Critical Care Medicine  |   April 2020
Ultrasound to Detect Central Venous Catheter Placement Associated Complications: A Multicenter Diagnostic Accuracy Study
Author Notes
  • From the Department of Intensive Care Medicine, Research VU University Medical Center (VUmc) Intensive Care, Amsterdam Cardiovascular Sciences, and Amsterdam Infection and Immunity Institute, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands (J.M.S., M.E.H., E.H.T.L., T.S.S., H.R.W.T., A.R.J.G., L.M.A.H., P.R.T.); the Department of Intensive Care Medicine, Rijnstate Hospital, Arnhem, The Netherlands (M.J.B., F.H.B.), and the Department of Intensive Care Medicine, Groene Hart Hospital, Gouda, The Netherlands (M.P., B.V.).
  • The preliminary results were reported as a poster at the annual LIVES congress of the European Society of Intensive Care Medicine in Paris, France, October 22, 2018.
    The preliminary results were reported as a poster at the annual LIVES congress of the European Society of Intensive Care Medicine in Paris, France, October 22, 2018.×
  • Submitted for publication March 7, 2019. Accepted for publication December 11, 2019. Published online first on January 21, 2020.
    Submitted for publication March 7, 2019. Accepted for publication December 11, 2019. Published online first on January 21, 2020.×
  • Address correspondence to Dr. Smit: Amsterdam University Medical Center, VU University, Department of Intensive Care Medicine, Boelelaan 1117, Postbus 7057, 1007 MB Amsterdam, The Netherlands. j.smit6@vumc.nl. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Critical Care Medicine / Clinical Science / Critical Care / Radiological and Other Imaging / Respiratory System
Critical Care Medicine   |   April 2020
Ultrasound to Detect Central Venous Catheter Placement Associated Complications: A Multicenter Diagnostic Accuracy Study
Anesthesiology 4 2020, Vol.132, 781-794. doi:https://doi.org/10.1097/ALN.0000000000003126
Anesthesiology 4 2020, Vol.132, 781-794. doi:https://doi.org/10.1097/ALN.0000000000003126
Abstract

Background: Mechanical complications arising after central venous catheter placement are mostly malposition or pneumothorax. To date, to confirm correct position and detect pneumothorax, chest x-ray film has been the reference standard, while ultrasound might be an accurate alternative. The aim of this study was to evaluate diagnostic accuracy of ultrasound to detect central venous catheter malposition and pneumothorax.

Methods: This was a prospective, multicenter, diagnostic accuracy study conducted at the intensive care unit and postanesthesia care unit. Adult patients who underwent central venous catheterization of the internal jugular vein or subclavian vein were included. Index test consisted of venous, cardiac, and lung ultrasound. Standard reference test was chest x-ray film. Primary outcome was diagnostic accuracy of ultrasound to detect malposition and pneumothorax; for malposition, sensitivity, specificity, and other accuracy parameters were estimated. For pneumothorax, because chest x-ray film is an inaccurate reference standard to diagnose it, agreement and Cohen’s κ-coefficient were determined. Secondary outcomes were accuracy of ultrasound to detect clinically relevant complications and feasibility of ultrasound.

Results: In total, 758 central venous catheterizations were included. Malposition occurred in 23 (3.3%) out of 688 cases included in the analysis. Ultrasound sensitivity was 0.70 (95% CI, 0.49 to 0.86) and specificity 0.99 (95% CI, 0.98 to 1.00). Pneumothorax occurred in 5 (0.7%) to 11 (1.5%) out of 756 cases according to chest x-ray film and ultrasound, respectively. In 748 out of 756 cases (98.9%), there was agreement between ultrasound and chest x-ray film with a Cohen’s κ-coefficient of 0.50 (95% CI, 0.19 to 0.80).

Conclusions: This multicenter study shows that the complication rate of central venous catheterization is low and that ultrasound produces a moderate sensitivity and high specificity to detect malposition. There is moderate agreement with chest x-ray film for pneumothorax. In conclusion, ultrasound is an accurate diagnostic modality to detect malposition and pneumothorax.

Editor’s Perspective:

What We Already Know about This Topic:

  • Catheter malposition and pneumothorax are known complications of central line placement. Earlier recognition of these complications can lead to reduced morbidity and mortality. Chest x-ray film is typically used to evaluate for appropriate central line positioning and potential pneumothorax.

What This Article Tells Us That Is New:

  • This prospective multicenter diagnostic accuracy study found that ultrasound can detect central line malposition with moderate sensitivity and high specificity.

  • This study found that there is moderate agreement between chest x-ray film and ultrasound detection of central line–related pneumothorax.