Dataset Information

Bedside ultrasound diagnosis of a malpositioned central venous catheter: A case report.

ABSTRACT:

Rationale

Central venous catheter (CVC) placement is commonly performed in intensive care unit. And CVC placement is associated with risks including CVC malposition, pneumothorax. Many of the previously reported cases are about catheter misplacement detected by bedside ultrasound, chest x-ray (CXR) and computed tomography. In this case, malposition was detected by bedside ultrasound incidentally particularly with no clinical manifestation.

Patient concerns

An 88-year-old male with severe diabetic peripheral neuropathy secondary to type 2 diabetes mellitus was admitted for further treatment.

Diagnoses

We cannulated a single-lumen CVC via the right subclavian vein, and the tip ended up in the internal jugular vein on the same side. With bedside ultrasound, we discovered the malposition though it was mistaken by aspiration of venous blood. Later, CXR revealed malposition of the tip once again.

Interventions

Since the patient was asymptomatic and the catheter was functioning normally, the catheter was used for the following 20 days without complications. Ultimately, we carefully performed the catheter removal.

Outcomes

After the inserted catheter was removed, we attempted a new CVC through the left internal jugular vein. After the procedure, bedside ultrasound and CXR confirmed the correct position of CVC. Following successful replacement of the central catheter, no further complications were observed.

Lessons

Bedside ultrasound offers safety and effectiveness during insertion of CVC. It also exhibits promptness and accuracy compared to post-intervention radiological imaging.

SUBMITTER: Song F

PROVIDER: S-EPMC5908571 | biostudies-literature | 2018 Apr

REPOSITORIES: biostudies-literature

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Publications

Bedside ultrasound diagnosis of a malpositioned central venous catheter: A case report.

Song Feier F Huang Daozheng D Chen Ying Y Xiao Zhiyuan Z Su Ke K Wen Jianyi J Guo Weixin W Wang Zhonghua Z Wu Yan Y Wang Shouhong S Qin Tiehe T

Medicine 20180401 15

<h4>Rationale</h4>Central venous catheter (CVC) placement is commonly performed in intensive care unit. And CVC placement is associated with risks including CVC malposition, pneumothorax. Many of the previously reported cases are about catheter misplacement detected by bedside ultrasound, chest x-ray (CXR) and computed tomography. In this case, malposition was detected by bedside ultrasound incidentally particularly with no clinical manifestation.<h4>Patient concerns</h4>An 88-year-old male with ...[more]

PMID: 29642224

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Project description:BackgroundInsertion of a central venous catheter (CVC) is common practice in critical care medicine. Complications arising from CVC placement are mostly due to a pneumothorax or malposition. Correct position is currently confirmed by chest x-ray, while ultrasonography might be a more suitable option. We performed a meta-analysis of the available studies with the primary aim of synthesizing information regarding detection of CVC-related complications and misplacement using ultrasound (US).MethodsThis is a systematic review and meta-analysis registered at PROSPERO (CRD42016050698). PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched. Articles which reported the diagnostic accuracy of US in detecting the position of CVCs and the mechanical complications associated with insertion were included. Primary outcomes were specificity and sensitivity of US. Secondary outcomes included prevalence of malposition and pneumothorax, feasibility of US examination, and time to perform and interpret both US and chest x-ray. A qualitative assessment was performed using the QUADAS-2 tool.ResultsWe included 25 studies with a total of 2548 patients and 2602 CVC placements. Analysis yielded a pooled specificity of 98.9 (95% confidence interval (CI): 97.8-99.5) and sensitivity of 68.2 (95% CI: 54.4-79.4). US examination was feasible in 96.8% of the cases. The prevalence of CVC malposition and pneumothorax was 6.8% and 1.1%, respectively. The mean time for US performance was 2.83 min (95% CI: 2.77-2.89 min) min, while chest x-ray performance took 34.7 min (95% CI: 32.6-36.7 min). US was feasible in 97%. Further analyses were performed by defining subgroups based on the different utilized US protocols and on intra-atrial and extra-atrial misplacement. Vascular US combined with transthoracic echocardiography was most accurate.ConclusionsUS is an accurate and feasible diagnostic modality to detect CVC malposition and iatrogenic pneumothorax. Advantages of US over chest x-ray are that it can be performed faster and does not subject patients to radiation. Vascular US combined with transthoracic echocardiography is advised. However, the results need to be interpreted with caution since included studies were often underpowered and had methodological limitations. A large multicenter study investigating optimal US protocol, among other things, is needed.

Project description:ObjectiveEmerging 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.MethodsWe 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.ResultsTwenty-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 (29 minutes [1-269 minutes]; Mann-Whitney U, p < 0.01). Adequate protocol image acquisition was achieved in 76% of the patients.ConclusionThirty-minute training of POCUS in nonexperts demonstrates adequate diagnostic accuracy, efficiency, and feasibility of POCUS-guided CVC position confirmation, but not exclusion of pneumothorax.

Project description: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.

Dataset Information

Bedside ultrasound diagnosis of a malpositioned central venous catheter: A case report.

Rationale

Patient concerns

Diagnoses

Interventions

Outcomes

Lessons

Publications

Bedside ultrasound diagnosis of a malpositioned central venous catheter: A case report.

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