References
Diagnostic accuracy among trainees to safely confirm peripherally inserted central catheter (PICC) placement using bedside ultrasound
Abstract
Background
Real-time utilization of ultrasound to confirm peripherally inserted central catheter (PICC) placement improves efficacy and reduces patient radiation exposure. We evaluated if novice ultrasound users could accurately confirm appropriate PICC tip location via ultrasound assessment.
Methodology
A prospective data collection study was conducted in an academic center with an established PICC team. Novice ultrasonography users performed 2 echocardiographic views (subcostal and apical 4 chamber) and noted position of visible wire. The presence of central bubbles (visualized in the heart) after a saline infusion, as well as time to bubbles (push-to-bubbles) seen in all patients, was also recorded. Image quality and confidence in imaging acquisition was also recorded.
Results
Twenty-eight patients between ages 0 and 18 were enrolled over the study period with mean patient age of 10 years and median weight of 34 kg. The quality of image acquisition was rated as great only 34–44%. The wire was visualized only 25% of the time. The median push-to-bubble time when the PICC was later confirmed to be in appropriate positioning was 1.5 seconds with a delay of greater than 3 seconds 40% of the time when the line was malpositioned. The overall positive predictive value of ultrasound identifying malpositioned lines in this study was 43%.
Conclusions
With this PICC placement technique, ultrasound confirmation of PICC placement by novice ultrasound users was not superior to confirmation with chest radiograph. There may remain potential for future ultrasound protocols, with pediatric-specific technology or echogenic catheter tips, to reduce radiation exposure from chest radiograph during PICC line positioning verification.
Central venous catheter (CVC) insertion is a common procedure among hospitalized patients with more than 5 million CVCs placed annually in the United States.1 As peripherally inserted central catheters (PICCs) can be inserted through a cephalic vein or basilic vein in the upper arm with low risk of complications, they are often a preferred option for long-term intravenous access.2
Immediate complications can occur at the time of catheter insertion and include injury to local structures, including possible nerve injury, phlebitis, air embolism, hematoma, induced arrhythmias, catheter malposition, and rare cardiac and vascular complications.3 The use of ultrasound in combination with the known Seldinger technique used for insertion of CVCs has been demonstrated to yield better puncture success rates and lower incidence rates of postoperative complications.4
Catheter tip malposition is common surrounding PICC insertion, often requiring repositioning or even replacement.5 While the exact position for catheter tip placement continues to be controversial, the lower one-third of the superior vena cava (SVC) at the caval-atrial junction (CAJ) is commonly targeted with upper extremity PICC placement.6 Several methods to confirm PICC line positioning have been proposed, and chest radiography is still the gold standard7; however, identification of exact tip location of PICC line on chest radiography at the CAJ may be less accurate with reports as low as 14% positive predictive value,8 which has prompted investigations into other methods to improve identification and accuracy.
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