Diagnostic accuracy of point-of-care ultrasound for catheter-related thrombosis in children

Abstract

Background: Compared with consultative US performed by the radiology department, point-of-care US performed by non-radiology physicians can accurately diagnose deep venous thrombosis in adults.

Objective: In preparation for a multicenter randomized controlled trial, we determined the accuracy of point-of-care US in diagnosing central venous catheter-related thrombosis in critically ill children.

Materials and methods: Children <18 years old with a central venous catheter who were admitted to the intensive care unit were enrolled. Consultative and point-of-care compression ultrasounds with Doppler were done on the vein where the catheter was inserted within 24 h after insertion. Repeat US was obtained within 24 h of removal of the catheter. All images were centrally, blindly and independently adjudicated for thrombosis by a team of pediatric radiologists. Chance-corrected agreement between readings was calculated.

Results: From 84 children, 152 pairs of consultative and point-of-care ultrasounds were analyzed. A total of 38 (25.0%) consultative and 17 (11.2%) point-of-care ultrasounds were positive for thrombosis. The chance-corrected agreement between consultative and point-of-care ultrasounds was 0.17 (standard error: 0.07; P = 0.008). With consultative US as a reference, the sensitivity of point-of-care US was 28.1% (95% confidence interval: 13.7%-46.7%) with a specificity of 91.8% (95% confidence interval: 84.4%-96.4%). A catheter in the subclavian vein was associated with discordant readings (adjusted odds ratio: 4.00; 95% confidence interval: 1.45-13.94).

Conclusion: Point-of-care US, when performed by non-radiology physicians and centrally adjudicated by pediatric radiologists in the setting of a multicenter randomized controlled trial, may not accurately diagnose catheter-related thrombosis in critically ill children.

Keywords: Central venous catheter; Children; Intensive care unit; Point-of-care ultrasound; Ultrasound; Venous thromboembolism.

Fig. 1

A 6-day-old girl with shock. Unevaluable images on point-of-care US (a–c) and normal scan on consultative US (d–e). The right supraclavicular region was scanned. Only 3 images were obtained on point-of-care US because of poor sonographic access (small child). The images were considered unevaluable because the pediatric radiologists could not identify with confidence any vein in the images despite arrow notation on (b) and presence of color Doppler box on (c). d–e Longitudinal images of the right supraclavicular region depicting the medial (d) and mid (e) portions of the right subclavian vein with normal flow on color and spectral Doppler

Fig. 1

A 6-day-old girl with shock. Unevaluable images on point-of-care US (a–c) and normal scan on consultative US (d–e). The right supraclavicular region was scanned. Only 3 images were obtained on point-of-care US because of poor sonographic access (small child). The images were considered unevaluable because the pediatric radiologists could not identify with confidence any vein in the images despite arrow notation on (b) and presence of color Doppler box on (c). d–e Longitudinal images of the right supraclavicular region depicting the medial (d) and mid (e) portions of the right subclavian vein with normal flow on color and spectral Doppler

Fig. 1

A 6-day-old girl with shock. Unevaluable images on point-of-care US (a–c) and normal scan on consultative US (d–e). The right supraclavicular region was scanned. Only 3 images were obtained on point-of-care US because of poor sonographic access (small child). The images were considered unevaluable because the pediatric radiologists could not identify with confidence any vein in the images despite arrow notation on (b) and presence of color Doppler box on (c). d–e Longitudinal images of the right supraclavicular region depicting the medial (d) and mid (e) portions of the right subclavian vein with normal flow on color and spectral Doppler

Fig. 1

A 6-day-old girl with shock. Unevaluable images on point-of-care US (a–c) and normal scan on consultative US (d–e). The right supraclavicular region was scanned. Only 3 images were obtained on point-of-care US because of poor sonographic access (small child). The images were considered unevaluable because the pediatric radiologists could not identify with confidence any vein in the images despite arrow notation on (b) and presence of color Doppler box on (c). d–e Longitudinal images of the right supraclavicular region depicting the medial (d) and mid (e) portions of the right subclavian vein with normal flow on color and spectral Doppler

