American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma clinical protocol for postdischarge venous thromboembolism prophylaxis after trauma.

ABSTRACT: Trauma patients are at an elevated risk for developing venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis. In the inpatient setting, prompt pharmacologic prophylaxis is utilized to prevent VTE. For patients with lower extremity fractures or limited mobility, VTE risk does not return to baseline levels postdischarge. Currently, there are limited data to guide postdischarge VTE prophylaxis in trauma patients. The goal of these postdischarge VTE prophylaxis guidelines are to identify patients at the highest risk of developing VTE after discharge and to offer pharmacologic prophylaxis strategies to limit this risk.

TQIP mortality reporting system case reports: Unanticipated mortality due to inadequate preoperative ICU "clearance".

ABSTRACT: The Trauma Quality Improvement Program Mortality Reporting System is an online anonymous case reporting system designed to share experiences from rare events that may have contributed to unanticipated mortality at contributing trauma centers. The Trauma Quality Improvement Program Mortality Reporting System Working Group monitors submitted cases and organizes them into emblematic themes. This report summarizes unanticipated mortality from a case of inadequate clearance by the intensive care unit service before surgical intervention in an injured patient and presents strategies to mitigate these events locally with the hope of decreasing unanticipated mortality nationwide.

Emergencies do not shut down during a pandemic: COVID pandemic impact on Acute Care Surgery volume and mortality at a level I trauma center.

BACKGROUND: The aim of this study was to evaluate the impact of the COVID-19 pandemic on volume and outcomes of Acute Care Surgery patients, and we hypothesized that inpatient mortality would increase due to COVID+ and resource constraints. METHODS: An American College of Surgeons verified Level I Trauma Center's trauma and operative emergency general surgery (EGS) registries were queried for all patients from Jan. 2019 to Dec. 2020. April 1st, 2020, was the demarcation date for pre- and during COVID pandemic. Primary outcome was inpatient mortality. RESULTS: There were 14,460 trauma and 3091 EGS patients, and month-over-month volumes of both remained similar (p > 0.05). Blunt trauma decreased by 7.4% and penetrating increased by 31%, with a concomitant 25% increase in initial operative management (p < 0.001). Despite this, trauma (3.7%) and EGS (2.9-3.0%) mortality rates remained stable which was confirmed on multivariate analysis; p > 0.05. COVID + mortality was 8.8% and 3.7% in trauma and EGS patients, respectively. CONCLUSION: Acute Care Surgeons provided high quality care to trauma and EGS patients during the pandemic without allowing excess mortality despite many hardships and resource constraints.

American Association for the Surgery of Trauma/American College of Surgeons-Committee on Trauma Clinical Protocol for inpatient venous thromboembolism prophylaxis after trauma.

ABSTRACT: Trauma patients are at increased risk of venous thromboembolism (VTE), which includes both deep vein thrombosis and pulmonary embolism. Pharmacologic VTE prophylaxis is a critical component of optimal trauma care that significantly decreases VTE risk. Optimal VTE prophylaxis protocols must manage the risk of VTE with the competing risk of hemorrhage in patients following significant trauma. Currently, there is variability in VTE prophylaxis protocols across trauma centers. In an attempt to optimize VTE prophylaxis for the injured patient, stakeholders from the American Association for the Surgery of Trauma and the American College of Surgeons-Committee on Trauma collaborated to develop a group of consensus recommendations as a resource for trauma centers. The primary goal of these recommendations is to help standardize VTE prophylaxis strategies for adult trauma patients (age ≥15 years) across all trauma centers. This clinical protocol has been developed to (1) provide standardized medication dosing for VTE prophylaxis in the injured patient; and (2) promote evidence-based, prompt VTE prophylaxis in common, high-risk traumatic injuries. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.

PATHway to success: Implementation of a multiprofessional acute trauma health care team decreased length of stay and cost in patients with neurological injury requiring tracheostomy.

