Diagnostic Accuracy of Central Venous Catheter Confirmation by Bedside Ultrasound Versus Chest Radiography in Critically Ill Patients: A Systematic Review and Meta-Analysis

Abstract

Objective We performed a systematic review and meta-analysis to examine the accuracy of bedside ultrasound for confirmation of central venous catheter position and exclusion of pneumothorax compared to chest radiography. Data Sources PubMed, EMBASE, Cochrane Central Register of Controlled Trials, reference lists, conference proceedings and ClinicalTrials.gov Study Selection Articles and abstracts describing the diagnostic accuracy of bedside ultrasound compared with chest radiography for confirmation of central venous catheters in sufficient detail to reconstruct 2×2 contingency tables were reviewed. Primary outcomes included the accuracy of confirming catheter positioning and detecting a pneumothorax. Secondary outcomes included feasibility, inter-rater reliability, and efficiency to complete bedside ultrasound confirmation of central venous catheter position. Data Extraction Investigators abstracted study details including research design and sonographic imaging technique to detect catheter malposition and procedure-related pneumothorax. Diagnostic accuracy measures included pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio. Data Synthesis 15 studies with 1553 central venous catheter placements were identified with a pooled sensitivity and specificity of catheter malposition by ultrasound of 0.82 [0.77, 0.86] and 0.98 [0.97, 0.99] respectively. The pooled positive and negative likelihood ratios of catheter malposition by ultrasound were 31.12 [14.72, 65.78] and 0.25 [0.13, 0.47]. The sensitivity and specificity of ultrasound for pneumothorax detection was nearly 100% in the participating studies. Bedside ultrasound reduced mean central venous catheter confirmation time by 58.3 minutes. Risk of bias and clinical heterogeneity in the studies were high. Conclusions Bedside ultrasound is faster than radiography at identifying pneumothorax after central venous catheter insertion. When a central venous catheter malposition exists, bedside ultrasound will identify four out of every five earlier than chest radiography.

International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

“…line placement in neonates and children-strong agreement (quality of evidence B). Paediatric trials comparing US-guided femoral line placement with landmark technique showed higher overall success rate and on the first attempt as well as fewer needle passes [113][114][115][116].…”

Study Protocol for Draup: De-implementation Ofroutine Chest Radiographs After Adoption of Ultrasound Guided Insertion and Confirmation of Central Venous Catheter Protocol, A Hybrid Implementation/effectiveness Study

“…[37] Clinical e ciency has always been a bene t of POCUS. [7] E ciency in this context is measured by the time needed to perform the POCUS guided CVC position con rmation and exclusion of PTX compared to ordering and performing a CXR. Clinical effectiveness is measured by the diagnostic accuracy of POCUS-guided CVC PCEP compared to in-hospital CXRs (which will be obtained at some point during the patient hospital stay).…”

“…Three recent meta-analyses found that POCUS for CVC position con rmation was feasible (98% adequate visualization), fast (reducing mean CVC con rmation time compared to CXR), and accurate. [7,9,11] In the RCT, POCUS-only CVC PCEP reduced the time from insertion to rst use of CVC and reduced overall CXR utilization by 56.7% (P < .0001). [9] Additionally, the annual cost to the United States healthcare system for CXRs after CVC placement exceeds $500 million.…”

“…Observational data and a randomized controlled trial (RCT) have shown that POCUS can also provide similar yet faster diagnostic information to CXR after CVC insertion, thus demonstrating superior e ciency. [7][8][9][10] A POCUS-guided CVC PCEP protocol consists of three ultrasound imaging steps (Fig. 1).…”

The authors reply

“…Regarding the evaluation of mechanical complications after CVC insertion (most commonly catheter malposition and pneumothorax), the diagnostic accuracy of ultrasound versus chest radiography (CXR) is garnering increased attention in the literature. Since our meta-analysis on this subject (3), there have been several recently published studies supporting the role of ultrasound for CVC position confirmation and pneumothorax exclusion. These data are consistent with our findings and suggest that when compared to supine CXR, ultrasound: 1) allows for faster results compared to CXR, 2) can confirm CVC catheter position with acceptable sensitivity and excellent specificity, and 3) can exclude pneumothorax with excellent sensitivity and specificity.…”