DYNAMIC EMERGENCY MEDICINE Use of Echocardiography to Identify Appropriate Placement of a Central Venous Catheter Wire in the Vena Cava Prior to Cannulation Abstract Ultrasound guidance is now the standard of care when placing a central venous catheter (CVC), resulting in decreased complications and increased first-pass success rates. However, even with ultrasound guidance being used for the initial venipuncture, misplacement of a CVC in either an unwanted vein or in an artery still occurs. Here, we discuss a simple technique to assist in the adequate placement of the CVC in the vena cava using bedside echocardiography. ACADEMIC EMERGENCY MEDICINE 2014;21:E1–E2 © 2014 by the Society for Academic Emergency Medicine
Central venous catheter (CVC) placement is a critical intervention that can assist in the monitoring and resuscitation of a critically ill, crashing patient.1 Traditionally, the landmarkbased approach was used for placement of a CVC, but recent literature shows that using ultrasound (US) guidance decreases complication rates and increases first-pass success, shifting the standard of care when performing a CVC toward US guidance.2–8 Recently, emphasis has been placed on identifying the guidewire in the proximal central vein prior to cannulation after dynamic US guidance has been used for the initial venipuncture.3,6 In this publication, a novel two-person technique of using US to identify the guidewire in the vena cava prior to cannulation will be described, which can be used avoid misplacement of the CVC in an unwanted central vein, or an artery, as even with dynamic US guidance, arterial puncture has been described.9 Ultrasound has a multitude of uses when placing a CVC. However, US is not traditionally used to assure the provider that the CVC is in the vena cava; that is a job that is generally reserved for the postprocedure X-ray. We suggest that point-of-care echocardiography can be used to identify appropriate placement of the guidewire in the right atrial (RA)/inferior vena cava (IVC) junction prior to advancement of the CVC. This technique is shown in the Video Clip S1 (available as supporting information in the online version of this paper) and is described as follows:
• • • •
The patient is prepared for the procedure in the typical sterile technique.10 After a vascular US transducer has been used to place the introducer needle and guidewire into the central vein, a phased-array transducer is placed into the subxiphoid window by a second operator. The guidewire is slowly advanced until a bright, hyperechoic, pinpoint structure is identified in the IVC or the RA/IVC junction, which represents the tip of the guidewire. After the tip of the guidewire has been located in the IVC or RA/IVC junction, the dilator can be introduced, and the
© 2014 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12430
CVC can subsequently be placed with high confidence that it is present in the vena cava. Using a cardiac US window for the evaluation of the correct placement of a transvenous pacing wire has been described previously in the emergency medicine literature, where various echo windows were used to identify the pacer lead in the right ventricle.11,12 A similar technique focusing on the RA junction can be used to observe the adequate placement of the CVC guidewire. Sparse literature exists in emergency medicine describing the technique for using bedside echocardiography to identify adequate placement of the guidewire into the vena cava,13 and no published data directly addressing accuracy in the emergency department (ED) have been identified. However, a recent critical care publication by Bedel et al.,14 which included 99 patients with a total of 101 CVCs, compared transthoracic echocardiography with chest radiography for confirmation of adequate central line placement. In that prospective observational study, they showed a sensitivity of 96%, specificity of 83%, positive predictive value of 98%, and negative predictive value of 55% for diagnosing adequate guidewire placement using bedside echo.14 These findings suggest that this technique can be successfully performed in an ED to confirm guidewire placement into the vena cava. Further randomized prospective studies would help validate this technique as an accurate and viable adjunct to the chest X-ray in the confirmation of appropriate CVC placement. Jacob O. Avila, MD ([email protected]) Benjamin C. Smith, MD David C. Seaberg, MD Department of Emergency Medicine University of Tennessee College of Medicine Chattanooga Emergency Heart-Stroke Center Erlanger Medical Center Chattanooga, TN Supervising Editor: Scott Joing, MD.