BACKGROUND: The aim of this study was to determine whether the implementation of a dedicated multiprofessional acute trauma health care (mPATH) team would decrease length of stay without adversely impacting outcomes of patients with severe traumatic brain and spinal cord injuries. The mPATH team was comprised of a physical, occupational, speech, and respiratory therapist, nurse navigator, social worker, advanced care provider, and physician who performed rounds on the subset of trauma patients with these injuries from the intensive care unit to discharge. METHODS: Following the formation and implementation of the mPATH team at our Level I trauma center, a retrospective cohort study was performed comparing patients in the year immediately prior to the introduction of the mPATH team (n = 60) to those in the first full year following implementation (n = 70). Demographics were collected for both groups. Inclusion criteria were Glasgow Coma Scale score less than 8 on postinjury Day 2, all paraplegic and quadriplegic patients, and patients older than 55 years with central cord syndrome who underwent tracheostomy. The primary endpoint was length of stay; secondary endpoints were time to tracheostomy, days to evaluation by occupational, physical, and speech therapy, 30-day readmission, and 30-day mortality. RESULTS: The median time to evaluation by occupational, physical, and speech therapy was universally decreased. Injury Severity Score was 27 in both cohorts. Time to tracheostomy and length of stay were both decreased. Thirty-day readmission and mortality rates remained unchanged. A cost savings of US $11,238 per index hospitalization was observed. CONCLUSION: In the year following the initiation of the mPATH team, we observed earlier time to occupational, physical, and speech therapist evaluation, decreased length of stay, and cost savings in severe traumatic brain and spinal cord injury patients requiring tracheostomy compared with our historical control. These benefits were observed without adversely impacting 30-day readmission or mortality. LEVEL OF EVIDENCE: Therapeutic/care management, Level III.

Trauma Center Youth Violence Screening and Brief Interventions: A Multisite Pilot Feasibility Study.

Every day, 16 American youths between the ages of 10 and 24 years are murdered; 84% of these fatalities involve a firearm. Nearly half of traumatic youth deaths result from violence-related injuries. In 2013, 580,250 youth suffered nonfatal, assault-related injuries, necessitating emergency department treatment. The aim of this multisite pilot study was to examine the process, feasibility, and challenges of violence brief interventions (VBIs). The participants were youth between 15 and 25 years of age, at 2 major Level 1 trauma centers (TCs; TC1, TC2) in the Southeastern United States. Eligible participants (N = 38; TC1: n = 20, TC2: n = 18) received at least 1 VBI during their hospital stay, which provided information about individual screening results and elicited patients' perspectives on violent and risky behaviors. More participants at TC2 than at TC1 completed 2 VBI sessions. Barriers to and support of implementation were identified at both sites, and factors for improving implementation were identified, including the need for staff support through clinical guidelines and coordinated prevention and outreach programs. Further research is needed to identify factors for successful implementation of VBIs in TCs.

Examining the role of follow-up skeletal surveys in non-accidental trauma.

BACKGROUND: Diagnosing NAT (non-accidental trauma) includes a skeletal survey to identify injuries. A follow-up survey is performed for missed injuries. This study examines the necessity of follow-up surveys. METHODS: The trauma database identified cases of suspected NAT in <4 years olds (2013-2014). Data were stratified by survey, age, injury, then analyzed for the prevalence of findings. All analyses (relative risk, prevalence and odds ratios) utilized RealStats Resource Pack (Trento, Italy). RESULTS: 79% positive initial findings and no new follow up findings. Those with negative initial imaging, had no missed injuries. Initial scans were 27.6X more likely to be positive. Fractured skull (31.3), femur (17.2) and ribs (15.7) were the most prevalent. No pelvic fractures and <1% spinal injuries despite both having the greatest radiation exposure. Repeat scans rarely identify findings for age >12 months. CONCLUSIONS: Follow-up skeletal surveys maybe unnecessary without clinical evidence. Uncommon pelvic and spinal fractures may warrant exclusion from surveys unless clinically indicated.

Trauma intensive care unit 'bouncebacks': identifying risk factors for unexpected return admission to the intensive care unit.

