(Last Updated On: March 14, 2016)

Welcome back for round 5 of the Knowledge Bomb.  The purpose and motivation for this series is outlined in the first entry.  As a reminder, the blog entry is a summary of the conference presentation meant to serve as a reference for #FOAMED and allow for discussion.

Thanks to Dr. Dan Eggemen for his work producing the following BOMB.

Background/Motivation

In the intensive care unit and emergency department, it is crucial to confirm central line placement to rule out procedural complications (pneumothorax, carotid injury, etc.) and to begin administration of life saving medications (pressors to improve end organ perfusion). The faster this can occur, the better for the patient.

Recently, I was frustrated by my reliance on the portable x-ray for confirmation, because it was often gone from the ICU for prolonged periods of time.

Is there a way I can confirm central line placement at the bedside using ultrasound?

Article

Saul T, Doctor M, Kaban NL, Avitabile NC, Siadecki SD, Lewiss RE. The Ultrasound-Only Central Venous Catheter Placement and Confirmation Procedure. J Ultrasound Med. 2015 Jul;34(7):1301-6. doi: 10.7863/ultra.34.7.1301. PMID:26112635

Design

Literature review of multiple studies.  This paper focused on developing point of care ultrasound protocol for 3 aspects of central venous catheter placement above the diaphragm:

  1. Dynamic procedural guidance
  2. Evaluation for pneumothorax
  3. Confirmation of the catheter tip location

Results

  1. Dynamic procedure guidance resulted in fewer complications (eg. arterial puncture and pneumothorax), fewer cannulation attempts, and decreased procedure duration.
  2. Multiple studies demonstrate that lung US is more sensitive than supine AP CXR for pneumothorax.
  3. Injection of microbubbles can confirm that the catheter tip is in the inferior third of the superior vena cava (see figures below).

Screen Shot 2016-02-25 at 8.40.47 AM

Summary

US allows for faster confirmation of line placement at a decreased cost to patient.

Patient is not subjected to ionizing radiation and does not need repositioning.

US shown to be better than CXR for detection of pneumothorax.

Saline flush will reveal line in venous systems, even in distorted anatomy.

Application to our practice

Due to its novelty/comfort level, I will continue to use chest x-ray as a confirmatory test for central lines as I practice this protocol.

The goal will be to have a backup in times of crisis when the x-ray is not available and critical medications are needed emergently.

Ideally one day, this will be my primary method to confirm central lines are in the correct location.

 

Daniel EggemanDr. Daniel Eggeman is a current PGY2 in UIC’s EM Program.

Click to Watch Video Attending Response - Dr. Michael Joo

Thank-you Daniel for including me in the back to back knowledge bombs.  The use of Ultrasound for detection of central line placement is of particular interest to me since my research during my Ultrasound Fellowship was on cardiac ultrasound after placement of central line.

Joo

 

 

Dr. Joo is currently an attending physician at Mercy Hospital and Medical Center.  He completed an Ultrasound Fellowship at Allegheny General Hospital.

 

References

http://sinaiem.us/tips-and-tricks/bubble-test

Dolu H, Goksu S, Sahin L, Ozen O, Eken L. Comparison of an ultrasound-guided technique versus a landmark-guided technique for internal jugular vein cannulation. J Clin Monit Comput 2015; 29:177–182.

Gualtieri E, Deppe SA, Sipperly ME, Thompson DR. Subclavian venous catheterization: greater success rate for less experienced operators using ultrasound guidance. Crit Care Med 1995; 23:692–697.

Blaivas M, Lyon M, Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med 2005; 12:844–849.

Kirkpatrick AW, Ng AKT, Dulchavsky SA, et al. Sonographic diagnosis of a pneumothorax inapparent on plain radiography: confirmation by computed tomography. J Trauma 2001; 50:750–752.

Lichtenstein DA, Mezière G, Biderman P, Gepner A. The comet-tail artifact: an ultrasound sign ruling out pneumothorax. Intensive Care Med 1999; 25:383–388.

Duran-Gehring PE, Guirgis FW2, McKee KC, Goggans S, Tran H, Kalynych CJ, Wears RL. The bubble study: ultrasound confirmation of central venous catheter placement. Am J Emerg Med. 2015 Mar;33(3):315-9

Blaivas M, Lyon M, Duggal S. A prospective comparison of supine chest radiography and bedside ultrasound for the diagnosis of traumatic pneumothorax. Acad Emerg Med 2005; 12:844–849.