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ORIGINAL ARTICLE Table of Contents   
Year : 2007  |  Volume : 10  |  Issue : 2  |  Page : 127-131
Transoesophageal echocardiography and central line insertion


1 Division of Cardiac Anesthesia, Department of Anesthesia and Critical Care, University of Chicago, USA
2 Division of Cardiac Anesthesia, Department of Anesthesiology, UCLA Medical Center, Los Angeles, CA, USA
3 Alexian Brothers Medical Center, Elk Grove Village, IL, USA

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   Abstract 

We investigated the potential utility of transoesophageal echocardiography (TOE) in facilitating central venous catheter (CVC) insertion in patients undergoing cardiac surgery. Thirty five patients undergoing elective cardiac surgery and CVC insertion were prospectively included in the observational, single-centre clinical investigation. Following induction of general anaesthesia and tracheal intubation, the TOE probe was inserted and the bicaval view obtained prior to CVC insertion (site at discretion of the anaesthesiologist). Prospectively collected data included site and sequence of CVC insertion attempts, information regarding ease of guidewire insertion, whether or not guidewire was visualized via TOE, and other pertinent information. In 1 patient, the TOE bicaval view could not be readily obtained because of right atrial (RA) distortion. In 31 patients, the TOE bicaval view was obtained and CVC access was successful at the site of first choice (guidewire visualized in all). Three patients had noteworthy CVC insertions. In one, CVC insertion was difficult despite visualization of guidewire in the RA. In another, multiple guidewire insertions met with substantial resistance and without visualization of guidewire in the RA. One patient was found to have an unanticipated large mobile superior vena cava thrombus that extended into the RA, which changed clinical management by prompting initial CVC insertion into the femoral vein (potentially avoiding morbidity associated with thrombus dislodgement). Our prospective observational clinical study indicates that routine use of TOE during CVC insertion may help avoid potential complications associated with this intervention. If both CVC insertion and TOE are going to be used in the same patient, the benefits of TOE should be maximized by routine visualization of the bicaval view during guidewire insertion.

Keywords: Transoeosophageal echocardiography, Central venous catheters, Complications

How to cite this article:
Chaney MA, Minhaj MM, Patel K, Muzic D. Transoesophageal echocardiography and central line insertion. Ann Card Anaesth 2007;10:127-31

How to cite this URL:
Chaney MA, Minhaj MM, Patel K, Muzic D. Transoesophageal echocardiography and central line insertion. Ann Card Anaesth [serial online] 2007 [cited 2019 Nov 22];10:127-31. Available from: http://www.annals.in/text.asp?2007/10/2/127/37938



   Introduction Top


Transoesophageal echocardiography (TOE) has now been used in the operating room for over twenty years. The majority of the time, TOE is used during cardiac surgery, where it has been instrumental in advancing valvular reconstruction, congenital heart repair, and minimally invasive techniques. While not routine, TOE is widely used because it is perceived to provide information that substantially influences clinical management and likely improves patient outcome. However, there is limited scientific evidence to substantiate such perception.

Essentially all patients undergoing cardiac surgery are subjected to central venous catheter (CVC) insertion. While certain techniques may help reduce risks associated with CVC insertion (pressure transduction, blood gas analysis, ultrasound technology, etc.), complications from this procedure persist (arterial trauma/insertion, pneumothorax, etc.). [1],[2] The bicaval TOE view clearly reveals superior vena cava (SVC) and right atrium (RA) anatomy and easily identifies presence or absence of a "J" - tipped guidewire [Figure 1]. Such information may be useful during CVC insertion. This prospective, observational clinical study investigates the potential utility of TOE in facilitating CVC insertion in patients undergoing cardiac surgery.


   Materials and Methods Top


The patients described in this clinical investigation represent a subset of patients involved in another prospective, observational clinical study investigating the effect of routine intraoperative TOE on surgical management in patients undergoing cardiac surgery. [3] This larger study evaluated patients scheduled for coronary artery bypass grafting (CABG, on-pump or off­pump), valve surgery, thoracic aortic surgery, and other less common indications for surgery on the heart and/or great vessels (tumor, aneurysm, dissection, etc.). The study was approved by the Institutional Review Board, and informed consent was obtained from all participants, either the night before surgery or the morning of surgery (prior to any sedation). For emergency cardiac surgery, informed consent was obtained from the patient (if possible) preoperatively, or patient's family member (surrogate). Patients were to be excluded if any substantial documented oesophageal pathology or stomach pathology was present (none were excluded).

Perioperative anaesthetic and surgical care was not altered in any way. Following induction of general anaesthesia and tracheal intubation, the TOE probe was inserted and the bicaval view obtained prior to CVC insertion (site of CVC insertion at the discretion of the attending anaesthesiologist). Prospectively collected data included site and sequence of CVC insertion attempts, information regarding ease of guidewire insertion, whether or not the guidewire was visualized via TOE, and any other pertinent information.


