Additionally using transthoracic echocardiography during ultrasound‐guided jugular central venous catheter placement and the odds of catheter misplacement in children: A before‐and‐after study

Central venous catheter (CVC) misplacement is a major complication.1 To avoid CVC misplacement, real-time ultrasound (US) guidance is recommended for CVC placement in children.2, 3 Transthoracic echocardiography (TTE) can be additionally used to confirm correct CVC tip position.4, 5 Whether additionally using TTE during US-guided jugular CVC placement reduces the incidence of catheter misplacement remains scarcely described. We thus sought to test the hypothesis that additionally using TTE during US-guided jugular CVC placement reduces the odds of CVC misplacement in children. After approval by the ethics committee with waiver of informed consent, we performed a retrospective before-and-after study in children aged 0–6 years who received a jugular CVC during anesthetic induction for congenital heart disease surgery at the University Medical Center Hamburg-Eppendorf (Hamburg, Germany) between March 2015 and April 2020. In our institution, jugular CVCs in children having cardiac surgery are routinely placed using real-time US guidance since 2013. In October 2017, routine use of additional TTE during US-guided jugular CVC placement was implemented. In the 31-month "before period" (March 2015 to September 2017), anesthesiologists did not use TTE but chose the CVC insertion depth considering patient height (no-TTE-group). In the 31-month "after period" (October 2017 to April 2020), additional TTE (subcostal long-axis view) was routinely used during US-guided jugular CVC placement to confirm the correct position of the guidewire and the CVC tip (rapid saline flush test) (TTE-group) (Figure S1). During both study periods, chest x-ray was used to confirm correct CVC tip position after surgery. We categorized CVCs as misplaced when the CVC tip ended above the level of the superior vena cava in a noncentral vein or deep in the right atrium (Figure S2). We investigated the associations between CVC misplacement and TTE use by logistic regression for all patients including age as covariate—and separately for patients aged <1 year and 1–6 years. We report the odds ratios (OR) with 95% confidence intervals. We included 373 patients (156 no-TTE-group and 217 TTE-group) (Table S1). CVC misplacement occurred in 15/156 no-TTE-group patients (9.6%) and in 5/217 TTE-group patients (2.3%). The odds for CVC misplacement were 371% lower when TTE was used compared to when it was not used (p = .004, OR = 0.21 [0.067–0.57]) (Figure 1). Of all 373 patients, 229 (61%) were younger than 1 year. In these patients, CVC misplacement occurred in 8/76 no-TTE-group patients (11%) and in 4/153 TTE-group patients (2.6%). The odds for CVC misplacement were 319% lower when TTE was used (p = .023, OR = 0.24 [0.062–0.79]). Of all 373 patients, 144 (39%) were between 1 and 6 years old. In these patients, CVC misplacement occurred in 7/80 no-TTE-group patients (8.8%) and in 1/64 TTE-group patients (1.6%). The odds for CVC misplacement were 480% lower when TTE was used (p = .107, OR = 0.17 [0.0090–1.0]). In our study, additionally using TTE during US-guided jugular CVC placement in children reduced the odds for CVC misplacement by more than 300%—which obviously is clinically meaningful. In only about 1% of children, the subcostal long-axis view could not be obtained—and TTE could thus not be used to confirm the CVC tip position. In general, children provide an excellent acoustic window for TTE examination of the right atrium and the superior vena cava. Nevertheless, TTE requires technical skills and operator experience. Our results need to be interpreted in light of the inherent limitations of retrospective before-and-after studies. Additionally, we only included children with congenital heart disease, whose anatomy may differ from healthy children. However, as we excluded patients with irregular venous conformations, we assume that our findings can be transferred to pediatric patients in general. Additionally using TTE during US-guided jugular CVC placement reduces the odds of CVC misplacement in children aged 0–6 years. Clinicians should consider additionally using TTE during US-guided jugular CVC placement to increase patient safety. This work was supported solely from institutional and/or department sources. There are no conflicts of interest to declare. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Supporting Information Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.