Official Proceedings - AIUM

American Institute of Ultrasound in Medicine Proceedings J Ultrasound Med 32(suppl):S1–S134, 2013nals from the saline flush signaled proper catheter tip placement. We comparedthe agreement between BUE results and those of CXR or computedtomography (CT) using a κ statistic.Results—Twenty-seven patients were enrolled, and 26 wereanalyzed. One subject was excluded because his surgery was canceled,and he no longer required CVC. Eight patients were enrolled from the ED,9 from the ICU, and 9 from the OR. On BUE, 1 patient had a technicallylimited study, and 25 demonstrated saline echoes in the right heart. One ofthe 25 demonstrated intracardiac catheter malposition, confirmed by CXR.All 26 patients had CXR, and 2 had additional CT; 25 had confirmedproper CVC placement, including the 1 patient for whom BUE was inconclusive.Timing for BUE was as follows: 20 cases done concurrentlywith CVC placement, 2 done within 1 hour, and 3 done within 24 hours.Of the 25 BUEs that were interpretable, there was 100% agreement betweenBUE and CXR in detecting CVC location (P = .000).Conclusions—Despite the small sample size, this study showspromise for the use of BUE to accurately confirm CVC placement morequickly than CXR. A larger study is needed before we can recommendusing BUE routinely to replace post-CVC CXR.1513191 Bedside Thoracic Ultrasound for Pulmonary Edema:Which Zones Are the Best?Zoe Howard,* Feras Khan, Anne-Sophie Beraud, LalehGharahbaghian, Raymond Balise, Ravi Pamnani, MichaelSchaller, Joelle Barral, Sidhartha Sinha, Sarah WilliamsEmergency Medicine, Stanford University Medical Center,Stanford, California USAObjectives—Thoracic ultrasound (US) has been validated topredict pulmonary edema with high sensitivity and specificity in the presenceof B-lines, a US reverberation artifact caused by interstitial fluid. Ourstudy investigates whether there are specific anatomic zones with a greaterpositive predictive value for pulmonary edema. If so, we could performthis test more rapidly, an important consideration from both a resource utilizationand patient care perspective.Methods—We performed a prospective observational study,scanning a convenience sample of adult emergency department (ED) patientswith shortness of breath at a large tertiary care academic center. Followingpreviously published protocols, the right anterior chest was dividedinto 4 zones with zones 1 and 2 representing an upper and lower midclaviculardistribution, respectively, and 3 and 4 upper and lower midaxillary.The division was mirrored on the left with 5 and 6 anterior and 7 and8 lateral. When there were at least 2 bilateral positive zones, the patient wasenrolled. Compared to a gold standard of chest radiography combinedwith brain natriuretic peptide, echocardiography, and discharge diagnosis,patients were confirmed to have acute pulmonary edema. All imageswere reviewed by 2 US fellowship-trained ED physicians, and each zonewas scored according to an a priori scale.Results—During the initial pilot, 24 patients were analyzed.There was no dominant pattern that emerged among the 8 zones. Thirteenpercent (3/24) were positive in every zone. On the right, zones 2, 3, and 4were positive in 79% (19/24), while on the left, zone 5 was positive in71% (17/24) and zone 7 in 67% (16/24). When the right chest was notedto be positive, the contralateral zone noted to be positive in the greatestnumber of patients was zone 5.Conclusions—While the small number of patients limits thisstudy, trends were noted in specific zones, particularly the right chest andzone 5. However, there is no dominant pattern or statistically significantresults to suggest that any zone is more predictive for diagnosing acutepulmonary edema by B-lines on US. This suggests that it is necessary toscan all 8 zones and perform a thorough but expeditious thoracic US examinationwhen rapid diagnosis of critically ill patients is crucial.1538301 Central Venous Catheterization Location Changes andComplication Rates After the Institution of an EmergencyUltrasound DivisionTahisha Tolbert,* Lawrence Haines, Lucas McArthur,Victoria Terentiev, Antonios Likourezos, Eitan DickmanEmergency Medicine, Maimonides Medical Center, Brooklyn,New York USAObjectives—To look at central venous catheter (CVC) placementpatterns before and after the establishment of an emergency ultrasounddivision (EUSD). We hypothesized that the internal jugular vein(IJ) site would be used more often as familiarity with ultrasound (US)increased. A secondary objective was to compare the mechanical complicationrates associated with CVC placement before and after the establishmentof an EUSD.Methods—This was a retrospective chart review looking at allCVCs placed in an urban tertiary care medical center’s emergency department(ED) with an emergency medicine residency program and115,000 ED visits per year. We queried our electronic medical record forall CVCs placed in the ED between the years 2004 and 2007 and the years2007 and 2010, representing the 3 years before and after the establishmentof the EUSD. The locations of these CVCs were compared to assess forany changes. This data set was then queried for patients who had a documentedmechanical complication from the CVC placement.Results—In all, 1876 CVCs were placed between 2004 and2007, and 1707 were placed between 2007 and 2010. Selection of thefemoral vein CVC location changed from 50.8% to 42.5%, subclavianfrom 37.0% to 17.3%, and IJ from 12.2% to 40.2% (P = .0001 for all). Themechanical complication rate decreased from 9.1% to 5.4% (P = .0001).Conclusions—The establishment of an EUSD, with formaltraining in the use of US for CVC placement, is associated with a significantchange in CVC site selection patterns, most notably a sharp increasein selection of the IJ site and a dramatic reduction in the selection of thesubclavian site. In addition, there was a 41% decrease in the complicationrates such as pneumothorax and arterial puncture.Table 1. Specific Complicationsn (%)Complication 2004–2007 2007–2010 PPneumothorax 23 (1.2) 6 (0.4) .004Chest tube 18 (1) 4 (0.2) .005Arterial puncture 47 (2.5) 21 (1.2) .0051539748 Faster = Better? Pilot Sonographic Evaluation of InternalJugular Vein Collapsibility Versus Inferior Vena CavaCollapsibility Indices in Critically Ill PatientsDavid Evans, 1 * Daniel Eiferman, 1 Alistair Kent, 1 CreaghBoulger, 2 Andrew Springer, 3 Eric Adkins, 2 Susan Yeager, 1Geoffrey Roelant, 1 Stanislaw Stawicki, 1 David Bahner 21Surgery, 2 Emergency Medicine, 3 Anesthesiology, Ohio StateUniversity, Columbus, Ohio USAObjectives—Intensivist-performed bedside sonographic assessmentof volume status is a rapidly evolving area. Although the inferiorvena cava collapsibility index (IVC-CI) has been shown to correlatewith both clinical assessment and invasive monitoring of intravascularvolume status, it is limited by difficult visualization of the IVC, interferenceby surgical dressings and tubes, and a relatively steep learning curve.Many physicians already have experience with internal jugular ultrasoundfor vascular access. Due to the ease of the technique and simpler anatomy,we hypothesized that the internal jugular vein collapsibility index (IJV-CI) would be easier to perform than the IVC-CI.Methods—A prospective observational pilot study comparingIVC-CI and IJV-CI was performed in surgical intensive care unit patients.S19