Fig. 1

A 6-day-old girl with shock. Unevaluable images on point-of-care US (a–c) and normal scan on consultative US (d–e). The right supraclavicular region was scanned. Only 3 images were obtained on point-of-care US because of poor sonographic access (small child). The images were considered unevaluable because the pediatric radiologists could not identify with confidence any vein in the images despite arrow notation on (b) and presence of color Doppler box on (c). d–e Longitudinal images of the right supraclavicular region depicting the medial (d) and mid (e) portions of the right subclavian vein with normal flow on color and spectral Doppler

Fig. 2

An 8-year-old girl with acute liver failure. Unevaluable images on point-of-care US. a Composite transverse point-of-care US image at the level of the right common femoral vein (arrows) with (right) and without (left) color Doppler. The images were considered unevaluable because the pediatric radiologists could not identify the vein with confidence despite arrow notations on both images and presence of color Doppler box on the image on the right. Bandages caused a veil-like shadow artifact along the center of both images (arrowheads), which likely contributed to obscuration of the vein. b The corresponding consultative US images were read as normal. A slightly more lateral approach during scanning brought the bandage artifact (arrowhead) out of the region of interest, allowing depiction of a normal vein

Fig. 2

An 8-year-old girl with acute liver failure. Unevaluable images on point-of-care US. a Composite transverse point-of-care US image at the level of the right common femoral vein (arrows) with (right) and without (left) color Doppler. The images were considered unevaluable because the pediatric radiologists could not identify the vein with confidence despite arrow notations on both images and presence of color Doppler box on the image on the right. Bandages caused a veil-like shadow artifact along the center of both images (arrowheads), which likely contributed to obscuration of the vein. b The corresponding consultative US images were read as normal. A slightly more lateral approach during scanning brought the bandage artifact (arrowhead) out of the region of interest, allowing depiction of a normal vein

Fig. 3

An 11-month-old boy with acute respiratory failure. Normal scans on both consultative (a and b) and point-of-care (c and d) US. a Composite transverse consultative US image at the level of the right femoral vein (arrows), before (left) and after (right) compression depicts full compressibility of the vein. b Longitudinal consultative US image at the level of the bifurcation of the right common femoral vein depicts normal flow on color Doppler. c Composite transverse point-of-care US image at the same level as (a) also depicts full compressibility of the vein. d Longitudinal point-of-care US image at the same level as (b) depicts normal flow on color Doppler

Fig. 3

An 11-month-old boy with acute respiratory failure. Normal scans on both consultative (a and b) and point-of-care (c and d) US. a Composite transverse consultative US image at the level of the right femoral vein (arrows), before (left) and after (right) compression depicts full compressibility of the vein. b Longitudinal consultative US image at the level of the bifurcation of the right common femoral vein depicts normal flow on color Doppler. c Composite transverse point-of-care US image at the same level as (a) also depicts full compressibility of the vein. d Longitudinal point-of-care US image at the same level as (b) depicts normal flow on color Doppler

Fig. 3

An 11-month-old boy with acute respiratory failure. Normal scans on both consultative (a and b) and point-of-care (c and d) US. a Composite transverse consultative US image at the level of the right femoral vein (arrows), before (left) and after (right) compression depicts full compressibility of the vein. b Longitudinal consultative US image at the level of the bifurcation of the right common femoral vein depicts normal flow on color Doppler. c Composite transverse point-of-care US image at the same level as (a) also depicts full compressibility of the vein. d Longitudinal point-of-care US image at the same level as (b) depicts normal flow on color Doppler

Fig. 3

An 11-month-old boy with acute respiratory failure. Normal scans on both consultative (a and b) and point-of-care (c and d) US. a Composite transverse consultative US image at the level of the right femoral vein (arrows), before (left) and after (right) compression depicts full compressibility of the vein. b Longitudinal consultative US image at the level of the bifurcation of the right common femoral vein depicts normal flow on color Doppler. c Composite transverse point-of-care US image at the same level as (a) also depicts full compressibility of the vein. d Longitudinal point-of-care US image at the same level as (b) depicts normal flow on color Doppler

