PURPOSE: Use of ultrasonography for Central Venous Catheter (CVC) insertion is now routine and has significantly reduced complication rates. However inadvertent arterial cannulation is associated with significant mortality and morbidity. We describe our experience using post guidewire insertion ultrasound (US) to confirm guidewire placement in venous system vs. intra-arterial vessel cannulation before vessel dilation and catheter insertion.
METHODS: A retrospective analysis of a database of all patients undergoing CVC insertion in Central Venous Access Service at Mount Sinai Hospital from January 2010 to October 2010. Data collected included catheter type, insertion site, and indication; use of US for guidewire location, confirmatory image; and complications. The technique involves placing the US probe in transverse axis over the vein just distal to the puncture site, identifying the guidewire as a hyperechoic structure within the lumen of the vein, and also US of the artery to verify no arterial cannulation. Needle insertion technique is performed near parallel to the transducer to identify inadvertent vein though artery puncture and guidewire placement in a similar US plane.
RESULTS: 1338 patients were reviewed of which 1060 had complete data including images. Of these, 677 were central venous catheters - 525 (77.5%) Triple Lumen Catheters (TLC) and 152 (22.5%) Hemodialysis (HD) catheters. In the TLC group 475 (90.47%), 22 (4.19%), 20 (3.81%) and 4 (0.76%) were inserted in Internal Jugular, Femoral, Subclavian, and External Jugular veins respectively. In the HD group 131 (86.18%) and 21 (13.82%) were inserted in Internal Jugular and Femoral veins respectively. All the catheter placements had US of the guidewire to confirm placement in the venous system and absence of guidewire in the artery, and were confirmed by manometry. There were no events of arterial dilatation or arterial catheter placement.
CONCLUSIONS: Ultrasonography of the guidewire location prior to vessel dilation and catheter insertion to confirm position in the venous system and absence in the arterial system is safe and reliable.
CLINICAL IMPLICATIONS: Guidewire ultrasonography can replace other more risky and cumbersome methods of vessel confirmation.
DISCLOSURE: The following authors have nothing to disclose: Zafar Akram Jamkhana, John Oropello, Satyanarayana Reddy Mukkera, Aditya Uppalapati, Anthony Manasia, Roopa Kohli-Seth, Adel Bassily-Marcus, Rosanna DelGiudice, Ernest Benjamin
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