Intravenous literature: Schweickert, W.D., Herlitz, J., Pohlman, A.S., Gehlbach, B.K., Hall, J.B. and Kress, J.P. (2009) A randomized, controlled trial evaluating postinsertion neck ultrasound in peripherally inserted central catheter procedures. Critical Care Medicine. 37(4), p.1217-21.
OBJECTIVE: Insertion of peripherally inserted central catheters (PICCs) at the bedside may result in tip malposition. This study was designed to evaluate whether the addition of ultrasound (US) inspection of the ipsilateral neck provides immediate recognition of PICCs in aberrant position facilitating catheter reposition before completion of the procedure.
DESIGN: Randomized, controlled trial.
SETTING: University-affiliated hospital.
PATIENTS: Totally, 300 patients ordered for PICC placement.
INTERVENTIONS: Patients were randomized to either postinsertion US inspection of the ipsilateral neck (intervention, n = 151) or to usual practice (control, n = 149). In the intervention group, catheters detected by US to be traveling within the ipsilateral internal jugular vein (IJ), were further adjusted before procedural completion. All procedures included US localization of the peripheral vein and postprocedural chest radiograph to assess catheter tip position. The primary end point was defined as the rate of PICC tip malposition in the ipsilateral IJ as detected by postprocedure chest radiograph. The secondary end point was procedure duration.
MEASUREMENTS AND MAIN RESULTS: In the control arm, 140 of 149 PICC placement attempts (94%) were completed, including 11 procedures with catheter tips terminating in the ipsilateral IJ (7.9%). In the intervention arm, 142 of 151 attempts (94.7%, p = 0.98) were completed; one procedure resulted in a catheter tip in the ipsilateral IJ (0.7%, p = 0.007). Eleven intervention procedures included successful PICC repositioning during the initial procedure based on US detection of malposition. The median duration of the procedure in the control group was 8 minutes (6-10.5 minutes) and increased to 9.0 minutes (7-11 minutes) in the intervention group.
CONCLUSIONS: Bedside PICC placement morbidity can be reduced via US inspection of the ipsilateral neck for PICC tip malposition in the IJ. This modality can guide catheters to be successfully repositioned during the initial procedure.