Fig. 4

A 15-year-old girl with shock. Deep venous thrombosis on both consultative (a and b) and point-of-care (c–e) US. Transverse (a) and longitudinal (b) consultative US images at the level of the right internal jugular vein depict the presence of intravenous echoic material (arrows). c–e Transverse point-of-care US images at the same level depict the presence of intravenous echoic material (arrow on c), inability to fully compress the vein (d) and abnormal color Doppler flow (e)

Fig. 4

A 15-year-old girl with shock. Deep venous thrombosis on both consultative (a and b) and point-of-care (c–e) US. Transverse (a) and longitudinal (b) consultative US images at the level of the right internal jugular vein depict the presence of intravenous echoic material (arrows). c–e Transverse point-of-care US images at the same level depict the presence of intravenous echoic material (arrow on c), inability to fully compress the vein (d) and abnormal color Doppler flow (e)

Fig. 4

A 15-year-old girl with shock. Deep venous thrombosis on both consultative (a and b) and point-of-care (c–e) US. Transverse (a) and longitudinal (b) consultative US images at the level of the right internal jugular vein depict the presence of intravenous echoic material (arrows). c–e Transverse point-of-care US images at the same level depict the presence of intravenous echoic material (arrow on c), inability to fully compress the vein (d) and abnormal color Doppler flow (e)

Fig. 4

A 15-year-old girl with shock. Deep venous thrombosis on both consultative (a and b) and point-of-care (c–e) US. Transverse (a) and longitudinal (b) consultative US images at the level of the right internal jugular vein depict the presence of intravenous echoic material (arrows). c–e Transverse point-of-care US images at the same level depict the presence of intravenous echoic material (arrow on c), inability to fully compress the vein (d) and abnormal color Doppler flow (e)

Fig. 4

A 15-year-old girl with shock. Deep venous thrombosis on both consultative (a and b) and point-of-care (c–e) US. Transverse (a) and longitudinal (b) consultative US images at the level of the right internal jugular vein depict the presence of intravenous echoic material (arrows). c–e Transverse point-of-care US images at the same level depict the presence of intravenous echoic material (arrow on c), inability to fully compress the vein (d) and abnormal color Doppler flow (e)

Fig. 5

A 5-month-old boy with acute respiratory failure. Deep venous thrombosis on consultative US (a and b) and normal scan on point-of-care US (c). a–b Transverse consultative US images at the level of the right internal jugular vein depict the presence of intravenous echoic material (arrow on a) and abnormal color Doppler flow (b). c No intravenous abnormality was convincingly identified at the same level on point-of-care US (arrow indicates location of vein). It seemed that there is a subtle veil-like shadow artifact along the left-most aspect of the image (arrowheads), which might have contributed to missing the finding. The remainder of the point-of-care US images (not shown) on this child did not demonstrate abnormal vein compressibility or abnormal color Doppler flow

Fig. 5

A 5-month-old boy with acute respiratory failure. Deep venous thrombosis on consultative US (a and b) and normal scan on point-of-care US (c). a–b Transverse consultative US images at the level of the right internal jugular vein depict the presence of intravenous echoic material (arrow on a) and abnormal color Doppler flow (b). c No intravenous abnormality was convincingly identified at the same level on point-of-care US (arrow indicates location of vein). It seemed that there is a subtle veil-like shadow artifact along the left-most aspect of the image (arrowheads), which might have contributed to missing the finding. The remainder of the point-of-care US images (not shown) on this child did not demonstrate abnormal vein compressibility or abnormal color Doppler flow

Fig. 5

A 5-month-old boy with acute respiratory failure. Deep venous thrombosis on consultative US (a and b) and normal scan on point-of-care US (c). a–b Transverse consultative US images at the level of the right internal jugular vein depict the presence of intravenous echoic material (arrow on a) and abnormal color Doppler flow (b). c No intravenous abnormality was convincingly identified at the same level on point-of-care US (arrow indicates location of vein). It seemed that there is a subtle veil-like shadow artifact along the left-most aspect of the image (arrowheads), which might have contributed to missing the finding. The remainder of the point-of-care US images (not shown) on this child did not demonstrate abnormal vein compressibility or abnormal color Doppler flow

Fig. 6

Association between fixed effects parameters and discordant readings (a) and unevaluable images (b). CVC central venous catheter