title: Ultrasound-guided placement of midline catheters in the surgical intensive care unit: a cost-effective proposal for timely central line removal.
abstract: BACKGROUND
  The early removal of central intravenous (IV) catheters, as a means of reducing the incidence of central line-associated blood stream infections (CLABSI), remains a major health care initiative. However, attaining IV access in the surgical intensive care unit (SICU) can be quite difficult. We report the success of a novel, resident-driven program for the placement of ultrasound-guided midline catheters in critically ill patients.
  
  
  METHODS
  A prospective pilot study of 31 subjects admitted to the SICU from June to December 2011 was performed. Intermediate-length (20 cm) midline catheters were placed by trained housestaff, under ultrasound guidance, into the basilic or cephalic veins. Procedural details including time to cannulation, complications, and costs were recorded.
  
  
  RESULTS
  Successful placement was achieved in 96.8% (n = 30), with a mean follow-up of 9.8 ± 5.6 (range 2-21) days. An average of 1.3 ± 0.7 (range 1-4) attempts with a median of 13.0 ± 14.5 (range 0.5-68) minutes was required for successful venous cannulation. The most common site was the basilic vein (n = 23). Only minor complications were encountered; three catheters leaked at the insertion site and one patient developed phlebitis. No CLABSI occurred. The total procedure cost was $87 per catheter for the SICU team compared with $1500 per catheter when performed by an interventional radiologist. During the study period, a total of 283 central line days were avoided with an estimated cost savings of $13,614.
  
  
  CONCLUSIONS
  Ultrasound-guided midline catheters placed by the housestaff are a cost-effective alternative for patients in the SICU with difficult IV access. Successful placement can help facilitate early central line removal and thus may reduce CLABSI rates.
authors.affiliation: Department of General Surgery, North Shore-Long Island Jewish Health System, New Hyde Park, New York.
authors.forename: Gary B
authors.initials: GB
authors.lastname: Deutsch
authors.affiliation: Department of General Surgery, North Shore-Long Island Jewish Health System, New Hyde Park, New York.
authors.forename: Sandeep Anantha
authors.initials: SA
authors.lastname: Sathyanarayana
authors.affiliation: Department of General Surgery, North Shore-Long Island Jewish Health System, New Hyde Park, New York.
authors.forename: Narendra
authors.initials: N
authors.lastname: Singh
authors.affiliation: Department of General Surgery, North Shore-Long Island Jewish Health System, New Hyde Park, New York. Electronic address: jnicastro1@nshs.edu.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Nicastro
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002405:Catheterization, Central Venous / Q000191:economics / Q000379:methods*; D003362:Cost-Benefit Analysis; D003422:Critical Care / Q000191:economics / Q000379:methods*; D016638:Critical Illness / Q000628:therapy; D020878:Device Removal / Q000191:economics / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D017721:Hospital Costs; D006801:Humans; D007396:Internship and Residency; D008297:Male; D008505:Medical Staff, Hospital; D008875:Middle Aged; D010865:Pilot Projects; D015397:Program Evaluation; D011446:Prospective Studies; D018084:Ultrasonography, Interventional / Q000191:economics / Q000379:methods*
keywords: CLABSI; Catheter; Central line; Intensive care unit; Intravenous; Midline; Ultrasound