Return transfer (RT) to the intensive care unit (ICU) negatively impacts patient outcomes, length of stay (LOS), and hospital costs. This study assesses the most common events necessitating RT in trauma patients. We performed a retrospective chart review of ICU RT from 2004 to 2008. Patient demographics, injuries and injury severity, reason for transfer, LOS, interventions, and outcomes data were collected. Overall, 158 patients required readmission to the ICU. Respiratory insufficiency/failure (48%) was the most common reason for RT followed by cardiac (16%) and neurological (13%) events. The most commonly associated injuries were traumatic brain injuries (TBIs) (32%), rib fractures (30%), and pulmonary contusions (20%). Initial ICU LOS was 6.6 ± 8 days (range, 1 to 44 days) with 4.4 ± 7.8 ventilator days. Mean floor time before ICU RT was 5.7 ± 6.3 days (range, 0 to 33 days). Forty-nine patients (31%) required intubation and mechanical ventilation on RT. ICU RT incurred an additional ICU LOS of 8 ± 8.5 days (range, 1 to 40 days) and 5.2 ± 7.5 ventilator days. Mortality after a single RT was 10 per cent (n = 16). RT to the ICU most often occurs as a result of respiratory compromise, and patients with TBI are particularly vulnerable. Trauma pulmonary hygiene practices should be evaluated to determine strategies that could decrease RT.

The Organ Donation Breakthrough Collaborative: has it made a difference?

BACKGROUND: The Organ Donation Breakthrough Collaborative (ODBC) was established in 2003 to increase the number of transplantable organs in the United States. However, recent publications have suggested that the ODBC has not impacted donation conversion rates at local organ procurement organizations (OPOs). We sought to determine the impact, if any, of our becoming part of the ODBC on organ donation rates in our OPO or in our institution (Carolinas Medical Center [CMC]), particularly among minority donors. METHODS: This is a retrospective review of data entered concurrently into a patient referral database maintained by our local OPO. Donation approach and consent rates were calculated. They were then analyzed by race and institution, and trends were analyzed over the study period of 2002 to 2010. Statistical differences between the various patient groups were determined by the chi-square test or the Fisher exact test. Statistical differences over time were determined by the Cochran-Armitage trend test. RESULTS: From 2002 to 2010, 10,855 patients were screened by our OPO for potential organ donation. The overall approach rate was 13.4%, and the consent rate was 57.6%. An increase in approach and consent rates was noted beginning in 2004, but this increase was not sustained. Consent rates in general were higher for white patients than for black and Hispanic patients. Consent rates for CMC did increase significantly (P = .02), but they did not increase for the non-CMC hospitals. When analyzed by race, no significant changes were noted in consent rates over time. When analyzed by race and institution, the only statistically significant increase in consent rates occurred for white patients at CMC. CONCLUSIONS: Since joining the ODBC, we have noted an increase in consent rates at a single institution (CMC), but no other significant changes. Greater emphasis should be placed on methods to increase and sustain consent rates for all racial groups in general, with a special emphasis on increasing consent rates in minority patients.

Breakdown of the consent process at a quaternary medical center: our full disclosure.

Circumstances may arise in the intensive care unit (ICU) when the physician is unable to obtain informed consent. We undertook this study to determine the variations in the consent process. An anonymous survey was distributed to all critical care nurses (RN), resident physicians (RES), advanced practitioners (AP), and attending physicians (ATT). Participants were asked to describe the risks of nine common ICU procedures (central venous line, peripherally inserted central catheter, bronchoscopy, tube thoracostomy, tracheostomy, vena cava filter, angioembolization, image-guided drainage, and percutaneous endoscopic gastrostomy tube). Participants were also asked which member of the healthcare team should obtain consent. All groups were compared with ATT responses and RN responses were compared with the remaining groups. The response rate was 134 of 610 participants (22%) with 51 per cent RN (n = 68), 17 per cent RES (n = 23), 7 per cent AP (n = 9), and 25 per cent ATT (n = 34). Compared with ATT, RN assessment of important risks varied significantly for eight of nine procedures. RES responses varied in three procedures. A minority believed that nurses should obtain consent. However, many physicians (34% ATT and 27% RES) denied having informed consent discussions with 50 per cent or more of their patients. This study has exposed a wide variation in consent practices. Future efforts to standardize consent processes are needed to protect patients and physicians.

The reward is worth the wait: a prospective analysis of 100 consecutive organ donors.