ISSN 1069-6563 PII ISSN 1069-6563583
1 E1
E2
Avila et al. • ECHOCARDIOGRAPHY FOR GUIDEWIRE POSITIONING
References 1. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368–77. 2. Shojania KG, Duncan BW, McDonald KM, Wachter RM, Markowitz AJ. Making health care safer: a critical analysis of patient safety practices. Evid Rep Technol Assess 2001;43:1–668. 3. Stone MB, Nagdev A, Murphy MC, Sisson CA. Ultrasound detection of guidewire position during central venous catheterization. Am J Emerg Med 2010;28:82–4. 4. Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med 1996; 12:2053–8. 5. Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices for central venous cannulation: a meta-analysis. BMJ 2003;327:361–4. 6. Dodge KL, Lynch CA, Moore CL, Biroscak BJ, Evans LV. Use of ultrasound guidance improves central venous catheter insertion success rates among junior residents. J Ultrasound Med 2012;31:1519–26. 7. Milling TJ Jr, Rose J, Briggs WM, et al. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: the Third Sonography Outcomes Assessment Program (SOAP-3) trial. Crit Care Med 2005;8:1764–9. 8. Leung J, Duffy M, Finckh A. Real-time ultrasonographically-guided internal jugular vein catheterization in the emer-
9.
10. 11.
12.
13. 14.
gency department increases success rates and reduces complications: a randomized, prospective study. Ann Emerg Med 2006;48:540–7. Blaivas M. Video analysis of accidental arterial cannulation with dynamic ultrasound guidance for central venous access. J Ultrasound Med 2009;28:1239–44. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123–33. Aguilera PA, Durham BA, Riley DA. Emergency transvenous cardiac pacing placement using ultrasound guidance. Ann Emerg Med 2000;36:224–7. Harrigan RA, Chan TC, Moonblatt S, Vilke GM, Ufberg JW. Temporary transvenous pacemaker placement in the emergency department. J Emerg Med 2007;32:105–11. Ma OJ, Mateer J. Emergency Ultrasound, 3rd ed. New York, NY: McGraw Hill, 2014:202. Bedel J, Vallee F, Mari A, et al. Guidewire localization by transthoracic echocardiography during central venous catheter insertion: a periprocedural method to evaluate catheter placement. Intensive Care Med 2013;39:1932–7.
Supporting Information The following supporting information is available in the online version of this paper: Video Clip S1. Use of echocardiography to identify appropriate placement of a central venous catheter wire in the vena cava prior to cannulation.
Central venous catheter (CVC) placement is a critical intervention that can assist in the monitoring and resuscitation of a critically ill, crashing patient.1 Traditionally, the landmarkbased approach was used for placement of a CVC, but recent literature shows that using ultrasound (US) guidance decreases complication rates and increases first-pass success, shifting the standard of care when performing a CVC toward US guidance.2–8 Recently, emphasis has been placed on identifying the guidewire in the proximal central vein prior to cannulation after dynamic US guidance has been used for the initial venipuncture.3,6 In this publication, a novel two-person technique of using US to identify the guidewire in the vena cava prior to cannulation will be described, which can be used avoid misplacement of the CVC in an unwanted central vein, or an artery, as even with dynamic US guidance, arterial puncture has been described.9 Ultrasound has a multitude of uses when placing a CVC. However, US is not traditionally used to assure the provider that the CVC is in the vena cava; that is a job that is generally reserved for the postprocedure X-ray. We suggest that point-of-care echocardiography can be used to identify appropriate placement of the guidewire in the right atrial (RA)/inferior vena cava (IVC) junction prior to advancement of the CVC. This technique is shown in the Video Clip S1 (available as supporting information in the online version of this paper) and is described as follows:
• • • •
The patient is prepared for the procedure in the typical sterile technique.10 After a vascular US transducer has been used to place the introducer needle and guidewire into the central vein, a phased-array transducer is placed into the subxiphoid window by a second operator. The guidewire is slowly advanced until a bright, hyperechoic, pinpoint structure is identified in the IVC or the RA/IVC junction, which represents the tip of the guidewire. After the tip of the guidewire has been located in the IVC or RA/IVC junction, the dilator can be introduced, and the