   Results Top


Thirty Five patients were studied (25 male, 10 female, mean age 62.1 years, mean height 173.1 cm, mean weight 84.2 kg). Central venous access was safely secured in all patients without complications.

In 31 patients, the TOE bicaval view was obtained and CVC access was successful at the site of first choice (29 right internal jugular [RIJ], 2 left subclavian [LS]). In all of these 31 patients, the guidewire was easily inserted and visualized via TOE. In 1 patient, the TOE bicaval view could not be readily obtained because of RA distortion associated with a large ascending aortic dissection. In this patient, CVC was uneventfully inserted via RIJ (site of first choice) using pressure transduction to verify venous access.

In the remaining three patients, (TOE bicaval view obtained in all) CVC insertions were noteworthy:

In one patient, the site of first choice was the right subclavian (RS), which was entered and the guidewire visualized via TOE. However, CVC insertion over the guidewire met with substantial resistance (likely secondary to the clavicle). Subsequently, the RIJ was uneventfully used as the second choice of CVC insertion (guidewire visualized).

In another patient, the first three choices (RIJ, LS, left internal jugular [LIJ]) were entered, yet guidewire insertion met with substantial resistance and was not visualized via TOE. It is not known why guidewire insertion in this patient was difficult (perhaps altered anatomy?). Subsequently, the CVC was inserted into the right femoral vein (FV) as the fourth choice of insertion (guidewire not visualized).

One patient, scheduled for elective off-pump CABG, was found to have an unanticipated large mobile SVC thrombus that extended into the RA [Figure 2]. This patient also had end-stage renal failure requiring regular haemodialysis via a RS vein dialysis catheter. His off-pump CABG was initially delayed for two days secondary to fever and hypotension (possible sepsis). During this time, he was treated with intravenous antibiotic therapy and the RS dialysis catheter was removed. Surgery was rescheduled when he became afebrile and haemodynamically stable. Preoperative echocardiography was not performed in the patient. In order to avoid disruption of the mobile thrombus, the CVC was inserted into the right FV (guidewire not visualized, pulmonary artery catheter not inserted). Following successful off­pump CABG, the SVC was directly inspected and the thrombus partially removed by curettage through a right atriotomy (under partial inflow occlusion). TOE bicaval view following curettage revealed the presence of a small amount of residual thrombus in the SVC, verifying incomplete removal. He was extubated within the immediate postoperative period and had an unremarkable recovery. He eventually had insertion of a LIJ vein dialysis catheter prior to hospital discharge.


   Discussion Top


Our prospective, observational clinical study indicates that routine use of TOE during CVC insertion may help decrease complications associated with this intervention. The bicaval view was easily obtained in essentially all (97%) patients and easily distinguishes between the "J"­tipped guidewire and indwelling rhythm management devices. Furthermore, transthoracic echocardiography would give an equally good image of the SVC/RA junction and could be used in patients who are not anaesthetized at the time of insertion of central lines. Visualization of the guidewire in the right atrium may thus represent a confirmatory "gold standard", having substantial advantages over pressure transduction, blood gas analysis, and/or ultrasound technology guidance. This knowledge (guidewire in right atrium) likely decreases risk of complications associated with subsequent CVC insertion.

The complications of CVC insertion can be roughly divided into three categories: complications of vascular access, complications of catheter insertion, or complications of catheter presence. [4] Claims for injuries related to CVC insertion are associated with a high severity of injury and the most common complications in claims against anaesthesiologists are wire/catheter embolus, cardiac tamponade, carotid artery injury, haemothorax, and pneumothorax. [1] In the 1990s, claims for CVC injuries related to vascular access were more common than claims related to vascular use/maintenance. [1] The most common techniques used clinically to assure proper CVC insertion are pressure transduction, blood gas analysis, and ultrasound technology, yet none of these techniques are foolproof.

To our knowledge, this series represents the first to assess the benefits of routine TOE during CVC insertion in adult patients. A previously published prospective, randomized, controlled clinical trial involving 145 patients undergoing congenital heart surgery (mean age approximately 4 years, mean weight approximately 16 kilograms) concluded that TOE was useful in guiding proper CVC insertion. [5] However, the primary focus of this clinical study was using TOE information (bicaval view) to guide proper depth of CVC insertion (tip in SVC within 10 mm of SVC/RA junction) in order to potentially decrease risk of RA trauma. In one patient randomized to the control group (no TOE during initial insertion), SVC perforation from a RS catheter occurred, necessitating surgical re­exploration. However, this catheter was noted to be in good position both by TOE and postoperative chest radiography (functioned well throughout surgery and immediate postoperative period). Three hours postoperatively, the child sat up (likely moving CVC) and within minutes was noted to have increased bloody output from the right pleural tube. Surgical re-exploration revealed CVC tip perforation at the junction of the RS and right brachiocephalic veins. While TOE was unable to prevent this individual complication (nor decrease overall complication rate), the authors conclude that TOE was useful in guiding CVC positioning in these young patients undergoing congenital heart surgery.

