +/- 3.3 (4-20) mm, and medial intrapericardial was 28.3 +/- 7.0 (20-52) mm. The averaged superior vena cava length of both sides was 60.3 +/- 9.0 (44.5-90) mm. Almost half of the superior vena cava was found to be within the pericardium and half out. This information may be helpful in deciding how far a central venous catheter should be withdrawn beyond the superior vena cava-right atrial junction during right atrial electrocardiographic guided insertion, and in the prediction of optimal central venous catheter insertion depth.     

Hydrothorax as a late complication of central venous indwelling catheters

Two cases of delayed onset hydrothorax following central venous catheterization are reported. Both involved left internal jugular vein percutaneous insertion sites, and chest roentgenograms of both demonstrated that the catheter tips were juxtaposed against the superior vena cava wall. Although both catheters functioned well for several days, we believe that this left neck site allowed for catheter tip motion, resulting in delayed perforation of the vessel. To avoid this complication we recommend that central venous catheters be checked routinely for position, with the catheter tip being parallel to the vessel wall. The left neck approach should be avoided if possible because of anatomic and mobility problems. These cases emphasize the fact that hydrothorax can occur long after successful catheter insertion, and they demonstrate the need to have continued suspicion of the possibility of this occurrence.     

Evaluation of a formula for optimal positioning of a central venous catheter through the right internal jugular vein

OBJECTIVE: To evaluate the efficiency of a formula for predicting the optimal length of catheter inserted through the right internal jugular vein. PATIENTS AND METHOD: A prospective study in which the length of catheter to insert was calculated by the following formula: (height in cm/10)-1 cm. Punctures were approximately at the cricoid cartilage and length was measured from the point of insertion. Catheter tip placement was confirmed by anteroposterior chest film, read by a radiologist blinded as to the objective of the study. The position was considered optimal if the catheter tip was in the distal portion of the superior vena cava. Patients enrolled required insertion of a central venous line for therapy or monitoring and were excluded if they had risk factors that could predispose them to poor placement. RESULTS: Fifty-eight catheterizations were performed. Three of them were excluded due to poor positioning in the contralateral subclavian vein. Among the 55 remaining patients, we observed the catheter tip in the superior vena cava in 52 cases and in the right atrium in 3. CONCLUSIONS: The aforementioned formula predicted appropriate placement of the catheter tip in 94.54% of the patients.     

The carina as a radiological landmark for central venous catheter tip position

Background. Many publications, including the instructions accompanyingcentral venous catheters, state that it is negligent to sitethe catheter tip in the right atrium. If the catheter tip isabove the carina on a post-procedure radiograph then it is generallyaccepted that the catheter lies outside the right atrium. Itis also recommended that the catheter tip should lie in thelong axis of the superior vena cava without acute abutment tothe vein wall. We performed a retrospective audit of the positionof central venous catheter tips on routine post-procedure chestradiographs in intensive care unit patients, to see if thesepotentially conflicting requirements had been met. Methods. We identified 213 central venous catheters suitablefor analysis, within a study population of 200 consecutive cases.We measured the distance of the central venous catheter tipabove or below the carina and the angle of the central venouscatheter tip to the vertical (a surrogate marker for the angleof abutment of the tip to the approximately vertical superiorvena cava wall). Results. For right-sided catheters there was a high (74/163)number placed with their tips below the carina, but a very lownumber (4/163) with their tips at a steep (>40°) angleto the vertical. For left-sided catheters very few (7/50) wereplaced with their tips below the carina, but for those 43 sitedabove the carina most could be considered to be in suboptimalpositions. This was because they were either too high and hadnot even crossed the midline (9), or had an acute angle (>40°)between the tip and the vertical (27). Conclusions. We suggest that for left-sided catheters placementof the tip below the carina is more likely to result in a satisfactoryplacement.     

