Critical Care: Ultrasound in the ICU |

Posterior Needle Misplacement Rate in Trainees Performing Simulated Central Venous Access FREE TO VIEW

Lida Fatemi, MD; Jarrod Frizzell, MD; Joshua Duchesne, MD; Michel Boivin, MD
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University of New Mexico, Albuquerque, NM

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):466A. doi:10.1016/j.chest.2016.08.479
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SESSION TITLE: Ultrasound in the ICU

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Monday, October 24, 2016 at 04:30 PM - 05:30 PM

PURPOSE: Central venous catheterization (CVC) complications are increasingly recognized as preventable events. Pneumothorax from CVC placement is a “Hospital Acquired Condition” that is tracked by the Centers for Medicaid and Medicare services (CMS) and events seriously affect reimbursement. Ultrasound guidance has been proved to reduce mechanical complications from CVC placement. However, little is known about learner’s ability to track the needle tip during ultrasound placement. Effective needle tip guidance should eliminate mechanical complications of CVC placement. We designed a unique simulator to detect advancement of the needle past the depth of the target vessel. We then assessed for risk factors for excessive needle depth including experience, transducer position and use of a needle guide.

METHODS: Twenty resident trainees consented to the study and made 60 attempts. The trainees attempted to obtain fluid from a simulated vessel within an ultrasound gel phantom, with the vessel at a depth of 2cm. At 6 mm posterior to the vessel, the gel block rested on a metal plate. The introducer needle was attached to an electrode and touching the metal plate with the needle completed the circuit and notified the personnel that excessive needle depth occurred. The trainees made attempts in 3 ultrasound probe positions in random order: transverse probe position, longitudinal and longitudinal with a needle guide.

RESULTS: The average time to vessel cannulation in the trainees was 15 seconds. Out of 60 attempts, 8 learners made attempts that resulted in excess needle depth (13%). Use of a needle guide was associated with a time to cannulation of 14.0s, transverse probe position 16.1s and longitudinal position 16.5s. Longitudinal probe position resulted in 2 placements with excessive depth, transverse position with 2 placements of excessive depth and the needle guide assisted placement with 4. None of these differences were statistically significant. Trainee inexperience (<5 CVCs placed) was associated with a significantly longer time to successfully cannulate the vessel (12.1s vs 23.5s, p<0.01), but not a significantly higher rate of needle misplacement (17% vs 12%).

CONCLUSIONS: Learners attempting to place a CVC introducer needle into a simulated vessel using ultrasound used excessive depth 13% of the time. Ultrasound probe position, use of a needle guide and self-reported CVC experience did not effect this rate. Further subjects will be enrolled to confirm these findings.

CLINICAL IMPLICATIONS: This indicates that loss of ultrasound visualization of the needle tip is a common occurrence, and not necessarily related to learner experience. Deliberate practice to ensure constant needle visualization has the potential to reduce complications of ultrasound-guided CVC placement.

DISCLOSURE: The following authors have nothing to disclose: Lida Fatemi, Jarrod Frizzell, Joshua Duchesne, Michel Boivin

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