Evaluation of proper above-the-diaphragm central venous catheter placement: the saline flush test

hest radiographs are routinely obtained after the insertion of above-the-diaphragm central venous catheters to confirm placement and detect mechanical complications. At times, performing the radiograph can be time-consuming and findings may be inaccurate. We present a case of a patient with difficult access who required emergent resuscitation. A central venous catheter was inserted under ultrasound guidance into the patient's right internal jugular vein. After the procedure, a 2-dimensional bedside ultrasound of the heart was performed with simultaneous flush of saline through the catheter. Ultrasound detected an immediate echogenic turbulent pattern from the flush in the right atrium and then the right ventricle. This correlated to the proper placement of the catheter tip in the superior vena cava. A bedside ultrasound of the ipsilateral lung evaluated and ruled out iatrogenic pneumothorax. Other investigators have demonstrated different methods to confirm central venous catheter placement by bedside ultrasound, utilizing multiple views, Doppler technology, or microbubble contrast. This novel technique, as described here, is most simple. Further research is needed to demonstrate accuracy and utility.