The right supraclavicular fossa ultrasound view for correct catheter tip positioning in right subclavian vein catheterisation: a prospective observational study

Central venous catheter misplacement is common (approximately 7%) after right subclavian vein catheterisation. To avoid it, ultrasound-guided tip navigation may be used during the catheterisation procedure to help direct the guidewire towards the lower superior vena cava. We aimed to determine the number of central venous catheter misplacements when using the right supraclavicular fossa ultrasound view to aid guidewire positioning in right infraclavicular subclavian vein catheterisation. We hypothesised that the incidence of catheter misplacements could be reduced to 1% when using this ultrasound technique. One -hundred and three adult patients were prospectively included. After vein puncture and guidewire insertion, we used the right supraclavicular fossa ultrasound view to confirm correct guidewire J-tip position in the lower superior vena cava and corrected the position of misplaced guidewires using real-time ultrasound guidance. Successful catheterisation of the right subclavian vein was achieved in all patients. The guidewire J-tip was initially misplaced in 15 patients, either in the ipsilateral internal jugular vein (n = 8) or in the left brachiocephalic vein (n = 7). In 12 patients it was possible to adjust the guidewire J-tip to a correct position in the lower superior vena cava. All ultrasound-determined final guidewire J-tip positions were consistent with the central venous catheter tip positions on chest X-ray. Three out of 103 catheters were misplaced, corresponding to an incidence (95%CI) of 2.9 (0.6–8.3) %. Although the hypothesis could not be confirmed, this study demonstrated the usefulness of the right supraclavicular fossa ultrasound view for real-time confirmation and correction of the guidewire position in right infraclavicular subclavian vein catheterisation.     

Secondary migration of a central venous catheter. A case report

A case of central venous catheter (CVC) secondary migration in a patient with Hodgkin's lymphoma is reported. The catheter was inserted in the right internal jugular vein with anterior approach. The correct position of the catheter tip in the superior vena cava was confirmed by X-ray. Secondary migration to the right subclavian vein, without displacement at the point of insertion, was reported 8 days later by a chest X-ray performed for worsening of the respiratory condition. CVC was removed and reinserted with the same procedure. The correct position of the catheter tip was confirmed by thoracic radiography till 10 days later. Epidemiological data present in the literature and secondary migration predisposing factors are reported.     

Combined endovascular and surgical recanalization after central venous catheter-related obstructions

Central venous occlusion in children is a challenging problem that can occur after a central venous catheter insertion. Long-term catheter-related complications include sepsis and venous thrombosis with consequent loss of central access. We describe 2 cases of children younger than 1 year who were dependent on a central venous catheter for total parenteral nutrition. They developed a chronic extensive obstruction of the right and left brachiocephalic veins with a superior vena cava syndrome. The patients' survival was dependent on the restoration of central venous access until the planned intestinal transplantation could be performed. Retrograde recanalization of the superior vena cava was successfully achieved using a pathway created under general anesthesia from the femoral vein to, respectively, the right thyroid vein and the right subclavian vein.     

EKG guided placement of subclavian CVP catheters using J-wire.

In an attempt to improve the accuracy of central venous pressure (CVP) catheter tip location, 84 consecutive cardiac surgery patients in sinus rhythm were studied prospectively with respect to subclavian insertion of a CVP catheter using a guidewire technique. The presence of cardiac arrhythmia was used as an index of right atrial (RA) location of the guidewire tip, before threading the catheter over the guidewire. Correct catheter tip location (superior vena cava [SVC] or RA) was achieved in 100% of patients (N = 78) with premature atrial contractions (PACs) related to guidewire insertion. This fell to 50% (N = 4) if no arrhythmias were noted from the guidewire. Ventricular arrhythmias were noted in two of 84 patients (2.4%). Other problems related to the use of this technique are discussed.     

Late development of hydrothorax induced by a central venous catheter: Report of a case

We report herein the case of a 47-year-old woman who suffered a hydrothorax induced by a central venous catheter (CVC) which had been placed to facilitate total parenteral nutrition following a left sleeve pneumonectomy for lung cancer. The CVC was inserted into the superior vena cava (SVC) through the left subclavian vein after the operation; however, the tip inadvertently turned upward and came in contact with the lateral wall of the SVC. The patient suddenly developed dyspnea due to a right-sided hydrothorax 47 days after the insertion of the catheter. Indocyamine green administered through the catheter was thereafter found in the pleural fluid. The continuous mechanical force of the catheter tip against the SVC wall was thus considered to be the cause of this life-threatening delayed hydrothorax.     

