Intraoperative Chest Xray Prior to Use of Newly Inserted IJ or Subclavian Central Line

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Our pediatric anesthesia group has recently been asked how we confirm correct central line placement when we've inserted them in a jugular or subclavian vein in the operating room. Apparently there have been a few central lines recently in our children's hospital that have been placed too deep resulting in atrial ectopy in one case and SVT in another. I might be wrong, but I get the sense that we are going to be asked to get intraoperative chest films on all of these patients before using central lines.

My typical method is to wait until I see atrial ectopy with the wire before dilating, measure out the length of catheter needed (add on a bit for the vessel depth dimension). Doing this I have never had a catheter found to be not appropriately place on postoperative chest xray (I'd guess an N of 300). None of the institutions that I trained at used intraoperative chest xray prior to use of these lines and in many cases we have multiple means of checking depth (e.g. TEE, cardiotomy, xray for spine fusion etc that are not necessarily a permanent part of the record or interpreted by a third party).

I'm having a hard time finding any relevant literature and was wondering if any of you would weigh in on this. It would likely be a policy that I would not be 100% compliant with, particularly in caring for tenuous single ventricle and anomalous vein babies, for example.
 
hudsontc said:
Our pediatric anesthesia group has recently been asked how we confirm correct central line placement when we've inserted them in a jugular or subclavian vein in the operating room. Apparently there have been a few central lines recently in our children's hospital that have been placed too deep resulting in atrial ectopy in one case and SVT in another. I might be wrong, but I get the sense that we are going to be asked to get intraoperative chest films on all of these patients before using central lines.

My typical method is to wait until I see atrial ectopy with the wire before dilating, measure out the length of catheter needed (add on a bit for the vessel depth dimension). Doing this I have never had a catheter found to be not appropriately place on postoperative chest xray (I'd guess an N of 300). None of the institutions that I trained at used intraoperative chest xray prior to use of these lines and in many cases we have multiple means of checking depth (e.g. TEE, cardiotomy, xray for spine fusion etc that are not necessarily a permanent part of the record or interpreted by a third party).

I'm having a hard time finding any relevant literature and was wondering if any of you would weigh in on this. It would likely be a policy that I would not be 100% compliant with, particularly in caring for tenuous single ventricle and anomalous vein babies, for example.
Click to expand...
Asked by whom? Please tell me it's not a clipboard nurse.

Who is placing the central lines that are purportedly too deep? And if there is ectopy - what's the solution? Pull it back a little and problem solved. Seems like intra-op chest films is a total waste unless you have reason to believe they're placed improperly.
 
+1. They can do a CXR in the ICU if they feel like it.

Btw, I am pretty sure the current adult critical care opinion is that one shouldn't withdraw the catheter just based on the CXR, in the absence of ectopy.

https://emcrit.org/pulmcrit/does-ce...use-ultrasonography-to-confirm-line-position/
https://emcrit.org/squirt/us-line/

This is another "problem" invented by a clipboard nurse. Fear-mongering. Like the geniuses from the FDA who invent black box warnings based on just a few case reports, and the next thing you know the drug disappears from the market.

On the other hand, with neonates, it might be a different story: https://www.researchgate.net/public..._A_Risk_Factor_for_Neonatal_Cardiac_Tamponade
 
Last edited by a moderator:
jwk said:
Who is placing the central lines that are purportedly too deep? And if there is ectopy - what's the solution? Pull it back a little and problem solved.
Click to expand...

It isn't the ectopy that is the problem. It's the hole in the right atrium.
 
hudsontc said:
Our pediatric anesthesia group has recently been asked how we confirm correct central line placement when we've inserted them in a jugular or subclavian vein in the operating room. Apparently there have been a few central lines recently in our children's hospital that have been placed too deep resulting in atrial ectopy in one case and SVT in another. I might be wrong, but I get the sense that we are going to be asked to get intraoperative chest films on all of these patients before using central lines.

