Internal and Emergency Medicine

, Volume 8, Issue 2, pp 173–180 | Cite as

Verification of correct central venous catheter placement in the emergency department: comparison between ultrasonography and chest radiography

  • Maurizio Zanobetti
  • Alessandro Coppa
  • Federico Bulletti
  • Serena Piazza
  • Peyman Nazerian
  • Alberto Conti
  • Francesca Innocenti
  • Stefano Ponchietti
  • Sofia Bigiarini
  • Aurelia Guzzo
  • Claudio Poggioni
  • Beatrice Del Taglia
  • Yuri Mariannini
  • Riccardo Pini
EM - ORIGINAL

Abstract

In 210 consecutive patients undergoing emergency central venous catheterization, we studied whether an ultrasonography examination performed at the bedside by an emergency physician can be an alternative method to chest X-ray study to verify the correct central venous catheter placement, and to identify mechanical complications. A prospective, blinded, observational study was performed, from January 2009 to December 2011, in the emergency department of a university-affiliated teaching hospital. Ultrasonography interpretation was completed during image acquisition; ultrasound scan was performed in 5 ± 3 min, whereas the time interval between chest radiograph request and its final interpretation was 65 ± 74 min p < 0.0001. We found a high concordance between the two diagnostic modalities in the identification of catheter position (Kappa = 82 %, p < 0.0001), and their ability to identify a possible wrong position showed a high correlation (Pearson’s r = 0.76 %, p < 0.0001) with a sensitivity of 94 %, a specificity of 89 % for ultrasonography. Regarding the mechanical complications, three iatrogenic pneumothoraces occurred, all were correctly identified by ultrasonography and confirmed by chest radiography (sensitivity 100 %). Our study showed a high correlation between these two modalities to identify possible malpositioning of a catheter resulting from cannulation of central veins, and its complications. The less time required to perform ultrasonography allows earlier use of the catheter for the administration of acute therapies that can be life-saving for the critically ill patients.

Keywords

Emergency medicine Emergency ultrasonography Chest radiography Central venous catheter 

Introduction

The central venous catheterization, performed by cannulation of subclavian or internal jugular veins, is currently a common procedure in the care of critically ill patients, both in the emergency department (ED) and in the Intensive Care Unit (ICU). This procedure represents an essential means for the monitoring of central venous pressure, the administration of drugs, fluids, blood products and total parenteral nutrition. Despite its widespread use, the placement of a central venous catheter (CVC) remains a procedure followed by complications in a rate ranging from 0.3 to 12 % depending on operator’s experience and definition of a complication itself [1]. Even when the procedure is performed by an expert operator, a CVC can advance in the wrong vessel. The main mechanical complications relate to vessel puncture and catheter advancement are pneumothorax, vascular complications such as arterial puncture and hematoma at the insertion point, and damage of neural structures [2]. Unlike these early mechanical complications, at present, serious complications like infections or thrombosis are relatively uncommon [1, 3, 4, 5]. The correct position of the catheter tip remains a controversial issue. Its localization in the superior vena cava, just above its outlet into the right atrium is usually considered to be the ideal position for minimizing the risk of cardiac tamponade and venous thrombosis [6]. After the CVC placement, a standard chest radiography (CXR) is recommended to verify the CVC position, and to rule out possible complications. Although several other methods have been proposed to locate the tip of the catheter and to exclude any malposition, such as endocavitary electrocardiography, transesophageal echocardiogram, or flush with saline testing [7, 8, 9, 10], the CXR is currently considered the gold standard. However, its accuracy in locating the catheter tip is certainly overestimated [11]. Despite the simplicity of this diagnostic modality, the entire procedure of a CXR, from the examination request to the final report, requires a considerable time interval that can be very harmful to the critically ill patient. The use of ultrasound (US) guidance, which has become a common practice in particular for transjugular and peripheral CVC insertion, has made this procedure safer and increased the success rate [12]. As recently demonstrated, a focused ultrasonography aims to provide emergency response to specific questions, and performed at the bedside by an emergency physician (EP) or an intensivist, can be an extremely useful tool in caring for a critically ill patient [13, 14]. The US examination of blood vessels, heart and chest performed by a non-radiologist physician is a feasible diagnostic modality with many clinical advantages [15, 16, 17, 18]. However, despite its growing use, there are only few scientific papers demonstrating that transthoracic US is as accurate as CXR in defining the position of the CVC tip [19, 20, 21, 22], and all these studies were carried out in the ICU. While the transthoracic US accuracy in detecting the presence of pneumothorax [16, 23] as well as the ease in the display of the inferior vena cava, the subclavian and the internal jugular vein has been demonstrated [24, 25], the visualization of the superior vena cava, particularly in its lower portion at the level of its junction with the right atrium, is sometimes difficult. The aim of our study was to determine whether, in a series of patients undergoing emergency central venous catheterization, the US performed at the bedside by an EP can be an alternative method to CXR to verify the correct placement of the catheter and to diagnose mechanical complications such as pneumothorax, pleural and pericardial effusion.

