PONE-D-22-14765Assessing Central Venous Catheter tip location- a different approach?PLOS ONE

Dear Dr. Merin,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Aug 28 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Martin Kieninger

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear authors,

thank you for submitting your article and data. I believe that the article needs some major revision to clarify the message for the readers. I hope that my suggestions help you to improve your article.

Major concerns:

The title of your work suggests that you present a new/different approach to controlling catheter location with x-rays. But, you do not! Instead, you investigate catheter migration over time with consecutive x-rays. Choose an appropriate title.

In the discussion section, you write: …..examine the movement of CVC tip throughout its use. Exactly, this should be reflected in the title.

Follow up is 72 hours? Why? You state that every x-ray was evaluated in the method section. Why did you only use a 72 hour follow up as mentioned in the abstract and figure 3 and 4?

Material and Method

Clarify, how patients were included into the study. Do you have a database. Did you screen your PDMS, etc. for every patient admitted between xxx and xxx?

The exclusion criteria are documented sufficiently.

How was the mentioned distance between carina and catheter tip measured? Did you use a software? Did you use a x-ray fluoroscope/screen? A difference between tow investigators of more than 1 cm is mentioned – this seems large using a software?

Who are the investigators? Part of your study team or part of the wards? What was there training? How did the training of the ICU specialist differ how was consulted in case of poor x-ray quality? Did you check with radiology?

Statistics. You used a T-test. Did you check for normal distribution? If data does not show normal distribution a non-parametric test should be used.

The multi-parameters regression model used in table 3 has to be explained in the method section.

Results and Discussion

Major influencing factors of possible catheter mobilizations are not investigated or mentioned; e.g. prone positioning, mobilization of patients, insertion duration of the catheters, etc. If these data are not available, it should at least be discussed as limitation.

Adverse events/e.g. the non-existence of adverse events is not mentioned or discussed. Not one catheter had to be removed (even the one in the subclavian vein)?

Conclusions

You only included 101 patients. Relativize your conclusion: ….. a 15 cm CVC inserted through the RIJ in most adults will likely initially reside ….. Refer to the height and weight of the studied patients.

General

I suggest to revise the paper. Focus on your major statement: catheters may move by several centimeters of the course of time (with or without major adverse events???).

Include data to these observed/non-observed adverse events? After all, what does the catheter movement mean for our patients/clinical practice?

Minor concerns

Abstract:

Design and Settings: Retrospective, single-center study, conducted in the Intensive Care and Cardiovascular Intensive Care Units between January and June 2019….

- State the name of the hospital/institution here including city and country

The average initial tip position was 1.52 (±1.9)…..

- Clarify, you probably refer to mean ± SD

Central Venous Catheterization (CVC) is a common procedure in intensive care units (ICU),

operating rooms (OR), and other hospital departments.

- Specify ‘other hospital departments’ or give examples ‘other departments like…..’ or delete.

….a routine chest XRay (CXR) is obtained after insertion and before using the CVC in order to detect insertion related complications and to assess catheter tip position (CTP).

- Really? One x-ray after insertion and a new one before use? How long do you wait until you use newly inserted CVCs in your ICU?

In addition, the use of bedside-US has been shown to be faster and more accurate in detecting these complications when they occur.

- Specify, faster than what else (x-rays)?

CTP

- You already use CVC as abbreviation. I suggest to use only CVC and refer to the ‘tip of the CVC’, since both abbreviations are similar.

….performing US assisted or guided CVC insertion

- Clarify. What is the difference?

…m the upper part of the SVC to the right atrium10,13–19 (Zone A and B).

- Clarify, Zone A and B as depicted in figure xxx.

All data were analysed by SPSS version 21.0.

- Suggestion: All data were analysed using SPSS version 21.0.

At each follow-up CXR, the chance of an initially well-positioned and initially malpositioned catheter to be in the "safezone" were similar (48% vs 39% at first CXR, 49% vs 26% at second and 40% vs 50% at third CXR.

- Do not use ‘safezone’, use the terminology introduced above. You refer to similar, but I do not see a statistical evaluation. If a descriptive approach was used it has to be explained in the method section.

We examined both the range of daily movement…

- No! Do you perform routine daily x-rays on your ICU? If so, explain in the method section. This would contribute to the work. Explain, when follow up x-rays were taken.

There was a significant average movement of was 1.9 (±1) cm of CTP and thus predicting accurately the tip position (within a narrow range) is limited.

- Does not make sense. Clarify. Of course, one cannot predict a future positioning because of a current exact position.

Reviewer #2: This manuscript is a retrospective study on assessing the migration of the tip of IVC in hospitalized patients. The authors have concluded that the tip of CVC can migrate throughout patients’ hospitalization course, but “will remain within a wide range of the top of the right atrium and the middle of the Superior Vena Cava (SVC), if accepted as well-positioned”.

In terms of the originality of the article, there have been descriptions of several cases of catheter migration, but I could not find any prospective or retrospective studies in this area.

The title of this manuscript could be changed, it should be more explanatory of the study itself. Please, consider changing the title. The abstract portion of the manuscript clearly reflects its content.

In results in Table 2, please specify the descriptions. If catheter was malpositioned since initial placement, how you can make a column of “Well-positioned catheter”. Consider revising.

In the discussion, you should also add several limitations of the study secondary to its retrospective origin:

1. Even though catheters were placed by two teams of providers, there is a necessity to mention that difference in providers skills should be a consideration

2. There was no mention of how the CVCs were secured in place. That also might add to a higher or lower possibility of migration, depending on how CVCs were secured and dressings applied.

In conclusion, I would recommend this Manuscript for publication with the change of the title and minor correction as I mentioned above.

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Reviewer #1: No

Reviewer #2: Yes: Eugenia Ayrian, MD

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PONE-D-22-14765R1Central catheter tip migration in critically ill patientsPLOS ONE

Dear Dr. Merin,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Oct 23 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Martin Kieninger

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear authors,

thank you for accepting the suggestions.

Some of the revised scentences are hard to read:

Another limitation rests with the retrospective origin of the trail- CVC's were inserted

by different physicians, and although all were ICU or Anaesthesia physicians with similar

training working under the same guidelines, of nature each have different skill that were not

taken into account.

-> Please, consider to break it down.

Some typos 'sneaked' into the revised version:

... with hight over 155 cm and BMI<40....

-> Should be: height

The article needs to be checked for typos and akward phrasing before publication.

Reviewer #2: Please make minor changes to the manuscript:

Materials and methods: -"Patients under the age of 18, hospitalized less than 24 hours, prone position, pregnant individuals..." - Add ‘Patients in' prone position...

-“After proving normality“ - please revise

Table 2: when describe the “Malpositioned CVCs” you have to change the name of “Well-positioned tip”, since there is no well-positioned tip in mal-positioned catheters. You possibly mean that the catheter tip was not migrated from initial malposition, but it is not well understood from the description - revise.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

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[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Central catheter tip migration in critically ill patients

PONE-D-22-14765R2

Dear Dr. Merin,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Martin Kieninger

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: In the method section you wrote:

Data was proved for normal distribution before performing T-test.

It should be:

Data was tested for normal distribution before performing a T-test. (or: Normal distribution was proven before performing a T-test.)

Reviewer #2: Thank you for accepting my suggestions. I am satisfied with all changes. Manuscript can be published

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

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