© 2014 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12430
CVC can subsequently be placed with high confidence that it is present in the vena cava. Using a cardiac US window for the evaluation of the correct placement of a transvenous pacing wire has been described previously in the emergency medicine literature, where various echo windows were used to identify the pacer lead in the right ventricle.11,12 A similar technique focusing on the RA junction can be used to observe the adequate placement of the CVC guidewire. Sparse literature exists in emergency medicine describing the technique for using bedside echocardiography to identify adequate placement of the guidewire into the vena cava,13 and no published data directly addressing accuracy in the emergency department (ED) have been identified. However, a recent critical care publication by Bedel et al.,14 which included 99 patients with a total of 101 CVCs, compared transthoracic echocardiography with chest radiography for confirmation of adequate central line placement. In that prospective observational study, they showed a sensitivity of 96%, specificity of 83%, positive predictive value of 98%, and negative predictive value of 55% for diagnosing adequate guidewire placement using bedside echo.14 These findings suggest that this technique can be successfully performed in an ED to confirm guidewire placement into the vena cava. Further randomized prospective studies would help validate this technique as an accurate and viable adjunct to the chest X-ray in the confirmation of appropriate CVC placement. Jacob O. Avila, MD ([email protected]) Benjamin C. Smith, MD David C. Seaberg, MD Department of Emergency Medicine University of Tennessee College of Medicine Chattanooga Emergency Heart-Stroke Center Erlanger Medical Center Chattanooga, TN Supervising Editor: Scott Joing, MD.
ISSN 1069-6563 PII ISSN 1069-6563583
1 E1
E2
Avila et al. • ECHOCARDIOGRAPHY FOR GUIDEWIRE POSITIONING
References 1. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368–77. 2. Shojania KG, Duncan BW, McDonald KM, Wachter RM, Markowitz AJ. Making health care safer: a critical analysis of patient safety practices. Evid Rep Technol Assess 2001;43:1–668. 3. Stone MB, Nagdev A, Murphy MC, Sisson CA. Ultrasound detection of guidewire position during central venous catheterization. Am J Emerg Med 2010;28:82–4. 4. Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med 1996; 12:2053–8. 5. Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices for central venous cannulation: a meta-analysis. BMJ 2003;327:361–4. 6. Dodge KL, Lynch CA, Moore CL, Biroscak BJ, Evans LV. Use of ultrasound guidance improves central venous catheter insertion success rates among junior residents. J Ultrasound Med 2012;31:1519–26. 7. Milling TJ Jr, Rose J, Briggs WM, et al. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: the Third Sonography Outcomes Assessment Program (SOAP-3) trial. Crit Care Med 2005;8:1764–9. 8. Leung J, Duffy M, Finckh A. Real-time ultrasonographically-guided internal jugular vein catheterization in the emer-
9.
10. 11.
12.
13. 14.
gency department increases success rates and reduces complications: a randomized, prospective study. Ann Emerg Med 2006;48:540–7. Blaivas M. Video analysis of accidental arterial cannulation with dynamic ultrasound guidance for central venous access. J Ultrasound Med 2009;28:1239–44. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123–33. Aguilera PA, Durham BA, Riley DA. Emergency transvenous cardiac pacing placement using ultrasound guidance. Ann Emerg Med 2000;36:224–7. Harrigan RA, Chan TC, Moonblatt S, Vilke GM, Ufberg JW. Temporary transvenous pacemaker placement in the emergency department. J Emerg Med 2007;32:105–11. Ma OJ, Mateer J. Emergency Ultrasound, 3rd ed. New York, NY: McGraw Hill, 2014:202. Bedel J, Vallee F, Mari A, et al. Guidewire localization by transthoracic echocardiography during central venous catheter insertion: a periprocedural method to evaluate catheter placement. Intensive Care Med 2013;39:1932–7.
Supporting Information The following supporting information is available in the online version of this paper: Video Clip S1. Use of echocardiography to identify appropriate placement of a central venous catheter wire in the vena cava prior to cannulation.
![[Superior vena cava syndrome secondary to the placement of a central venous catheter in a neonate].](/assets/img/hold.png)