Methods

A prospective, blinded, observational study was performed. The study consistent with the principles of Declaration of Helsinki on clinical research involving human subjects was approved by an ad hoc ethics committee. For each patient, written informed consent about the procedure and the processing of personal data were obtained. Patients were enrolled, from January 2009 to December 2011, in the ED of an urban academic level I trauma center and a tertiary-care facility with an annual ED census of 70,000 visits. The ED is the primary teaching site for the emergency medicine residency. The indication for central venous catheterization was based on clinical judgment by EPs participating in the study. The most common indications included central venous pressure monitoring, rapid restoration of blood volume and administration of drugs requiring central venous delivery. Patients younger than 18 years were excluded from the study.

Three-way Blue FlexTip catheters (Arrow-Howes, Reading, PA, USA) with 7 French diameter and 20-cm length were used. The catheter placement was performed by a senior EP or by an emergency medicine resident. The procedures performed by in-training physicians were carried out under the tutor supervision. The approach, transjugular or subclavicular, was chosen by the operator according to the clinical situation, the characteristics of the patient and personal preferences. The catheters were inserted with the patient in a supine position under sterile conditions using the Seldinger technique. The subclavian vein use a subclavicular approach based on the recognition of anatomical landmarks; access in the internal jugular vein was instead performed by the use of the ultrasonographic guide. Immediately after CVC insertion, an US B-scan was performed to identify the catheter tip position and to rule out any mechanical complications. The US examination was performed by the same operator who had placed the CVC. To acquire the necessary skill to perform the US examination, EPs and residents attended a theoretical training on vascular, cardiac and chest ultrasonography lasting 8 h for each area, and performed, under a tutor supervision, 25 ultrasonographic examinations of each kind, as suggested by American College of EP’ guidelines [26].

US examinations were performed with an iE33 ultrasound system (Philips Ultrasound, Bothell, WA, USA) equipped with a 4–8 MHz linear probe and a 2.5–3.5 MHz sector probe. The images were recorded, and in case of discordance with the CXR were revised. The US examination was performed with the patient in a supine position; if not contraindicated by the clinical condition, images from the apical window were acquired with the patients in a left lateral decubitus position. Internal jugular and subclavian veins were extensively scanned bilaterally by the linear probe from latero-cervical, supraclavicular and infraclavicular fossae to identify the CVC. Heart chambers and pericardial space were visualized from apical and subcostal windows by the sector probe to identify the presence of the catheter inside the heart, and to rule out pericardial effusion and tamponade. If the CVC was inserted through the internal jugular vein and the US scan was unable to visualize a tip entrance into the contra lateral jugular vein, into the subclavian veins bilaterally, and into the heart chambers, we assumed that the catheter tip was at the level of the superior vena cava. When the subclavicular access was used and the catheter was not visualized in the contralateral subclavian vein and at the level of the internal jugular veins bilaterally, and within the heart chambers, we similarly assumed that the catheter tip was in the superior vena cava. We considered as correct placements all cases in which the catheter tip position has been defined at the level of the superior vena cava or into the right atrium nearby the superior venae cava outlet; the finding of the catheter tip at the level of venous vessels other than the superior vena cava or too far distally into the right atrium has been considered as wrong positioning. Chest examination was performed with linear probe to check for the presence of complications such as pneumothorax and pleural effusion. Longitudinal and transversal scanning of both hemithoraces were performed along the parasternal, midclavicular, anterior, middle, and posterior axillary lines. The presence of pneumothorax was defined by the following ultrasound findings: absence of gliding sign, absence of vertical artifacts (B line); appearance of lung point [27]. The presence of pleural effusion was identified as an hypoechoic area between the parietal pleura and visceral pleura.