Aggressive donor management protocols have evolved to maximize the number of procured organs. Our study assessed donor management time and the number and types of organs procured with the hypothesis that shorter management time yields increased organ procurement and transplant rates. We prospectively analyzed 100 donors managed by a regional organ procurement organization (OPO) during 2007 to 2008. Data included patient demographics, number and types of organs procured and transplanted, patient management time by the OPO, and achievement of donor preprocurement goals. One hundred consecutive organ donors were managed with a mean age 41 ± 18 years and mean management time 23 ± 9 hours; 376 organs were procured and 327 successfully transplanted. Donors managed greater than 20 hours yielded significantly more heart (5 vs 26, P < 0.01) and lung (6 vs 40, P < 0.01) procurements, more organs procured per donor (3.2 ± 1.4 vs 4.2 ± 1.6, P < 0.01), and more organs transplanted per donor (2.6 ± 1.5 vs 3.7 ± 1.8, P < 0.01) than those managed 20 hours or less. No difference in the attainment of donor management goals was observed between these populations. Contrary to our initial hypothesis, donor management times greater than 20 hours yielded increased organ procurement and transplant rates, particularly for hearts and lungs, despite no differences in the achievement of donor preprocurement management goals.

Vena cava filter insertion and the general surgery armamentarium: a 13-year experience.

The prevention of pulmonary emboli has a long surgical history. Through the development of percutaneous technologies, vena cava filters (VCFs) are now commonly inserted by interventional radiologists. This study reviews our experience with VCFs inserted by general surgeons. We retrospectively reviewed data from our VCF performance improvement database, which is a prospective collection of the VCF experience of the Department of General Surgery from February 1996 to May 2009. Demographics, procedural information, and complications were recorded. Eight hundred fifty-five VCFs were inserted in 853 patients. The mean age was 42.0 years (range, 14 to 90 years). One hundred ninety-seven VCFs were placed in the operating room, and 658 were placed in the intensive care unit. Twelve VCFs were intentionally inserted in a suprarenal position, and four were placed in the superior vena cava. Two patients received both superior vena cava and inferior vena cava filters. Complications included deep vein thrombosis at the insertion site (n=16), vena cava thrombosis (n=9), post-VCF pulmonary embolism (n=2), and a ventricle perforation requiring operative repair (n=1). No deaths were attributed to the presence of a VCF. Overall insertion success was 99.8 per cent. In two patients, an inferior VCF could not be placed as a result of inferior vena cava occlusion with no safe "landing zone" for deployment. The placement of VCFs is a vital skill in the general surgery armamentarium. Our experience demonstrates that general surgeons can safely insert VCFs with minimal perioperative complications.

An initiative by midlevel providers to conduct tertiary surveys at a level I trauma center.

INTRODUCTION: Increased patient volume and residents' work hour restrictions have escalated the workload at trauma centers. Because tertiary surveys (TSs) are integral to care, midlevel providers (MLPs) can help streamline this time-consuming process. In this study, we implemented a care plan in which MLPs conduct all TSs, initiate appropriate consultations, and offload residents' work hours. METHODS: From January 2007 to December 2008, we conducted a prospective evaluation of an initiative in which MLPs performed all TSs within 48 hours of admission. A TS consisted of a complete history and physical examination, follow-up of radiologic interpretations, and appropriate consultations. Data included patient demographics, incidence of additional diagnoses noted during TSs and reduction in residents' work hours. Data are presented as mean +/- standard error. RESULTS: During the 2-year period, there were 5,143 patients admitted to the trauma service. The mean age was 36 years +/- 4.8 years, and mean Injury Severity Score (ISS) was 14.2 +/- 4.2. Overall mortality was 5%. Blunt mechanisms accounted for 85%, and penetrating mechanisms resulted in 14% of injuries. MLPs conducted TSs in 56% of patients during the first year and 76% in the second year. In 80 patients (mean age of 44 years +/- 7.1 years, mean Injury Severity Score 21.7 +/- 2.8; p < 0.05 vs. entire cohort), TSs revealed additional injuries, for an incidence of 1.5%. The majority of these diagnoses were of "minor" fractures, half requiring consultations, and 9% necessitating operative intervention. Residents' workload was reduced by 1,802 hours. CONCLUSIONS: Implementation of a MLP initiative to conduct TSs in trauma patients can achieve a consistent and comprehensive workup while offsetting residents' workload and helping to ensure compliance with the 80-hour resident work policy.

Trauma attending physician continuity: does it make a difference?

