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The utility of transthoracic echocardiography to confirm central line placement: An observational study

  • Ramiro Arellano
  • Aliya Nurmohamed
  • Amir Rumman
  • Andrew G. Day
  • Brian Milne
  • Rachel Phelan
  • Robert TanzolaEmail author
Reports of Original Investigations

Abstract

Background

Ultrasound visualization of neck vessels is the standard method used to assist with internal jugular vein (IJV) central line placement. Nevertheless, this practice has not eliminated the risk of carotid puncture and/or inadvertent arterial cannulation. Transesophageal echocardiography (TEE) effectively verifies wire placement within the heart but is invasive and not always available. We examined the feasibility and potential utility of using transthoracic echocardiography (TTE) to verify the distal wire in the right atrium (RA) before dilation and cannulation of the IJV.

Methods

Following institutional Research Ethics Board approval and signed consent, 100 patients scheduled for elective cardiac surgery were recruited. As per standard practice at our institution, all patients were to have a central line inserted under general anesthesia with TEE visualization of the guidewire. Transesophageal echocardiography (apical or subcostal four-chamber images) was performed by one of four operators while another anesthesiologist performed central line placement. Following IJV puncture, blood was rapidly aspirated and reinjected to produce microbubbles. Subsequently, a 0.035-inch j-tipped flexible guidewire was inserted and visualized with TEE. The wire was then reinserted into the RA under TTE visualization.

Results

Overall, the RA was viewed 94% (95% confidence interval [CI] 87 to 98) of the time with TTE, and both the microbubbles and guidewire were detected 91% (95% CI 84 to 96) of the time. The subjects in whom the guidewire could not be well visualized had a higher mean body mass index (33.6 vs 28.8; P = 0.01).

Conclusions

Transesophageal echocardiography is a feasible, noninvasive, and potentially useful method to confirm appropriate placement of the guidewire before dilation and cannulation of the IJV.

Keywords

Chronic Obstructive Pulmonary Disease Inferior Vena Cava Internal Jugular Vein Superior Vena Cava Right Atrium 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

L’utilité de l’échocardiographie transthoracique pour confirmer le positionnement d’une voie centrale : une étude observationnelle

Résumé

Contexte

La visualisation par ultrasons des vaisseaux du cou est la méthode standard utilisée pour aider au positionnement des voies centrales au niveau de la veine jugulaire interne (VJI). Toutefois, cette pratique n’a pas éliminé le risque de ponction carotidienne et/ou la canulation artérielle faite par inadvertance. L’échocardiographie transœsophagienne (ÉTO) vérifie de façon efficace le positionnement du guide dans le cœur; toutefois, cette technique est invasive et elle n’est pas toujours disponible. Nous avons examiné la faisabilité et l’utilité potentielle de l’échocardiographie transthoracique (ÉTT) pour vérifier le positionnement du guide distal dans l’oreillette droite (OD) avant la dilatation et la canulation de la VJI.

Méthode

Après avoir obtenu l’approbation du Comité d’éthique de la recherche de notre institution et le consentement des patients, 100 patients devant subir une chirurgie cardiaque non urgente ont été recrutés. Conformément à la pratique standard de notre institution, une voie centrale devait être insérée sous anesthésie générale chez tous les patients avec une visualisation par ÉTO du guide. Une échocardiographie transœsophagienne (images apicales ou sous-costales des quatre chambres) a été réalisée par l’un de quatre opérateurs pendant qu’un autre anesthésiologiste positionnait la voie centrale. Après la ponction de la VJI, le sang a été aspiré rapidement et réinjecté afin de produire des microbulles. Par la suite, un guide flexible avec extrémité en J de 0,035 pouce a été inséré et visualisé par ÉTO. Le guide a ensuite été réinséré dans l’OD sous visualisation ÉTT.

Résultats

Globalement, l’OD a été visualisée 94 % (intervalle de confiance [CI] 95 % 87 à 98) du temps avec l’ÉTT, et les microbulles et le guide ont été détectés 91 % (IC 95 % 84 à 96) du temps. Les patients chez qui le guide n’a pas pu être bien visualisé avaient un indice de masse corporelle moyen plus élevé (33,6 vs. 28,8; P = 0,01).

Conclusion

L’échocardiographie transœsophagienne est une méthode faisable, non invasive et potentiellement utile pour confirmer le positionnement adapté du guide avant la dilatation et la canulation de la VJI.

Notes

Funding

Department of Anesthesiology & Perioperative Medicine, Queen’s University and Kingston General Hospital.

Conflicts of interest

The authors have no financial interests relating to patents and/or share holdings in corporations involved in the development and/or marketing of the products evaluated in this study.

Supplementary material

Video 1: Transthoracic echocardiograms showing microbubbles (arrows) in the right atria in the apical and subcostal four-chamber views (WMV 7189 kb)

Video 2: Transthoracic echocardiograms showing the guidewires (arrows) entering the right atria in the apical and subcostal four-chamber views (WMV 7243 kb)

Video 3: Transthoracic echocardiogram showing the guidewire (arrow) in the inferior vena cava subcostal inferior vena cava view (WMV 6991 kb)

Video 4: A demonstration of technique with one operator inserting the right central line and the transthoracic echocardiography operator scanning with the probe under the sterile drapes (WMV 5355 kb)

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Copyright information

© Canadian Anesthesiologists' Society 2014

Authors and Affiliations

  • Ramiro Arellano
    • 1
    • 2
  • Aliya Nurmohamed
    • 2
    • 3
  • Amir Rumman
    • 2
    • 3
  • Andrew G. Day
    • 4
  • Brian Milne
    • 1
  • Rachel Phelan
    • 1
  • Robert Tanzola
    • 1
    Email author
  1. 1.Department of Anesthesiology & Perioperative MedicineQueen’s University, Victory 2, Kingston General HospitalKingstonCanada
  2. 2.Department of Anesthesiology & Perioperative MedicineUniversity of Western OntarioLondonCanada
  3. 3.Queen’s University School of MedicineQueen’s UniversityKingstonCanada
  4. 4.Clinical Research CentreKingston General HospitalKingstonCanada

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