At the end of the US scan, the physician performing the procedure filled out a card recording the following information: patient name and date of birth, admission diagnosis, drugs used for the procedural sedation, presence of chest alteration, insertion point; time required to perform the US scan; catheter tip position as identified by US exam, the presence of pneumothorax, hemothorax, hemopericardium with or without tamponade. The admission diagnoses were grouped into nine main categories: septic shock, trauma, lung disease, heart disease, abdominal disease, acute renal failure or metabolic or fluid disturbances, inability to obtain peripheral access, hypovolemic shock, or cardiopulmonary arrest. Chest alteration was defined as anatomic changes of the rib cage due to chronic obstructive pulmonary disease such as barrel chest, deterioration due to restrictive lung disease, chest trauma with rib fractures, scars of previous thoracic surgery (resection or lung transplantation) and alterations such as chest scoliosis or pectus carinatum. At the end of the CVC insertion, a bedside CXR was obtained to verify the catheter tip position, with the radiologist blinded regarding the US scan findings. The CXR was acquired with the patient in a supine position by a Philips 300 Mobile Practix radiographic system (Philips Healthcare, Amsterdam, The Netherlands) and developed with a Cr 85-X digitizer (AGFA Healthcare, Morstel, Belgium). The US findings were then compared with those obtained from the CXR, considered as the gold standard. Because the catheter position and the presence of complications were evaluated during the US scanning, the time required to get the US final report was considered equal to the time spent for the US examination. For the radiological examination, we calculated the time interval between the CXR request and the final report availability. US sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) were calculated with the CXR as gold standard. Continuous variables are reported as mean ± standard deviation and comparisons between the two modalities were performed using the t Student test for paired-data. To compare categorical variables, Fisher’s exact test was used. The concordance between ultrasonography and radiography was analyzed using the Cohen’s K test. A p value <0.05 was considered statistically significant.

All statistical analyses were performed using SPSS statistical package version 19.0 (SPSS Inc., Chicago, IL, USA).

Results

From January 2009 to December 2011, 210 consecutive patients underwent central venous catheterization. Mean age was 72 ± 17 years (range 19–100 years); 101 subjects were males (48 %). Fourteen patients were intubated (5 %). The most frequent diagnosis for hospitalization was septic shock (47 %) (Table 1). Alterations of the rib cage were found in 28 patients (13 %). While US examination was performed in all enrolled patients, CXR was performed in 204 patients (97 %, p = 0.0301), because six patients died before the execution of CXR. Ultrasound scan and contemporary interpretation were completed in 5 ± 3 min (range 1–23 min), whereas the average time between CXR request and its final interpretation was 65 ± 74 min (range 6–540 min, p < 0.0001). The approach more frequently used to insert the CVC was the right internal jugular vein (120 patients or 57 %). Other approaches were right subclavicular (35 %), left transjugular (4 %) and left subclavicular (4 %). US visualized 112 catheter tips (53 %) in the right atrium near the junction with the superior vena cava (Fig. 1), five catheters in the ipsilateral jugular vein (2 %) and the remaining 93 catheters (45 %) were considered in the superior vena cava, because they have not been displayed either at the level of the right heart cavities neither in other veins other than the one used for insertion. All nine cases (4 %) of the wrong positioning of the catheter occurred in subjects in which the CVC was inserted through the right subclavian vein. In five cases, the US visualized the catheter tip in the ipsilateral jugular vein (Fig. 2), demonstrating that the catheter had climbed into the veins of the neck instead of proceeding toward the right atrium. In four cases, it was impossible to identify the end of catheter with US and the CXR showed it in the contralateral anonymous vein (Fig. 3). In all these cases, the catheter was correctly repositioned. As documented by ultrasonography as well as by CXR, there were five cases of pneumothorax, three were iatrogenic complications during cannulation of subclavian vein and two were already present before the procedure. There were no documented cases of hemothorax and hemopericardium. When we compared the ability of US and CXR in the identification of the catheter position (Table 2), the concordance between the two diagnostic modalities was high (Kappa = 82 %, p < 0.0001) with only 9 (4 %) cases of clinically relevant discordances. In fact, in clinical practice, the rationale to perform a routine imaging study is the need to verify that the CVC position allows its use and to rule out mechanical complications; thus, the placement of the catheter tip in the atrium or in the superior vena cava is not clinically relevant for performing a routine testing, but is to be able to identify those cases where there is a necessary repositioning of the catheter. We compared the ability of the two techniques to identify if the catheter tip is located in the terminal portion of the superior vena cava or in the proximal portion of the right atrium. With this assumption, US has been shown to have a sensitivity of 94 %, a specificity of 89 %, with the CXR as the goal standard and the correlation between the two methods was high (Pearson’s r = 0.76 %, p < 0.0001). To evaluate the discrimination ability of sonography regarding the identification of the catheter tip in right atrium, we have considered only cases where the catheter was properly positioned. We found a sensitivity of 88 %, a specificity of 89 %, a PPV of 91 %, and NPV equal to 93 %, the correlation between ultrasound and chest X-ray was found to be high (Kappa = 82 %, p < 0.0001).
Table 1

Reasons for hospitalization

Septic shock

99 (47 %)

Trauma

19 (9 %)