Continuity of care is important in achieving optimal outcomes in trauma patients, but the optimal length of the trauma attending (TA) rotation is unknown. We hypothesize that longer TA rotations provide greater continuity, and therefore improve outcomes. We did a retrospective comparison of trauma patient outcomes from two consecutive 6-month periods during which we transitioned from a 1-month TA rotation to a 1-week TA rotation. The Wilcoxon rank sum test, and the chi2 were used for statistical analysis. Over the 12-month study period 1924 patients were admitted to the Trauma Service. The two groups were similar with regard to age, gender, injury mechanism, Injury Severity Score and Glasgow Coma Scale scores, and Abbreviated Injury Scores for the chest, abdomen, and extremities. Although mortality, patient charges, and violations of the standard of care were similar between the two groups, overall morbidity was lower (18.6% vs. 23.2%), and hospital length of stay higher (9.07 days vs. 8.41 days) in the 1-week TA group compared with the 1-month TA group. A one-week TA rotation was associated with a longer hospital length of stay, but improved morbidity. Longer TA rotations do not necessarily provide improved continuity or improved outcomes.

Blunt cerebrovascular injury practice management guidelines: the Eastern Association for the Surgery of Trauma.

BACKGROUND: Blunt injury to the carotid or vertebral vessels (blunt cerebrovascular injury [BCVI]) is diagnosed in approximately 1 of 1,000 (0.1%) patients hospitalized for trauma in the United States with the majority of these injuries diagnosed after the development of symptoms secondary to central nervous system ischemia, with a resultant neurologic morbidity of up to 80% and associated mortality of up to 40%. With screening, the incidence rises to 1% of all blunt trauma patients and as high as 2.7% in patients with an Injury Severity Score of >or=16. The Eastern Association for the Surgery of Trauma organization Practice Management Guidelines committee set out to develop an EBM guideline for the screening, diagnosis, and treatment of BCVI. METHODS: A computerized search of the National Library of Medicine/National Institute of Health, Medline database was performed using citations from 1965 to 2005 inclusive. Titles and abstracts were reviewed to determine relevance, and isolated case reports, small case series, editorials, letters to the editor, and review articles were eliminated. The bibliographies of the resulting full-text articles were searched for other relevant citations, and these were obtained as needed. These papers were reviewed based on the following questions: 1. What patients are of high enough risk, so that diagnostic evaluation should be pursued for the screening and diagnosis of BCVI? 2. What is the appropriate modality for the screening and diagnosis of BCVI? 3. How should BCVI be treated? 4. If indicated, for how long should antithrombotic therapy be administered? 5. How should one monitor the response to therapy? RESULTS: One hundred seventy-nine articles were selected for review, and of these, 68 met inclusion criteria and are excerpted in the attached evidentiary table and used to make recommendations. CONCLUSIONS: The East Practice Management Guidelines Committee suggests guidelines that should be safe and efficacious for the screening, diagnosis, and treatment of BCVI. Risk factors for screening are identified (see ), screening modalities are reviewed indicating that although angiography remains the gold standard, multi-planar (>or==8 slice) CT angiography may be equivalent, and treatment algorithms are evaluated. It is noted that change in the diagnosis and management of this injury constellation is rapid due to technological advancement and the difficulties inherent in performing randomized prospective trials in this patient population.

Wasted hospital days impair the value of length-of-stay variables in the quality assessment of trauma care.

Hospital length of stay (LOS) is frequently used to evaluate the quality of trauma care but LOS may be impacted by nonmedical factors as well. We reviewed our experience with delays in patient discharge to determine its financial consequences and its impact on LOS. We performed an analysis of linked trauma registry and "delayed discharge" databases. Actual LOS (A-LOS) values were compared with calculated ideal LOS (I-LOS) values, and the per cent increase in LOS was calculated. Linear regression analysis was used to identify significant predictors of prolonged LOS. One thousand, five hundred and seventeen patients were studied, with an A-LOS of 6.54 days. Seven per cent of patients experienced discharge delays, resulting in 580 excess hospital days. Calculated I-LOS was 6.15 days, 6.34 per cent lower than A-LOS. Other I-LOS estimates were as much as 25 per cent lower than A-LOS. Estimated excess patient charges associated with delayed discharges were $4,000,000 to $15,000,000. Discharge delays are an infrequent, although costly, occurrence that has a significant impact on LOS. LOS therefore may not be an appropriate metric for assessing the quality of trauma care, and should only be used if it has been corrected for discharge delays. Concerted efforts should be directed towards identifying and correcting the factors responsible for delayed discharge in trauma patients.

