(414) Advanced Practice Providers Use Ultrasound Versus Xray to Confirm Central Venous Catheter Position

Introduction: Chest x-ray (CXR) confirmation after placement of internal jugular (IJ) central venous catheter (CVC) is standard before use; unfortunately CXRs are often delayed. Seeking an efficient method, the Advanced Practice Providers (APPs) at Robert Wood Johnson University Hospital adapted the Deimplementation of Routine Chest Radiographs after Adoption of Ultrasound-Guided Insertion and Confirmation of CVC Protocol (DRAUP) in the intensive care unit (ICU). The study was to evaluate the feasibility and accuracy of an APP driven ultrasound protocol for confirming CVC placement, assessing pneumothorax (PTX), and time to CVC use compared to traditional CXR.

Methods: DRAUP, created by Washington University in St. Louis, was used to assess a convenient sample of IJ CVCs. For DRAUP protocol, three ultrasound images confirm position and exclude a PTX: 1) right atrial swirl sign (RASS) in less than 2 seconds during rapid saline flush of CVC, 2) echo-free contralateral IJ vein during rapid saline flush of CVC, 3) lung slide on ipsilateral anterior chest. During our study, patients also received a CXR for comparison. Feasibility is percent of correct CVC images in DRAUP eligible cases. Accuracy is the correlation between APP reported findings about catheter position and PTX compared to CXR.

Results: From October 2023 to July 2024, there were 91 IJ CVCs placed by APPs. Of the 91, 30 CVCs used DRAUP (18 right IJ and 12 left IJ). The feasibility of DRAUP was 33%. Common reasons for DRAUP underutilization was APP buy-in and difficult image acquisition. The average patient age for DRAUP was 67 years which consisted of 21 males and 9 females. When compared to CXR, DRAUP sensitivity was 96.77% and specificity was 100%. The average time to CVC use for a DRAUP line would be 10 minutes, while the average time for CXR was 57 minutes. DRAUP protocol discovered one CVC that was malpositioned, where RASS was seen greater than 2 seconds and confirmed by CXR.

Conclusions: Although a small sample, out data supports the use of ultrasound for CVC confirmation and ruling out a PTX. DRAUP was equal to CXR for CVC position confirmation and no undetected issues occurred that DRAUP failed to detect. Our study demonstrates the diagnostic accuracy of the protocol and time saving benefits for ICU patients cared for by APPs.