Lung disease

26 (12 %)

Heart disease

17 (8 %)

Abdominal disease

10 (5 %)

Acute renal failure and/or hydro-electrolytic disturbances

23 (11 %)

Inability to obtain peripheral access

5 (2 %)

Hypovolemic shock

9 (4 %)

Cardiopulmonary arrest

2 (1 %)

Fig. 1

Ultrasound examination showing the tip of catheter (arrow) in the right atrium near the mouth of the superior vena cava

Fig. 2

Ultrasound examination showing the tip of the catheter (arrow) in the ipsilateral jugular vein (transversal scan)

Fig. 3

Chest radiography showing the tip of the catheter (arrow) in the contralateral vein

Table 2

Comparison of the position of catheter identified by ultrasonography with that showed on chest radiograph

 

Chest radiograph

Right atrium

Superior vena cava

Internal jugular vein

Other localization

Ultrasound scan

 Right atrium

98

10

0

1

 Superior vena cava

6

83

0

3

 Internal jugular vein

0

0

5

0

Overall, ultrasonography was not able to correctly define the catheter position in relation to the right atrium in six patients. In one of the cases in which at the ultrasound examination the catheter was mistakenly placed in the right atrium, the patient had a dual-chamber pacemaker, and a previously inserted tunneled central venous catheter for dialysis. The remaining five cases had chest wall abnormalities (one patient with chest trauma and previously subjected to lung bilateral transplantation, two patients with barrel chest for chronic obstructive pulmonary disease, one patient with pectus excavatum, and one with chest alteration due to restrictive lung disease). We have subsequently evaluated the ability of ultrasound in identifying the catheter within the atrium in two subgroups of patients, those who had a normal conformation of the rib cage and those with anatomy alterations. In the first subgroup we have found a sensitivity of 98 %, a specificity of 93 %, a PPV of 93 % and a NPV of 98 %. The correlation between two methods was high (Kappa = 87 %, p < 0.0001). In the group of patients who had abnormal chest structure, sensitivity of US was found to be 75 %, specificity 64 %, PPV of 75 % and NPV of 64 %. In this subgroup, the correlation between the two techniques was only moderate (Kappa = 45 %, p = NS). Finally, to check whether the differences in the two groups were statistically significant and, therefore, attributable to the presence or absence of alterations of the structure of the rib cage, we compared the cases where the US was unable to correctly locate the catheter in relation to the presence of altered thoracic anatomy. The difference was statistically significant (p = < 0.041), demonstrating that the ability to identify if the catheter was located within the right atrium was affected by the presence of alterations of the anatomy of the chest.

Discussion

The central venous catheterization is a safe procedure in most cases; but despite this, the wrong positioning of the catheter may be associated with even severe complications, including death of the patient. Some of these complications, such as the puncture bleeding, the development of hematoma or cervical nerve lesions, are easy and objective, while for the verification of the wrong positioning itself and the search for other complications such as pneumothorax, hemothorax or the hemopericardium, it is necessary to perform a chest X-ray as recommended by all protocols [28, 29]. The use of the catheter should be delayed until such time as it is certain that this is positioned correctly; often, however, the delay due to the time that elapses between the request of chest X-ray until reporting its results can be harmful to the critically ill patient. The time required to obtain the results of the X-ray is frequently very high, and in our series, the value was an average of 65 min ± DS 74. The time required to perform the US was found to be significantly shorter, with an average of 5 min ± DS 3, since with ultrasound diagnostic evaluation takes place during the acquisition of images itself. The time advantage of US is to be of great importance, particularly in emergency venous catheterization, for the opportunity to start treatment as early as possible greatly impacting on patient outcome, while in the case of the pending X-ray report, the patient cannot be handled properly, especially when mechanical complications have occurred. Some researchers have even questioned the real usefulness of the chest X-ray study performed after central venous catheterization in the absence of obvious clinical complications, whereas a simple procedure deemed by operator and a number less than three punctures to locate the blood vessel, has an high NPV for the presence of pneumothorax [30, 31], other studies have also highlighted the costs of this procedure [28, 32, 33].