My typical method is to wait until I see atrial ectopy with the wire before dilating, measure out the length of catheter needed (add on a bit for the vessel depth dimension). Doing this I have never had a catheter found to be not appropriately place on postoperative chest xray (I'd guess an N of 300). None of the institutions that I trained at used intraoperative chest xray prior to use of these lines and in many cases we have multiple means of checking depth (e.g. TEE, cardiotomy, xray for spine fusion etc that are not necessarily a permanent part of the record or interpreted by a third party).

I'm having a hard time finding any relevant literature and was wondering if any of you would weigh in on this. It would likely be a policy that I would not be 100% compliant with, particularly in caring for tenuous single ventricle and anomalous vein babies, for example.
Click to expand...

I have never done this.
Xray at the end of the case for heart cases or in ICU/pacu for all other comers.
 
Noyac said:
You could transduce it.
Click to expand...

It's not been raised as a question of being in the right circulation (for which transducing is great), rather that of being the appropriate depth for use. My feeling is that if I have obtained right heart ectopy, I know where the wire is. At that point, passing a catheter over said wire is just a matter of choosing an appropriate depth that is not ectopy-inducing. In the few cases that I have caused ectopy, the catheter is withdrawn during insertion. I've had zero problems with this because it's not hard to measure the distance from a central insertion site to the angle of Louis and if I'm fudging a bit due to habitus, well, it's no surprise that I need to adjust the depth a bit. My guess is that the cases bringing this topic to review are those of PICC lines which have a greater variability of depth based on arm position.

Yes, it feels like a nursing division review by those who have no idea what care is taken to appropriately line a patient.
 
hudsontc said:
It's not been raised as a question of being in the right circulation (for which transducing is great), rather that of being the appropriate depth for use. My feeling is that if I have obtained right heart ectopy, I know where the wire is. At that point, passing a catheter over said wire is just a matter of choosing an appropriate depth that is not ectopy-inducing. In the few cases that I have cause ectopy, the catheter is withdrawn during insertion. I've had zero problems with this because it's not hard to measure the distance from a central insertion site to the angle of Louis and if I'm fudging a bit due to habitus, well, ot's no surprise that I need to adjust the depth a bit. My guess is that the cases bringing this topic to review are those of PICC lines which have a greater variability of depth based on arm position.

Yes, it feels like a nursing division review by those who have no idea what care is taken to appropriately line a patient.
Click to expand...
That's not the transducing I'm talking about.
Anyone want to chime in?
 
I actually always wondered this for anesthesia-placed lines.

I've seen lines placed by IM, critical care of various stripes, EM, etc where they went all kinds of funny directions. Seen a subclavian go up the IJ instead of down the SVC, seen a subclavian go across to the contralateral subclavian, even seen an IJ make a U shape and go up the contralateral IJ (wouldn't believe it if I didn't see the x-ray with my own two eyes). Whenever I put one in myself, I always got an x-ray just to make sure it was in the SVC. Exactly how far down the SVC it made it wasn't as important for infusing meds for me.

Do these misplacements not happen in the OR or do y'all not care? I mean, obviously y'all place a lot of lines, but it seems like an easy thing to miss if it happens by accident.
 
Noyac said:
That's not the transducing I'm talking about.
Anyone want to chime in?
Click to expand...

I think the idea is to transduce the venous wave and by what you see on the monitor determine how deep you are, similar to placing a swan, the tracing looks different in the vein vs the atrium vs the ventricle... the question is would you rely on that tracing as definitive? maybe its enough to shut up the clipboard nurse though
 
Raryn said:
Do these misplacements not happen in the OR or do y'all not care? I mean, obviously y'all place a lot of lines, but it seems like an easy thing to miss if it happens by accident.
Click to expand...

We don't care. Basically we confirm it is in the vein. If it infuses and the meds/fluids we give are intravenous, then it doesn't particularly matter where the tip of it ended up for the short duration of being in the OR. The reason you get a CXR is that you might not want to leave the line in a particular bad spot for a week, but for the short duration in the OR it just doesn't matter. I've used lines for an entire case that were running back up the IJ on the other side. It doesn't cause a problem acutely.
 