Our clinical series indicates that routine use of TOE during CVC insertion may help decrease complications associated with this intervention. Visualization of the guidewire in the RA assures one beyond doubt of proper insertion and represents a confirmatory "gold standard". However, if the FV is chosen as the site of CVC insertion, the bicaval view will not be of benefit (guidewire not able to be visualized). Using TOE changed clinical management and likely avoided morbidity in our patient with the unanticipated SVC clot. Without TOE evaluation, we would have attempted instrumentation of the RIJ vein, potentially dislodging clot into the vascular system (perhaps resulting in stroke, pulmonary embolism, and/or bacteraemia) and/or initiating multiple cannulation attempts at multiple sites (once again, perhaps increasing morbidity). Such unexpected intraoperative TOE findings are not uncommon. Intraoperative TOE may provide new information regarding cardiac pathology in approximately 10% to 40% of patients undergoing cardiac surgery and this new information may result in altering clinical management in approximately 4% to 15% of such patients. [6],[7] Using TOE also perhaps avoided morbidity in the patient with multiple attempts at guidewire insertion (RIJ, LS, LIJ). In this patient, since the guidewire was never visualized in the RA, CVC insertion (potentially trauma-inducing in this patient) was never attempted (FV chosen as fourth site).

At the present time, the most common techniques used clinically to assure proper CVC insertion are pressure transduction, blood gas analysis, and ultrasound technology. None of these techniques are foolproof. The use of real-time ultrasound guidance for insertion of CVC catheters is advocated by many physicians and may increase the probability of successful catheter placement and may reduce the risk of complications and the need for multiple catheter placement attempts. [8],[9] Ultrasound devices may be used to locate a vein in two ways. Real-time ultrasonography generates a two-dimensional grey scale image of the vein and surrounding tissues. Continuous-wave Doppler ultrasonography generates an audible sound from flowing venous blood, with no information on depth of the vessel. Such devices do not possess colour-flow Doppler technology, information that may at times be beneficial when differentiating between artery and vein. [10] Furthermore, ultrasound technology (nor pressure transduction or blood gas analysis) would not have benefited the patient with the SVC clot nor the patient with multiple attempts at guidewire insertion.

Potential drawbacks of using TOE in this fashion include the potential requirement of two anaesthesiologists (one for TOE imaging, one for guidewire insertion), increased costs involved with routine use of TOE, potential oesophageal injury, and potential inability to interpret problems because of inability to assess the entire length of the internal jugular vein and SVC via TOE.

In conclusion, if both CVC insertion and TOE are going to be used in the same patient undergoing cardiac surgery, the benefits of TOE should be maximized by routine visualization of the bicaval view during guidewire insertion, potentially reducing CVC insertion complications.

 
   References Top

1.Domino KB, Bowdle TA, Posner KL, et al. Injuries and liability related to central vascular catheters; A closed claims analysis. Anesthesiology 2004; 100: 1411-1418.  Back to cited text no. 1    
2.McGee DC, Gould MK. Current concepts: Preventing complications of central venous catheterization (Review Article). N Engl J Med 2003; 348: 1123-1133.  Back to cited text no. 2    
3.Minhaj M, Patel K, Muzic D, et al. Effect of routine intraoperative transesophageal echocardiography on surgical management in patients undergoing cardiac surgery. J Cardiothorac Vasc Anesth 2007; (In press).  Back to cited text no. 3    
4.Reich DL, Mittnacht A, London M, Kaplan JA. Monitoring of the heart and vascular system. In: Kaplan JA, Reich DL, Lake CL, Konstadt SN, eds. Kaplan's Cardiac Anesthesia, Fifth Edition. Philadelphia: Saunders­Elsevier, pp 385-436, 2006.  Back to cited text no. 4    
5.Andropoulos DB, Stayer SA, Bent ST, et al. A controlled study of transesophageal echocardiography to guide central venous catheter placement in congenital heart surgery patients. Anesth Analg 1999; 89: 65-70.  Back to cited text no. 5    
6.Jneid H, Bolli R. Inotrope use at separation from cardiopulmonary bypass and the role of prebypass TEE (Editorial). J Cardiothorac Vasc Anesth 2004;18: 401-403.  Back to cited text no. 6    
7.Hillel Z. Refining intraoperative echocardiography (Editorial). J Cardiothorac Vasc Anesth 2003; 17: 419-421.  Back to cited text no. 7    
8.Hall AP, Russell WC. Toward safer central venous access: Ultrasound guidance and sound advice (Editorial). Anaesthesia 2005; 60: 1-4.  Back to cited text no. 8    
9.Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices for central venous cannulation: Meta­analysis. BMJ 2003; 327: 1-7.  Back to cited text no. 9    
10.Chaney MA. "Epi-neck" scanning": another use for echocardiography? J Cardiothorac Vasc Anesth 2007; (In Press).  Back to cited text no. 10    

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Correspondence Address:
Mark A Chaney
Department of Anesthesia and Critical Care, University of Chicago, 5841 South Maryland Avenue, MC 4028 Chicago, Illinois 60637.
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.37938

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