A further topic against the execution of the chest X-ray study is represented by the exposure of the patient to ionizing radiation, especially for those admitted to the ICU where the daily recourse to the radiological diagnosis is high. The major technical advances of US that occurred in recent decades have led to considerable improvement in resolution of the images obtained with this method, so that the US is now a technique increasingly used in the field of emergency medicine and in ICU [34, 35, 36]. In fact, both the ability to perform the examination directly at the bedside, its non-invasiveness and repeatability are all features that make this method very advantageous in the management of critically ill patients, representing an important aid in the diagnosis, evaluation of the undertaken therapies and during invasive procedures. It has been demonstrated that the US has a specificity and sensitivity greater than the chest X-ray in the diagnosis of pneumothorax [16, 23, 34], especially in cases where the patient must maintain a supine obliged position. Similar data have also been obtained with regard to the diagnosis of hemothorax [34, 37]. With this method, we can also easily display both the jugular vein and the subclavian vein. Furthermore, the high echogenicity of the materials that make up the modern intravenous catheters makes their ultrasonographic identification particularly easy at the level of the main veins of the upper part of the body and also within the cardiac chambers [3, 34]. Although US is now widely used as a guide for insertion of central venous catheters, and this has led to an increased percentage of successful procedures [1, 24, 38] and to a reduction of time required for the procedure itself, so far, there are only few studies in the literature suggesting that this method for post-procedure evaluation is a possible alternative to chest X-ray [19, 20, 21, 22]. All these were made in ICU, in patients with different clinical characteristics and often undergoing mechanical ventilation; on the contrary, our population was formed of acutely ill patients who, in emergency situation, required the sudden insertion of a central venous line. Various studies have shown that US, limited to searching for the specific questions (focus directed), can be done by an EP without difficulty [34, 35, 36]. In all previous studies, it has always been necessary to have two operators for each procedure performed, one to insert the catheter and another to perform US. We thought that in clinical practice, it would be more advantageous, regarding the management of time and human resource, if both phases were carried out by one person. In our study, US was precisely performed by the EP who had placed the CVC, and was executable and interpretable in all cases contrary to the percentages of the feasibility of this method in the literature [20, 22]. Regarding the correct position of the CVC, the question appears to be still controversial. We believe that in case of short-term central venous catheterization, during medical emergencies, the correct position of the CVC is both at the level of terminal part of the superior vena cava, both inside the right atrium near the atrium–caval junction. In fact, in the literature, there are various studies which show that this position of the catheter tip is not associated with an increased risk of complications [39]. Indeed, it is important to note that most of the literature case reports of cardiac perforation associated with intra-atrial catheter placement date back to the 1970s and 1980s, a time when the catheter materials were very different from those used today, resulting in a more rigid catheter with high thrombogenic intrinsic properties [40, 41]. Even the placement of the catheter at the level of the atrium associated with clinically significant complications such as venous thrombosis, it turns out to be much more frequent at this level when the catheter is located inside atrium [39, 42, 43]. The position at the level of the upper part of right atrium is, therefore, now considered safe by most researchers, provided that the tip is not in contact with the heart wall, and does not pass through the tricuspid valve [2, 39, 44, 45, 46]. Moreover, the venous oxygen saturation measured at the level of the atrium would seem to correlate more adequately to the mixed venous saturation measured into the pulmonary artery than that measured at the level of the superior vena cava [47]. In our study, with US, we were able to identify five cases (2 %) of bad positioning of the catheter, which required a repositioning, showing a perfect correlation with the chest X-ray study. The catheter in all these cases was positioned at the level of the internal jugular vein ipsilateral to the cannulated subclavian. Regarding the mechanical complications, three cases of iatrogenic pneumothorax were detected, both shown by US and confirmed by chest X-ray study (sensitivity 100 %). The sensitivity and specificity of the US in identifying the intra-atrial position of the catheter were, respectively, 94 and 89 %, demonstrating a significant correlation with chest radiography, and these values were found to be higher in the subgroup of patients with a normal conformation of the thoracic cage (98 % sensitivity and specificity of the 93 %). The difference noted between the patients with abnormalities of the rib cage and those who showed normal anatomy appears to be statistically significant.

Among the limitations of our study is the fact that we compared US results with those obtained with chest X-ray, a technique which, though it is still considered the gold standard, in fact has a low accuracy in locating the catheter tip, and certainly much overestimated accuracy of the chest X-ray study. Indeed, the junction between the superior vena cava and right atrium is not directly visualized on chest X-ray study performed at the bedside. It has been demonstrated that the reading of the X-ray based on common radiological landmarks would lead from 20 to 40 % false-positive results as to the intra-atrial position of the tip of the catheter, and that none of the radiological landmarks used allows one to locate the catheter tip in a reliable manner to 100 % [48, 49]. In addition, inter-operator variability in reading the chest X-ray study is high [11]. We must also remember that ultrasound does not identify the possible, though very rare, malpositioning of the catheter at the level of small veins (e.g., within the azygos vein), on the other hand, even a chest X-ray study is often not be able to demonstrate this complication [39]. Our study showed that the US, performed at the bedside of patient in emergency conditions, is able to identify with accuracy and speed, possible malpositioning of the catheter resulting from cannulation of central veins, and its complications. A high correlation was found by comparison with chest X-ray study, still considered the gold standard, and the less time required to perform the US, justify the use of ultrasound as an alternative method to maintain control post-procedure, thus allowing early use of the catheter for the administration of acute therapies that can be life-saving for the critically ill patient. Moreover, the possibility that the same operator who has carried out the catheterization can check the positioning of the catheter and the possible presence of mechanical complications is very advantageous as regards the time management and human resources, resulting in a reduction of costs.