For the clipboard warriors you just need to show them a bunch of pie charts defending your current practice. The charts don't even have to be based on any real data...they just have to be colorful. Once you have convinced them that it is safe based on your pie chart PowerPoint, they will find some other department to bother in the name of "patient safety" (just make sure your arms and facial hair are completely covered when you give the presentation). Clipboard warriors are like gnats...occasionally you have to swat them away.

On the other hand, the OR administrators listen to dollars and cents. Talk about all the added OR time waiting for a portable chest x-ray. I'm sure the surgeons will be pleased when the x-ray tech is tied up and can't be in the OR for another 20 minutes.

Nobody in the administration or clipboard nurse coalition truly cares about patient care or safety. They care more about justifying their own existence more than anything else.
 
GravelRider said:
For the clipboard warriors you just need to show them a bunch of pie charts defending your current practice. The charts don't even have to be based on any real data...they just have to be colorful. Once you have convinced them that it is safe based on your pie chart PowerPoint, they will find some other department to bother in the name of "patient safety" (just make sure your arms and facial hair are completely covered when you give the presentation). Clipboard warriors are like gnats...occasionally you have to swat them away.
Click to expand...

Forget the PowerPoint. The good idea fairies respond better to charts pasted onto those tri-fold posterboards they sell at the drug store. You know, the ones you used back in grade school for presentations but are now produced solely for MSN's to set on tables they strategically place in busy hallways.
 
GravelRider said:
On the other hand, the OR administrators listen to dollars and cents. Talk about all the added OR time waiting for a portable chest x-ray. I'm sure the surgeons will be pleased when the x-ray tech is tied up and can't be in the OR for another 20 minutes.
Click to expand...

That is the truth.

Give the good idea fairies some basic reassurance that your practice is safe, and then educate them about the ludicrous cost of getting an xray after every line placed in the OR.
 
urge said:
Really?

Never heard of this. Show me some legitimate reference.
Click to expand...
https://www.researchgate.net/public...sitioning_the_tip_of_central_venous_catheters


ABSTRACT
Tip position of a central venous access is of paramount importance and should be verified before starting infusion.
Intra-procedural methods for verifying the location of the tip are to be preferred, since they avoid the risks, delays
and costs of repositioning the tip. Among the intra-procedural methods, the electrocardiography (EKG) method has
many advantages since it is as accurate as fluoroscopy, but simpler, more readily available, less expensive, safer and
more cost-effective. The only contraindication to utilizing the EKG method is the difficulty in identifying the standard
P-wave on a surface EKG (this happens - usually because of severe arrhythmias, such as atrial fibrillation - in only ap-
proximately 7% of cases: although such patients are easily identified before the procedure, and are referred to other
methods for tip positioning). When dealing with the insertion of peripherally inserted central catheters (PICC), the EKG
method (using the column of saline technique) virtually has no risk of false positives. The EKG method removes the need
for the post-procedural chest x-ray, as long as there is no expected risk of pleuropulmonary damage to be ruled out
(example: ultrasound guided central venipuncture for central venous catheter insertion or any kind of PICC insertion).
In conclusion, evidence is mounting that the EKG method may be a valid and cost-effective alternative to the standard
radiological control of the location of the tip of any central venous access device (VAD), and that will rapidly become
the preferential method for confirming the tip position during PICC insertion.
 
Noyac said:
https://www.researchgate.net/public...sitioning_the_tip_of_central_venous_catheters


