title: Prospective comparison of ultrasound and CXR for confirmation of central vascular catheter placement.
abstract: OBJECTIVE
  To prospectively compare ultrasound (US) versus CXR for confirmation of central vascular catheter (CVC) placement. Secondary objective was to determine the incidence of pneumothorax (PTX) and compare US with CXR completion times.
  
  
  METHODS
  Investigators performed the US saline flush echo test, and evaluated each anterior hemithorax for pleural sliding with US after subclavian or internal jugular CVC placement.
  
  
  RESULTS
  151 total (135 in the emergency department, 16 in the intensive care unit) patients after CVC placement, mean age 62.1±15.6 years and 83 (55%) female patients. The rapid atrial swirl sign ( RASS) was ultrasound finding of an immediate appearance of turbulence entering the right atrium via superior vena cava after a rapid saline flush of the distal CVC port. RASS was considered 'negative' for CVC malposition. US identified all correct CVC placements. Four suboptimal CVC tip placements were detected by CXR. US identified three of these misplacements (McNemar exact p value >0.99). There were no cases of PTX or abnormal pleural sliding by either CXR or US. Median times for US and CXR completion were 1.1 (IQR 0.7) minutes and 20 (IQR: 30) minutes, respectively, median difference 23.8 (95% CI 19.6 to 29.3) minutes, p<0.0001.
  
  
  CONCLUSIONS
  PTX and CVC tip malposition were rare after US-guided CVC placement. There was no significant difference between saline flush echo and CXR for the identification of catheter tip malposition. Benefits of US assessment for complications include reduced radiation exposure and time delays associated with CXR.
authors.affiliation: Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA.
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Weekes
authors.affiliation: Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA.
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Keller
authors.affiliation: Department of Emergency Medicine, Good Shepherd Medical Center, Longview, Texas, USA.
authors.forename: Bradley
authors.initials: B
authors.lastname: Efune
authors.affiliation: Department of Emergency Medicine, Chandler Medical Center, Lexington, Kentucky, USA.
authors.forename: Sama
authors.initials: S
authors.lastname: Ghali
authors.affiliation: Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Runyon
mesh_terms: D000328:Adult; D000368:Aged; D002405:Catheterization, Central Venous / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D019300:Medical Errors / Q000517:prevention & control; D008875:Middle Aged; D011030:Pneumothorax / Q000453:epidemiology / Q000209:etiology; D011446:Prospective Studies; D013902:Radiography, Thoracic / Q000379:methods* / Q000592:standards; D013909:Thorax; D014463:Ultrasonography / Q000592:standards*
keywords: cost effectiveness; imaging, ultrasound; intensive care; ultrasound