Notes

Conflict of interest

None.

References

  1. 1.
    Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM (1994) Complications and failures of subclavian-vein catheterization. N Engl J Med 331:1735–1738PubMedCrossRefGoogle Scholar
  2. 2.
    Polderman KH, Girbes AJ (2002) Central venous catheter use. Part 1: mechanical complications. Int Care Med 28:1–17CrossRefGoogle Scholar
  3. 3.
    Gilon D, Schechter D, Rein AJ, Gimmon Z, Or R, Rozenman Y, Slavin S, Gotsman MS, Nagler A (1998) Right atrial thrombi are related to indwelling central venous catheter position: insights into time course and possible mechanism of formation. Am Heart J 135:457–462PubMedCrossRefGoogle Scholar
  4. 4.
    McGee DC, Gould MK (2003) Preventing complications of central venous catheterization. N Engl J Med 348:1123–1133PubMedCrossRefGoogle Scholar
  5. 5.
    Ruesch S, Walder B, Tramer MR (2002) Complications of central venous catheters: internal jugular versus subclavian access—a systematic review. Crit Care Med 30:454–460PubMedCrossRefGoogle Scholar
  6. 6.
    Collier PE, Ryan JJ, Diamond DL (1984) Cardiac tamponade from central venous catheters: report of a case and review of the English literature. Angiology 35:595–600PubMedCrossRefGoogle Scholar
  7. 7.
    Ambesh SP, Pandey JC, Dubey PK (2001) Internal jugular vein occlusion test for rapid diagnosis of misplaced subclavian vein catheter into the internal jugular vein. Anesthesiology 95:1377–1379PubMedCrossRefGoogle Scholar
  8. 8.
    Ender J, Erdoes G, Krohmer E, Olthoff D, Mukherjee C (2009) Transesophageal echocardiography for verification of the position of the electrocardiographically-placed central venous catheter1. J Cardiothorac Vasc Anesth 23:457–461PubMedCrossRefGoogle Scholar
  9. 9.
    Parigi GB, Verga G (1997) Accurate placement of central venous catheters in pediatric patients using endocavitary electrocardiography: reassessment of a personal technique. J Pediatr Surg 32:1226–1228PubMedCrossRefGoogle Scholar
  10. 10.
    Rath GP, Bithal PK, Toshniwal GR, Prabhakar H, Dash HH (2009) Saline flush test for bedside detection of misplaced subclavian vein catheter into ipsilateral internal jugular vein. Br J Anaesth 102:499–502PubMedCrossRefGoogle Scholar
  11. 11.
    Wirsing M, Schummer C, Neumann R, Steenbeck J, Schmidt P, Schummer W (2008) Is traditional reading of the bedside chest radiograph appropriate to detect intraatrial central venous catheter position? Chest 134:527–533PubMedCrossRefGoogle Scholar
  12. 12.
    Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C, Thomas S (2003) Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 327:361PubMedCrossRefGoogle Scholar
  13. 13.
    Beaulieu Y, Marik PE (2005) Bedside ultrasonography in the ICU: part 1. Chest 128:881–895PubMedCrossRefGoogle Scholar
  14. 14.
    Beaulieu Y (2007) Bedside echocardiography in the assessment of the critically ill. Crit Care Med 35:S235–S249PubMedCrossRefGoogle Scholar
  15. 15.
    Gunst M, Ghaemmaghami V, Sperry J, Robinson M, O’Keeffe T, Friese R, Frankel H (2008) Accuracy of cardiac function and volume status estimates using the bedside echocardiographic assessment in trauma/critical care. J Trauma 65:509–516PubMedCrossRefGoogle Scholar
  16. 16.
    Lichtenstein DA, Menu Y (1995) A bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung sliding. Chest 108:1345–1348CrossRefGoogle Scholar
  17. 17.
    Melamed R, Sprenkle MD, Ulstad VK, Herzog CA, Leatherman JW (2009) Assessment of left ventricular function by intensivists using hand-held echocardiography. Chest 135:1416–1420PubMedCrossRefGoogle Scholar
  18. 18.
    Stawicki SP, Braslow BM, Panebianco NL, Kirkpatrick JN, Gracias VH, Hayden GE, Dean AJ (2009) Intensivist use of hand-carried ultrasonography to measure IVC collapsibility in estimating intravascular volume status: correlations with CVP. J Am Coll Surg 209:55–61PubMedCrossRefGoogle Scholar
