1. Lawrence Lau TJUH Emergency Medicine PGY-1

2. CVC Insertion with US Guidance  US procedural guidance has become standard of care in placing central venous catheters  Numerous studies show increased success, decreased arterial puncture, decreased PTX with US guidance  CXR to confirm placement is ordered to confirm placement

4. Placement in accessory vein (white) Arterial placement (black) Placement in right subclavian artery Curled catheter tip

5. Questions  Can US Guidance be used to confirm placement of CVC in SVC?  Can this approach minimize time to use of CVC?

6. CVC Identification in SVC  BY EXCLUSION:  IJV insertion Scan IJV b/l, Subclavian vein, heart chambers, IVC  Subclavian insertion Subclavian vein, IJV b/l, heart chambers, IVC

7. Anatomy

8. Matsushima et al. (2010)  Study: Prospective Blinded Study  Population: SICU patients requiring CVC or PICC  Method: One intensivist placing lines, one blinded sonographer, 5 & 13 mHz (sonosite)  Evaluated: PTX/hemoTX, Catheter tip placement in cardiac or SVC  All catheters evaluated by CXR and certified radiologist  Time to catheter evaluation recorded

9. Matsushima et al. (2010)  Results 83 catheters evaluated, 42 CVC Only 1 CVC false negative case (IJ in INV) Accuracy US Sono 90% (PPV 83%, NPV 91%) ○ Accuracy 93% if only 1 catheter (NPV 95%) Mean sono time 10.8min Mean CXR 75.3 min (p<001) Confounding factors to US technique ○ Patients with chest tubes, trauma pts Nonconfounding ○ Obesity, open abdomen, c-collar

10. Zanobetti et al. (2012)  Study: Prospective blind observational  Population: Level 1 Tertiary care center ED patients  Placement by ED physicians/residents, US by same physician/resident  US training according to ACEP guidelines  Bedside CXR to confirm placement

11. Zanobetti et al. (2012)  Results 210 patients US interpretation in 5+/- 3 min Time to CXR 65 +/- 74 min 5 PTX correctly identified by US and CXR US PPV 91%, NPV 93% Concordance kappa 82% p<0.0001 ○ Only 4% clinically relevant discordance Confounding US visualization ○ Multiple catheters, pacemaker leads, chest wall abnormalities (6 cases)

12. Geckle (July 2015)  Consecutive Prospective study  Population: 81 ED patients >18 years  13 excluded for improper sono recordings  CVC placed by ED Physician, verified by parasternal/SX cardiac US with Saline Flush test  CXR ordered for confirmation

13. Saline Flush Test

14. Geckle (July 2015)  Results Time to CVC confirmation with saline flush mean 8.80 minutes vs 45.78 CXR 100% concordance between modalities No discordance with evaluation of complications (PTX)

15. Take home points  US guidance prospectively has good NPV and PPV for confirming placement of CVC  US decreases time to confirmation compared to CXR  Populations with increased missed placement include Chest wall abnormalities Trauma patients Patients with chest tubes Patients with more than one CVC

16. References  Geckle et. Al. Saline Flush Test: Can Bedside Sonography Replace Conventional Radiography for Confirmation of Above-the-Diaphragm Central Venous Catheter Placement? J Ultrasound Med. 2015 Jul;34(7):1295-9. doi: 10.7863/ultra.34.7.1295.J Ultrasound Med.  Braviskar et. Al. Confirmation of endovenous placement of central catheter using the ultrasonographic “bubble test” Indian J Crit Care Med. 2015 Jan; 19(1): 38–41. doi: 10.4103/0972-5229.14864210.4103/0972-5229.148642  Zanobetti et. Al. Verification of correct central venous catheter placement in the emergency department: comparison between ultrasonography and chest radiography. Intern Emerg Med. 2013 Mar;8(2):173-80. doi: 10.1007/s11739-012-0885-7. Epub 2012 Dec 16.Intern Emerg Med.  Matsushima et al. 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. 2010 Sep;163(1):155-61. doi: 10.1016/j.jss.2010.04.020. Epub 2010 May 11.J Surg Res.