Trick of the Trade: Bubble Study for Confirmation of Central Line Placement

The safe placement a central venous catheter (CVC) remains an important part of caring for critically ill patients.1 Over 5 million CVCs are placed each year in the United States. It is crucial to confirm that the central line is placed in the correct position in order to rule out potential complications of the procedure (e.g. pneumothorax) and begin administration of life-saving medications. Post-procedure chest radiographs (CXR) are the standard of care for CVC placements above the diaphragm. However, the annual cost to the U.S. healthcare system for CXRs after CVC placement is estimated to be over $500 million.2 Further, in a busy ED, the limited availability of portable radiography may pose a considerable time delay. Radiography may also be limited in resource‐poor and austere settings, particularly the prehospital and military environments. We review a faster, cheaper, and more accurate alternative for evaluating CVC placement: point of care ultrasound (POCUS). The Problem Traditional dogma mandates that the tip of a CVC placed above the diaphragm must lie within the lower portion of the superior vena cava (SVC). This is best evaluated with a CXR. However, these can be time-consuming and expensive. The Trick: POCUS for Confirmation of CVC Placement Recent literature challenges the teaching that the optimal position for a CVC is within the lower portion of the SVC. Mounting evidence suggests that CVCs with its tip in the right atrium, SVC, brachiocephalic veins, or subclavian veins are well tolerated.3–5 Therefore, we only need to confirm that the CVC is placed within the venous system. This can be done with POCUS. The one exception is a catheter placed via a subclavian approach that is aberrantly directed into the internal jugular vein and points upwards towards the … Continue reading Trick of the Trade: Bubble Study for Confirmation of Central Line Placement