The intracavitary ECG method for positioning the tip of central venous catheters: results of an Italian multicenter study

Purpose: The aim of this multicenter study was to assess the feasibility, safety, and accuracy of the intracavitary ECG method for real-time positioning of the tip of different types of central venous catheters. Methods: A total of 1444 catheter insertions in adult patients were studied in eight Italian centers (539 ports, 245 PICCs, 325 tunneled CVCs, 335 non-tunneled CVCs). Patients with no visible P wave at the standard baseline ECG were excluded. Depending on the type of catheter and its purpose, the target was to position the tip either (a) at the cavo-atrial junction, or (b) in the lower third of the superior vena cava, or (c) in the upper part of the atrium. The final position was verified by a post-procedural chest x-ray. Results: The method was feasible in 99.3% of all cases. There were no complications potentially related to the method itself. At the final x-ray control, 83% of all tips were positioned exactly at the target; 12.4% were positioned within 1-2 cm from the target, but still in a correct central position; only 3.8% were malpositioned. The mismatch between intra-procedural ECG method and post-procedural x-ray was significantly lower when the x-ray was taken in supine position.Conclusions: Our multicenter study confirms that the intracavitary ECG method for real time verification of tip position is accurate, safe, feasible in all adult patients and applicable to any type of short-term or long-term central venous access device.     

Central venous catheters for haemodialysis: looking for optimal blood flow

Central venous catheters are commonly used for haemodialysis patients and represent, in our centre, about 15% of the permanent vascular accesses with a total number of more than 230 central venous catheters over the last 10 years. Inadequate blood flow may occur and upsets the nurses, the patients, and the nephrologist. The aim of this study was to identify the factors of the catheter dysfunction. We studied prospectively 25 chronic haemodialysed patients with central venous catheters, 14 women and 11 men, 65±16 (55-89) years of age, treated with haemodialysis for 6.7±7 (1-26) years. Catheters were tunnelled silicone twin catheters (Permcath Quinton® n=18, Twincath Hemotec® n=7) in right (n=19) and left internal jugular (n=6) inserted by percutaneous Seldinger techniques. We studied the localization of the catheter tip (superior vena cava, right atrium, right ventricular, inferior vena cava), the central venous pressure before and after haemodialysis, the blood pressure (BP) before and after haemodialysis, the interdialytic weight gain, the number of symptomatic hypotensions during the 10 last dialyses. The patients were divided into two groups: group I with usual adequate catheter function (n=18) and group I with frequent dysfunctions (n=7). Central venous pressure before dialysis was significantly higher in group I with adequate blood flow and the catheter's tip was more frequently found localized in the right cardiac cavities than in the vena cava. When central venous pressure before dialysis was over 5 mmHg, no dysfunction occurred. Blood pressure was not different between the two groups. We found no correlation between central venous pressure and BP, interdialytic weight gain and symptomatic hypotensions. We could not predict the central venous pressure from the mean BP but there was a higher frequency of hypotensions in the hypovolaemic patients. Optimal haemodynamic conditions will be provided by a catheter tip in the right cardiac cavities and a central venous pressure over 5 mmHg which can be provided with vascular filling or dry weight revaluation.     

Differential diagnosis of left-sided thoracic venous catheters: case report of a persistent left superior vena cava

The differential diagnosis of left-sided thoracic central venous catheters is discussed in context with the cannulation of a persistent left superior vena cava. In this case the catheter tip was seen lying to the left of the spine on frontal chest X-ray. In addition to the descending aorta, differential diagnoses are a persistent left-sided superior vena cava as well as other smaller veins such as the left internal thoracic vein, the left superior intercostal vein, or the pericardiophrenic vein. The misplacement of a venous catheter in a pericardiophrenic vein may result in a fatal pericardial tamponade.