ABSTRACT
Tip position of a central venous access is of paramount importance and should be verified before starting infusion.
Intra-procedural methods for verifying the location of the tip are to be preferred, since they avoid the risks, delays
and costs of repositioning the tip. Among the intra-procedural methods, the electrocardiography (EKG) method has
many advantages since it is as accurate as fluoroscopy, but simpler, more readily available, less expensive, safer and
more cost-effective. The only contraindication to utilizing the EKG method is the difficulty in identifying the standard
P-wave on a surface EKG (this happens - usually because of severe arrhythmias, such as atrial fibrillation - in only ap-
proximately 7% of cases: although such patients are easily identified before the procedure, and are referred to other
methods for tip positioning). When dealing with the insertion of peripherally inserted central catheters (PICC), the EKG
method (using the column of saline technique) virtually has no risk of false positives. The EKG method removes the need
for the post-procedural chest x-ray, as long as there is no expected risk of pleuropulmonary damage to be ruled out
(example: ultrasound guided central venipuncture for central venous catheter insertion or any kind of PICC insertion).
In conclusion, evidence is mounting that the EKG method may be a valid and cost-effective alternative to the standard
radiological control of the location of the tip of any central venous access device (VAD), and that will rapidly become
the preferential method for confirming the tip position during PICC insertion.
Click to expand...
1 Not sure why this is addressed to me. Hoya said that transducing CVP in the SVC versus the atrium would have a different waveform, which I questioned. Neither of us was talking about EKG.

2 I have done EKG positioning of central lines and you actually need some sort of sterile adapter to hook your ekg cable to your intravascular lead. The paper you quoted mentions it in case you overlooked.

I bet none of the hospitals where you guys work have it.
After insertion of each catheter, the correct position and depth of insertion were estimated by two different ECG-based methods using the Certodyn® universal adaptor (Fa. B. Braun Melsungen AG, Germany). The first measurement used the Seldinger wire as intra-atrial ECG lead. For the second, the guide wire was removed and replaced by a 10% saline lock as a conducting medium using the Alphacard-System® (B. Braun Melsungen AG). The line tip was placed at the point of maximum P-wave amplitude for each measurement and the depth measured. At this position, the line tip lies in close proximity to the crista terminalis, at the junction between the SVC and right atrium.[7 8] The saline-based reading was considered to be optimal and the line secured.
Click to expand...
 
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The standard at my place is not to get an intra-op XR unless there's a question about depth or location of placement... the few times I've obtained an XR for this purpose the CVC was indeed a bit deep (as I suspected) and I withdrew some. Otherwise, it seems that following some form of depth/length guidelines (e.g. the one Andropoulos published) is reliable without need for XR.
 
SaltyDog said:
Forget the PowerPoint. The good idea fairies respond better to charts pasted onto those tri-fold posterboards they sell at the drug store. You know, the ones you used back in grade school for presentations but are now produced solely for MSN's to set on tables they strategically place in busy hallways.
Click to expand...

Great point. The tri-fold posterboard is key. Every department should have a few handy with colorful pie charts and changeable titles. It's the best defense against the clipboard gnats.
 
urge said:
1 Not sure why this is addressed to me. Hoya said that transducing CVP in the SVC versus the atrium would have a different waveform, which I questioned. Neither of us was talking about EKG.

2 I have done EKG positioning of central lines and you actually need some sort of sterile adapter to hook your ekg cable to your intravascular lead. The paper you quoted mentions it in case you overlooked.

I bet none of the hospitals where you guys work have it.
Click to expand...
I wasn't trying to address anyone specifically.
We had the sterile connector. I didn't overlook it.
I haven't done them this way in years. I was just commenting on "another" approach which many are either unaware of or have since forgotten.
 
Noyac said:
I wasn't trying to address anyone specifically.
We had the sterile connector. I didn't overlook it.
I haven't done them this way in years. I was just commenting on "another" approach which many are either unaware of or have since forgotten.
Click to expand...
Ok.

My point being that I haven't seen these adapters in a long time and the way CMS and JACO and whomever are supervising the sterility of central line placement, there is no way you could jerry rig a connector yourself.
 
Another thought I had for placement.
Could you do an Apical 4 chamber TTE with US to verify that you are not too deep?
 
pgg said:
That is the truth.

Give the good idea fairies some basic reassurance that your practice is safe, and then educate them about the ludicrous cost of getting an xray after every line placed in the OR.
Click to expand...
Especially in the era of bundled payments, when the hospital won't get a cent for most of these X-rays.
 
