(1291) Bridging the Gap: Advancing Ultrasound Guidance for Central Venous Catheter Confirmation in the ICU

Introduction: Ultrasound (US) guided confirmation of central venous catheters (CVCs) has comparable sensitivity and safety to chest x-rays (CXR), as well as quicker CVC use. However, the practice change to US instead of CXR in the intensive care unit (ICU) is unknown. Patient body mass index (BMI)/weight has been reported as a barrier to image adequacy for multiple US applications. In 2020, a program called DRAUP was launched in an emergency department (ED), achieving 50% adoption of US as a substitution for CXR after CVC insertion. Now implementing this program in the ICU, we evaluate use and aim to identify barriers.

Methods: DRAUP is eligible when a supradiaphragmatic CVC is placed and three sonographic findings present: 1) right atrial swirl sign, 2) lack of echogenic material in contralateral jugular veins, 3) pleural slide on catheter insertion side. DRAUP implementation in the ICU included 2 strategies: 1) education and training and 2) algorithm dissemination. DRAUP training occurred in 10/2023 for fellows and advanced practice practitioners (APPs) in the surgical ICU. We conducted two retrospective chart reviews using 6 months of CVC data, pre-implementation (1/1/23-6/30/23) and post implementation (11/1/23-4/1/24). Descriptive statistics and single-tailed t-tests comparing the body habitus (weight, kilograms) of the successful and unsuccessful DRAUP attempts is performed.

Results: During pre-implementation (n=293), 82% of placed CVC would be DRAUP eligible. Most catheters were placed by the groups targeted for education (fellows 31%, APPs 22%), and 90% were placed using US guidance. In the implementation period, 58% of catheters were DRAUP eligible and placed by a trained clinician. DRAUP was only attempted 20% of the time. 44% of DRAUP attempts were aborted, and CXR was used for CVC confirmation. Inadequate or challenging US views was the most cited reason. There was no relationship between the body weights of the DRAUP and Non-DRAUP groups. The difference in the mean body weight for unsuccessful vs. successful DRAUP attempts was -28 kg. There is a statistically significant (p=.019) decrease in success based on increasing weight.

Conclusions: DRAUP is underutilized in the surgical ICU and faces a high rate of failed attempts from inadequate images, which can be associated with increasing BMI.