  19. 19.
    Lanza C, Russo M, Fabrizzi G (2006) Central venous cannulation: are routine chest radiographs necessary after B-mode and colour Doppler sonography check? Pediatr Radiol 36:1252–1256PubMedCrossRefGoogle Scholar
  20. 20.
    Matsushima K, Frankel HL (2010) Bedside ultrasound can safely eliminate the need for chest radiographs after central venous catheter placement: CVC sono in the surgical ICU (SICU). J Surg Res 163:155–161PubMedCrossRefGoogle Scholar
  21. 21.
    Maury E, Guglielminotti J, Alzieu M, Guidet B, Offenstadt G (2001) Ultrasonic examination: an alternative to chest radiography after central venous catheter insertion? Am J Respir Crit Care Med 164:403–405PubMedGoogle Scholar
  22. 22.
    Vezzani A, Brusasco C, Palermo S, Launo C, Mergoni M, Corradi F (2010) Ultrasound localization of central vein catheter and detection of postprocedural pneumothorax: an alternative to chest radiography. Crit Care Med 38:533–538PubMedCrossRefGoogle Scholar
  23. 23.
    Lichtenstein D, Meziere G, Biderman P, Gepner A (1999) The comet-tail artifact: an ultrasound sign ruling out pneumothorax. Int Care Med 25:383–388CrossRefGoogle Scholar
  24. 24.
    Lefrant JY, Cuvillon P, Benezet JF, Dauzat M, Peray P, Saissi G, de La Coussaye JE, Eledjam JJ (1998) Pulsed Doppler ultrasonography guidance for catheterization of the subclavian vein: a randomized study. Anesthesiology 88:1195–1201PubMedCrossRefGoogle Scholar
  25. 25.
    Randolph AG, Cook DJ, Gonzales CA, Pribble CG (1996) Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med 24:2053–2058PubMedCrossRefGoogle Scholar
  26. 26.
    American College of Emergency Physicians (2009) Emergency ultrasound guidelines. Ann Emerg Med 53:550–570Google Scholar
  27. 27.
    Lichtenstein D, Meziere G, Biderman P, Gepner A (2000) The “lung point”: an ultrasound sign specific to pneumothorax. Int Care Med 26:1434–1440CrossRefGoogle Scholar
  28. 28.
    Gladwin MT, Slonim A, Landucci DL, Gutierrez DC, Cunnion RE (1999) Cannulation of the internal jugular vein: is postprocedural chest radiography always necessary? Crit Care Med 27:1819–1823PubMedCrossRefGoogle Scholar
  29. 29.
    Gray P, Sullivan G, Ostryzniuk P, McEwen TA, Rigby M, Roberts DE (1992) Value of postprocedural chest radiographs in the adult intensive care unit. Crit Care Med 20:1513–1518PubMedCrossRefGoogle Scholar
  30. 30.
    Chang TC, Funaki B, Szymski GX (1998) Are routine chest radiographs necessary after image-guided placement of internal jugular central venous access devices? AJR Am J Roentgenol 170:335–337PubMedGoogle Scholar
  31. 31.
    Gladwin MT, Slonim A, Landucci DL, Gutierrez DC, Cunnion RE (1999) Cannulation of the internal jugular vein: is postprocedural chest radiography always necessary? Crit Care Med 27:1819–1823PubMedCrossRefGoogle Scholar
  32. 32.
    Aleman C, Alegre J, Armadans L, Andreu J, Falco V, Recio J, Cervera C, Ruiz E, De Fernandez ST (1999) The value of chest roentgenography in the diagnosis of pneumothorax after thoracentesis. Am J Med 107:340–343PubMedCrossRefGoogle Scholar
  33. 33.
    Harrison AM, Clay B, Grant MJ, Sanders SV, Webster HF, Reading JC, Dean JM, Witte MK (1997) Nonradiographic assessment of enteral feeding tube position. Crit Care Med 25:2055–2059PubMedCrossRefGoogle Scholar
  34. 34.
    Miller AH, Roth BA, Mills TJ, Woody JR, Longmoor CE, Foster B (2002) Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Acad Emerg Med 9:800–805PubMedCrossRefGoogle Scholar
  35. 35.
    Pierard LA, Lancellotti P (2009) Echocardiography in the emergency room: non-invasive imaging. Heart 95:164–170PubMedCrossRefGoogle Scholar
  36. 36.