Has the pendulum swung too far? The impact of missed abdominal injuries in the era of nonoperative management.

Nonoperative management for traumatic injuries has significantly influenced trauma care during the last decade. We undertook this study to assess the impact of nontherapeutic laparotomies for suspected abdominal injuries compared with delayed laparotomies for questionable abdominal injuries for patients with abdominal trauma. The records of patients admitted to the trauma service between 2002 and 2007 who underwent laparotomies deemed nontherapeutic or delayed were retrospectively reviewed. Demographics, severity of injury, management scheme, and outcome data were analyzed. Sixteen patients underwent delayed laparotomies, whereas 26 patients incurred nontherapeutic laparotomies. Injury severity scores, Glasgow coma scale scores, abdominal abbreviated injury scale score (AIS), and age were similar for both populations. Delayed laparotomies occurred an average of 7 +/- 9 days postinjury. Intensive care unit length of stay (26 +/- 24 vs 10 +/- 6 days), hospital length of stay (40 +/- 37 vs 11 +/- 10 days), ventilator days (31 +/- 29 vs 11 +/- 10), and number of abdominal operative procedures (1.9 +/- 1.5 vs 1 +/- 0) were significantly higher in the delayed laparotomies group versus the nontherapeutic laparotomies group, respectively. Delayed diagnosis of intra-abdominal injuries yielded a significantly increased morbidity and mortality. During the evolving era of technological imaging for traumatic injuries, we must not allow the nonoperative pendulum to swing too far.

Optimal management strategy for incidental findings in trauma patients: an initiative for midlevel providers.

BACKGROUND: Increasing patient volume and residents' work hour restrictions have increased the workload at trauma centers. Further, comprehensive tertiary surveys after initial stabilization and appropriate follow-up plans for incidental findings are time consuming. Midlevel providers (MLP) can help streamline this process. We initiated a care plan in which MLPs conducted all tertiary surveys and coordinated follow-ups for incidental findings. METHODS: From November 2005 through May 2006, we implemented a MLP-driven initiative aimed at performing tertiary surveys within 48 hours of admission on all trauma patients admitted to our Level-1 trauma center. Tertiary surveys consisted of a complete history and physical, radiographic evaluations and appropriate consultations. Incidental findings were recorded and communicated to the trauma attending. A follow-up plan was devised, and the course of action was documented. Patients or family members were informed, and their acknowledgments were filed. Data are presented as mean +/- SE. RESULTS: There were 1,027 patients admitted during the study period. Blunt mechanisms accounted for 81% of the injuries (primarily motor vehicle crashes and falls). Seventy-six patients had 87 incidental findings (7.4%); 53 were men. The mean age was 51.8 years +/- 2.1 years and mean injury severity score was 18.5 +/- 1.4. Incidental findings of clinical significance included 18 pulmonary nodules or neoplasms, 9 adrenal masses (>4 mm), 7 patients with lymphadenopathy, 5 benign cystic lesions, and 3 renal masses. Other neoplastic lesions included bladder (2), thyroid (2), ovary (1), breast (1), and rectum (1). CONCLUSIONS: With prevalent medicolegal pressure and restricted residents' work hours, a MLP-initiative to streamline the tertiary survey effectively addresses incidental findings. This MLP-driven care plan can help reduce residents' workload, provides appropriate follow-up, and minimizes legal risks inherent to incidental findings on the trauma service.

Imaging of the vena cava in the intensive care unit prior to vena cava filter insertion: carbon dioxide as an alternative to iodinated contrast.

This study evaluates the safety and effectiveness of carbon dioxide (CO2) as a contrast agent in patients in the intensive care unit undergoing vena cava filter (VCF) insertion. We prospectively evaluated patients in the intensive care unit undergoing bedside VCF insertion using CO2 cavagraphy. Blood pressure, pulse rate, mixed venous oxygen saturation, and intracranial pressure were monitored before, during, and after the CO2 injection. Fifty patients in the intensive care unit (mean age 48.2 +/- 16.5 years) were included in the study. Five patients had decreases in blood pressure, which resolved without intervention. Two patients required iodinated contrast as a result of inadequate CO2 imaging. All patients had successful insertion of VCF. The use of CO2 as a contrast agent is a safe and highly effective alternative for vena cava imaging and can be considered the first-line contrast agent for all critically ill patients requiring VCF placement.