Noyac said:
Another thought I had for placement.
Could you do an Apical 4 chamber TTE with US to verify that you are not too deep?
Click to expand...
Or try getting a right ventricular inflow tract view: from parasternal long axis view, tilt the transducer tail toward the left shoulder.

(I have never used it. Credit: The Washington Manual of Echocardiography.)
 
KISS

1. Place central line using sterile technique. Catheter typically is 13-16 cm for depth when utilizing the RIJ.
2. Use the catheter during the case if good venous return when drawing back blood from one of the lumens
3. Chest X Ray in PACU or ICU if the central line is to be left in place for postop use
 
BLADEMDA said:
KISS

1. Place central line using sterile technique. Catheter typically is 13-16 cm for depth when utilizing the RIJ.
2. Use the catheter during the case if good venous return when drawing back blood from one of the lumens
3. Chest X Ray in PACU or ICU if the central line is to be left in place for postop use
Click to expand...
Well of course! 😉

But the OP is talking about pedi cases.
 
Noyac said:
Well of course! 😉

But the OP is talking about pedi cases.
Click to expand...

I've placed central lines on many small patients under 10kg. If I want to confirm placement in the O.R. I would use Flouro or an Xray both of which can be read in the room immediately (the Xray machines display the image immediately). Typically, I just use a pediatric central line kit and guesstimate the depth of insertion based on the kid's size.
 
Based on these measurements, the investigators derived formulas for optimal insertion depth: 0.07 × height (cm) for the left internal jugular vein and 0.08 × height (cm) for the left subclavian vein. These formulas predicted correct vein lengths in 99% and 94% of the children, respectively. Optimal catheter depth for the right internal jugular vein was measured from the anterior border of the right clavicle, yielding a formula of 0.06 × height (cm), although this was not validated.

http://www.jwatch.org/na32583/2013/10/23/predicting-depth-pediatric-central-lines
 
Anesth Analg. 2001 Oct;93(4):883-6.
The optimal length of insertion of central venous catheters for pediatric patients.
Andropoulos DB1, Bent ST, Skjonsby B, Stayer SA.
Author information

Abstract
Incorrect positioning of central venous catheters (CVC) in infants and children may lead to serious complications such as perforation of the heart or great vessels. CVC position is not usually assessed until the first postoperative chest radiograph, potentially leaving malposition undetected for several hours. We studied a series of 452 right internal jugular and subclavian catheter placements in infants and children undergoing surgery for congenital heart disease, and measured the distance from the skin insertion site to the radiographic junction of the superior vena cava and right atrium (RA). Based on these data, the following formulae predict that a CVC will be positioned above the RA 97% of the time: correct length of insertion (cm) = (height in cm/10) - 1 for patients < or =100 cm in height, and (height in cm/10) - 2 for patients >100 cm in height. Weight-based recommendations were also developed which predict placement of CVC above the RA 98% of the time.

IMPLICATIONS:
This study assessed central venous catheter placement in 452 infants and children undergoing cardiac surgery. Simple, clinically useful guidelines based on height and weight were developed to prevent malposition of these catheters, which may cause serious complications such as perforation of the heart or great vessels.
 
Acta Anaesthesiol Scand. 2006 Mar;50(3):355-7.
Depth of a central venous catheter tip: length of insertion guideline for pediatric patients.
Yoon SZ1, Shin TJ, Kim HS, Lee J, Kim CS, Kim SD, Park CD.
Author information

Abstract
BACKGROUND:
In pediatric patients, several studies have been undertaken to establish central venous catheter (CVC) tip optimal depth. Assessments of catheter tip position using chest radiographs may be misleading, whereas transesophageal echocardiography (TEE) has been shown to accurately monitor catheter tip placement at the superior vena cava-right atrial (SVC-RA) junction. The aim of this study was to issue a guideline for ideal catheter insertion depth, from the right internal jugular vein (IJV) using TEE to confirm the position of the catheter tip at the SVC-RA junction.