    Vieillard-Baron A, Slama M, Cholley B, Janvier G, Vignon P (2008) Echocardiography in the intensive care unit: from evolution to revolution? Int Care Med 34:243–249CrossRefGoogle Scholar
  37. 37.
    Sisley AC, Rozycki GS, Ballard RB, Namias N, Salomone JP, Feliciano DV (1998) Rapid detection of traumatic effusion using surgeon-performed ultrasonography. J Trauma 44:291–296PubMedCrossRefGoogle Scholar
  38. 38.
    Hatfield A, Bodenham A (1999) Portable ultrasound for difficult central venous access. Br J Anaesth 82:822–826PubMedCrossRefGoogle Scholar
  39. 39.
    Fletcher SJ, Bodenham AR (2000) Safe placement of central venous catheters: where should the tip of the catheter lie? Br J Anaesth 85:188–191PubMedCrossRefGoogle Scholar
  40. 40.
    Aksenov AN, Kostiuchenko AL (2000) The significance of the material of vascular catheters in the development of thrombotic complications in cava catheterization. Vestn Khir Im I I Grek 159:79–81PubMedGoogle Scholar
  41. 41.
    Keltai M, Farkas P, Dekany P (1986) Catheter perforation of the heart. Cor Vasa 28:365–368PubMedGoogle Scholar
  42. 42.
    Puel V, Caudry M, Le MP, Baste JC, Midy D, Marsault C, Demeaux H, Maire JP (1993) Superior vena cava thrombosis related to catheter malposition in cancer chemotherapy given through implanted ports. Cancer 72:2248–2252PubMedCrossRefGoogle Scholar
  43. 43.
    Stanislav GV, Fitzgibbons RJ Jr, Bailey RT Jr, Mailliard JA, Johnson PS, Feole JB (1987) Reliability of implantable central venous access devices in patients with cancer. Arch Surg 122:1280–1283PubMedCrossRefGoogle Scholar
  44. 44.
    National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (2001) III. NKF-K/DOQI clinical practice guidelines for vascular access: update 2000. Am J Kidney Dis 37:S137–S181Google Scholar
  45. 45.
    Chamorro C, Pardo C, Alberto SJ, Borrallo Angel Romera Jose Manuel, Luis Martinez-Melgar J (2001) Malposition of central venous catheters in hospitalized patients. Med Clin (Barc) 117:12–13Google Scholar
  46. 46.
    Torres-Millan J, Torres-Lopez M, Benjumea-Serna M (2010) Location of the central venous catheter tip in the right atrium: description in 2348 critical patients. Med Int 34:595–599Google Scholar
  47. 47.
    Kopterides P, Bonovas S, Mavrou I, Kostadima E, Zakynthinos E, Armaganidis A (2009) Venous oxygen saturation and lactate gradient from superior vena cava to pulmonary artery in patients with septic shock. Shock 31:561–567PubMedCrossRefGoogle Scholar
  48. 48.
    Aslamy Z, Dewald CL, Heffner JE (1998) MRI of central venous anatomy: implications for central venous catheter insertion. Chest 114:820–826PubMedCrossRefGoogle Scholar
  49. 49.
    Reynolds N, McCulloch AS, Pennington CR, MacFadyen RJ (2001) Assessment of distal tip position of long-term central venous feeding catheters using transesophageal echocardiology. JPEN J Parenter Enteral Nutr 25:39–41PubMedCrossRefGoogle Scholar

Copyright information

© SIMI 2012

Authors and Affiliations

  • Maurizio Zanobetti
    • 1
    • 2
    • 4
  • Alessandro Coppa
    • 1
    • 2
  • Federico Bulletti
    • 1
    • 2
  • Serena Piazza
    • 1
    • 2
  • Peyman Nazerian
    • 3
  • Alberto Conti
    • 1
    • 2
  • Francesca Innocenti
    • 1
    • 2
  • Stefano Ponchietti
    • 3
  • Sofia Bigiarini
    • 1
    • 2
  • Aurelia Guzzo
    • 1
    • 2
  • Claudio Poggioni
    • 1
    • 2
  • Beatrice Del Taglia
    • 1
    • 2
  • Yuri Mariannini
    • 1
    • 2
  • Riccardo Pini
    • 1
    • 2
  1. 1.Intensive Observation UnitCareggi University HospitalFlorenceItaly
  2. 2.Department of Critical Care Medicine and SurgeryUniversity of FlorenceFlorenceItaly
  3. 3.Emergency DepartmentCareggi University HospitalFlorenceItaly
  4. 4.SOD Osservazione Breve IntensivaAzienda Ospedaliero-Universitaria CareggiFlorenceItaly

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