A Prospective Observational Quality Improvement Study of a Two-Step Ultrasound Protocol for Guidewire Confirmation During the Internal Jugular Central Venous Catheter Placement

Background Malposition of central venous catheters (CVCs) remains a relevant complication despite the use of ultrasound guidance. Traditional radiographic confirmation increases cost and radiation exposure. A minimal ultrasound protocol for guidewire confirmation may help reduce malposition rates without postprocedural radiographic imaging. Objectives To assess the effectiveness of a standardized two-step ultrasound protocol for confirming guidewire placement during internal jugular vein (IJV) CVC insertion in reducing catheter malposition rates. Methods This was a prospective observational quality improvement project conducted over six months in the anesthesia department of a tertiary hospital. Adult patients undergoing elective IJV CVC placement were included. A standardized two-step ultrasound protocol for guidewire confirmation during IJV CVC placement was introduced: (1) confirmation of caudal guidewire progression in the IJV and (2) exclusion of guidewire presence in the ipsilateral subclavian vein. Protocol adherence was evaluated prospectively by obtaining images and/or videos documenting the two-step ultrasound verification process. These recordings were captured by either the resident or the attending physician during the placement of the guidewire. All collected media were subsequently reviewed to confirm compliance with each step of the protocol. Catheter tip location was assessed routinely via postprocedural chest X-rays. The primary outcome was CVC malposition. Statistical analysis included Fisher's exact test and descriptive statistics. Results Out of 524 procedures, 506 were analyzed, while 18 were excluded due to a lack of postprocedural chest X-rays. Complete protocol adherence occurred in 243 (48%) cases. No malpositions occurred in the protocol-adherent group (0/243; 0%, 95% confidence interval (CI): 0-1.2%), whereas seven malpositions occurred among 263 partially adherent and non-adherent cases (2.7%). Fisher's exact test showed a significant association between non-adherence and malposition (p = 0.015). One contralateral pneumothorax unrelated to CVC insertion was observed. Conclusion A simple two-step ultrasound protocol for guidewire confirmation was associated with a significantly lower rate of CVC malposition. The method is feasible, efficient, and may serve as an alternative to routine radiographic confirmation in appropriate clinical contexts.