METHODS:
Over a 6-month period, we studied 60 right internal jugular vein catheterizations in infants and children undergoing surgery for congenital heart disease. Positions of CVC tips were confirmed to be at the SVC-RA junction by TEE. Distance from the skin puncture site to the SVC-RA junction, height, weight, and age were recorded.

RESULTS:
Distances measured were found to be highly correlated with patient height. The following guideline allows the CVC tip to be positioned above the RA in 97.5% of patients with an accuracy of 95%: optimal depth of insertion (cm) = 1.7 + (0.07 x height) in patients whose height is between 40 and 140 cm.

CONCLUSION:
The model proposed for the insertion of the CVC tip in pediatric patients could be used to prevent inadvertent catheter tip placement into the atrium.
 
BLADEMDA said:
So, is the OP using any of these formulas? Which formulas do the Peds gurus on SDN utilize (if any)?
Click to expand...

The Andropolous study result was my go to method when I was in cardiac fellowship. Having been in practice for awhile, I have a pretty keen sense of what length is needed for premies, term babies and older kids with normal body habitus....without actually considering the formulas.

I have never had a catheter on postoperative chest x-ray that has been found too deep (or even anywhere other than the SVC/cavoatrial junction). There are a few retrospective studies showing that when central lines are placed taking appropriate measures, intraoperative chest xray before use is a waste of resources. My experience in pediatric cardiac corroborates these adult studies.

https://www.ncbi.nlm.nih.gov/pubmed/27035241
 
hudsontc said:
The Andropolous study result was my go to method when I was in cardiac fellowship. Having been in practice for awhile, I have a pretty keen sense of what length is needed for premies, term babies and older kids with normal body habitus....without actually considering the formulas.

I have never had a catheter on postoperative chest x-ray that has been found too deep (or even anywhere other than the SVC/cavoatrial junction). There are a few retrospective studies showing that when central lines are placed taking appropriate measures, intraoperative chest xray before use is a waste of resources. My experience in pediatric cardiac corroborates these adult studies.

https://www.ncbi.nlm.nih.gov/pubmed/27035241
Click to expand...


Agree X-rays are a waste of time and resources. I can't remember the last time it showed anything but catheter in good position. I still get them in pacu or icu though. We probably need to revisit that. What's the NNT?
 
BLADEMDA said:
So, is the OP using any of these formulas? Which formulas do the Peds gurus on SDN utilize (if any)?
Click to expand...

We also use the Andropolous formula. If anything, I find it leaves you a little shallow, especially if you have a long pump run and the kid is edematous afterwards. The surgeon can easily cut off the tip of the line if it's in the RA, much harder to replace a central line that comes out of the vessel in PICU because the kid is puffy and agitated.
 
BLADEMDA said:
Anesth Analg. 2001 Oct;93(4):883-6.
The optimal length of insertion of central venous catheters for pediatric patients.
Andropoulos DB1, Bent ST, Skjonsby B, Stayer SA.
Author information

Abstract
Incorrect positioning of central venous catheters (CVC) in infants and children may lead to serious complications such as perforation of the heart or great vessels. CVC position is not usually assessed until the first postoperative chest radiograph, potentially leaving malposition undetected for several hours. We studied a series of 452 right internal jugular and subclavian catheter placements in infants and children undergoing surgery for congenital heart disease, and measured the distance from the skin insertion site to the radiographic junction of the superior vena cava and right atrium (RA). Based on these data, the following formulae predict that a CVC will be positioned above the RA 97% of the time: correct length of insertion (cm) = (height in cm/10) - 1 for patients < or =100 cm in height, and (height in cm/10) - 2 for patients >100 cm in height. Weight-based recommendations were also developed which predict placement of CVC above the RA 98% of the time.

IMPLICATIONS:
This study assessed central venous catheter placement in 452 infants and children undergoing cardiac surgery. Simple, clinically useful guidelines based on height and weight were developed to prevent malposition of these catheters, which may cause serious complications such as perforation of the heart or great vessels.
Click to expand...


Okay. So, this is the formula some of you use for pediatric central lines: height in cm/10 - 1 for kids less than 100 cm in height.
 
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