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Critical Care

, 18:P129 | Cite as

Is chest X-ray necessary after central venous catheter insertion?

  • MS Vallecoccia
  • F Cavallaro
  • M Biancone
  • D Settanni
  • C Marano
  • MG Annetta
  • M Pittiruti
  • M Antonelli
Open Access
Poster presentation

Keywords

Pneumothorax Central Venous Catheter Enteral Nutrition Superior Vena Superior Vena Cava 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Introduction

According to the European Society of Parenteral and Enteral Nutrition guidelines [1], post-insertion chest X-ray (CXR) is not necessary if the location of the tip has been verified during the procedure and if pleura-pulmonary damage has been ruled out by other methods. The aim of this study is to assess feasibility and safety of an echo-ECG-guided method of central venous catheter (CVC) insertion and to evaluate whether post-insertion CXR can be avoided.

Methods

We enrolled only patients admitted to our ICU and candidate to elective CVC insertion, who had a detectable P wave on surface ECG. Our insertion protocol included: preliminary ultrasound (US) scan of central veins and pleural space; US-guided puncture and US control of the correct direction of the guidewire; intracavitary ECG method for tip location (cavo-atrial junction (CAJ) = maximal P wave); and US scan of pleural space to rule out pneumothorax (PNX). Post-insertion CXR was performed in all patients to rule out PNX and verify tip location close to the CAJ (CAJ = 3 cm below the carina [2]). Tip location between 1 and 5 cm below the carina - in the lower 1/3 of the superior vena cava (SVC) or in the higher 1/3 of the right atrium (RA) - was considered acceptable [1].

Results

Eighty CVCs were placed in 78 patients, either by residents in training or by attending doctors. The vein was selected by US scan: right internal jugular (IJ) 64%, left IJ 17%, right axillary 11%, left axillary 4%, right innominate 4%. One pre-existing PNX was identified by US before the procedure. Accidental arterial puncture occurred in three cases (two by residents). In five cases, the wrong direction of the wire was detected by US and corrected during the procedure. The mean number of attempts was 1.65 (1.35 for attending vs. 1.95 for residents, P < 0.02) and mean insertion time was 10.4 minutes (8.72 for attending vs. 12.11 for residents, P < 0.005). Pleural US scan ruled out puncture-related PNX in all patients. At post-procedural CXR: no PNX was detected, 90% of tips were in the target zone, 5% were in the middle 1/3 of SVC and 5% were in the middle 1/3 of RA (all CVC with tips out of the target zone were inserted by residents).

Conclusion

Our insertion protocol was safe and effective, with minor differences between experienced versus nonexperienced operators. Our data suggest that immediate CXR is not necessary soon after CVC insertion, since PNX can be ruled out by US and since the intracavitary ECG method allows tip location in the SVC and RA in all cases.

References

  1. 1.
    Pittiruti M, et al.: Clin Nutr. 2009, 28: 365-377. 10.1016/j.clnu.2009.03.015CrossRefPubMedGoogle Scholar
  2. 2.
    Schuster M, et al.: Br J Anaesth. 2000, 85: 192-194. 10.1093/bja/85.2.192CrossRefPubMedGoogle Scholar

Copyright information

© Vallecoccia et al.; licensee BioMed Central Ltd. 2014

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors and Affiliations

  • MS Vallecoccia
    • 1
  • F Cavallaro
    • 1
  • M Biancone
    • 1
  • D Settanni
    • 1
  • C Marano
    • 1
  • MG Annetta
    • 1
  • M Pittiruti
    • 1
  • M Antonelli
    • 1
  1. 1.Catholic UniversityRomeItaly

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