Accuracy of physical examination in detecting central venous catheter-associated thrombosis in critically ill children
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Published on: December 23, 2014
Robert Marcel T Huibonhoa1, Matthew G Pinto2, E Vincent S Faustino3
1Department of Pediatrics, Metropolitan Hospital, New York, NY, United States.
Insights
Physical examination is inaccurate for detecting central venous catheter (CVC) associated deep venous thrombosis (CADVT) in critically ill children. Combining physical assessment with imaging is crucial for understanding CADVT clinical significance.
Area of Science:
- Pediatric Critical Care Medicine
- Vascular Medicine
- Diagnostic Accuracy Studies
Background:
- Standardized definitions for asymptomatic central venous catheter (CVC) associated deep venous thrombosis (CADVT) are lacking, hindering understanding of its clinical significance.
- Physical examination's role in detecting CADVT in critically ill children requires evaluation.
Purpose of the Study:
- To determine the accuracy of physical examination in detecting CADVT in critically ill children using standardized definitions.
- To identify factors associated with the accuracy of physical examination for CADVT detection.
Main Methods:
- A post hoc analysis of 236 children under 18 years old admitted to the pediatric intensive care unit.
- Children had an untunneled CVC and underwent paired physical examination and ultrasound surveillance for CADVT.
Main Results:
- CADVT was present in 33.5% of children on ultrasound. Physical examination showed low sensitivity (29.2%) but moderate specificity (80.2%) for CADVT detection.
- Excluding CVC dysfunction improved specificity but further reduced sensitivity. Point-of-care ultrasound and internal jugular vein CVC insertion were associated with lower sensitivity.
Conclusions:
- Physical examination demonstrates poor accuracy in detecting CADVT in critically ill children.
- Despite low accuracy, physical examination, including CVC dysfunction assessment, is vital when used with imaging to understand the clinical significance of asymptomatic CADVT.
Introduction:
Lack of standardized definition impedes our ability to understand the clinical significance of asymptomatic central venous catheter (CVC) associated deep venous thrombosis (CADVT). Using standardized definitions, we aimed to determine the accuracy of physical examination in detecting CADVT in critically ill children and to identify characteristics associated with this accuracy.
Materials And Methods:
In a post hoc study, we analyzed 236 children <18 years old admitted to the pediatric intensive care unit, had an untunneled CVC and surveilled for CADVT using ultrasound with paired physical examination.
Results:
Of 236 paired examinations, 79 (33.5 %) had CADVT on ultrasound, while 56 (23.7 %) had signs of inflammation or venous obstruction on physical examination or CVC dysfunction. Sensitivity was 29.2 % (95 % confidence interval, CI: 19.9 %, 38.5 %), specificity was 80.2 % (95 % CI: 73.9 %, 86.4 %) and area under the receiver operating characteristic curve (AUROC) was 0.55 (95 % CI: 0.49, 0.60). When CVC dysfunction was excluded, sensitivity was lower (11.1 %; 95 % CI: 4.6 %, 17.6 %; p = 0.002), but specificity was higher (88.7 %; 95 % CI: 83.6 %, 93.7 %, p = 0.04). AUROC was 0.50 (95 % CI: 0.46, 0.54; p = 0.17). Use of point-of-care ultrasound and CVC inserted in the internal jugular vein (vs femoral vein) had lower sensitivity. Sepsis or infection and vasoactive support had lower specificity. Center of enrollment was associated with variable sensitivity.
Conclusions:
Physical examination has poor accuracy in detecting CADVT in critically ill children. Despite poor accuracy, physical examination that includes assessment of CVC dysfunction, in combination with imaging, is key to understanding the clinical significance of asymptomatic CADVT.
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