Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Review: Ultrasonographic guidance for central venous catheter placement reduces failures, complications, and multiple attempts

ACP J Club. 1997 May-Jun;126:75. doi:10.7326/ACPJC-1997-126-3-075


Source Citation

Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med. 1996 Dec;24:2053-8.


Abstract

Objective

To determine the efficacy and safety of real-time Doppler ultrasonographic guidance for the placement of central venous catheters.

Data sources

Randomized controlled trials were identified by searching MEDLINE (1966 to October 1995) using the keywords catheterization; catheterization, central venous; catheterization, Swan-Ganz; catheters, indwelling; randomization; random allocation; randomized controlled trial(s); randomized response technique; and (controlled) clinical trials, randomized. Bibliographies of relevant studies, package inserts from catheter kits, and lists of conference abstracts were also scanned.

Study selection

Trials were selected if they included adults or children; evaluations of real-time ultrasonography or real-time Doppler ultrasonographic guidance for central venous catheter placement; and measures of success and rapidity of placement, complication rate, and rate of success after failure by an alternate method. Patients included were adults in the intensive care unit who were critically ill; had cardiothoracic, cardiac, or cardiovascular surgery; received a mixture of medical and surgical or low-risk medical and surgical treatment; and were obese or had coagulopathy. Operators consisted of 2 consultant anesthetists, residents, anesthesia staff, junior housestaff, 18 operators who had done < 30 procedures, and operators with a mean of 6 years of experience.

Data extraction

Data were extracted on patient numbers and characteristics; method of insertion; method of randomization; site of entry; number and experience of operators; method of ultrasonographic guidance; and speed, success, complications, and number of catheter placements.

Main results

8 trials met the selection criteria. Compared with the landmark placement method, ultrasonographic guidance reduced the rate of catheter placement failure (relative risk [RR] 0.32, 95% CI 0.18 to 0.55) whether placement was in the internal jugular vein (RR 0.38, CI 0.21 to 0.71) or subclavian vein (RR 0.15, CI 0.04 to 0.53). Placement complication rate was lower with ultrasonographic guidance than with the landmark method (RR 0.22, CI 0.10 to 0.45) whether placement was in the internal jugular vein (RR 0.26, CI 0.11 to 0.58) or subclavian vein (RR 0.11, CI 0.02 to 0.56). Ultrasonographic guidance also reduced the number of attempts before successful catheter placement compared with the landmark method (RR 0.60, CI 0.45 to 0.79). Success rates for ultrasonographic guidance after failure by the landmark method ranged from 33% to 100%.

Conclusion

Real-time ultrasonographic guidance reduces the risk for failure of central venous catheter placement, complications, and the need for multiple placement attempts.

Source of funding: In part, Agency for Health Care Policy and Research.

For article reprint: Dr. A.G. Randolph, Hospital for Sick Children, Department of Critical Care Medicine, Toronto, Ontario M5G 1X8, Canada. FAX 416-813-7299.


Commentary

Central venous catheterization is an essential skill for many physicians. Despite the potential for serious complications, the procedure is generally safe and successful. The use of ultrasonographic guidance is not widely practiced compared with the traditional anatomical landmark method. All the devices examined in this review use ultrasonography but involve various techniques. For example, 1 device consists of a probe placed through the cannulating needle connected to a speaker-containing instrument, whereas others consist of a cutaneous transducer and video screen. The former guides the operator by characteristic Doppler sounds, and the latter provides a 2-dimensional image of underlying anatomy. Safe use of these devices requires additional training beyond proficiency with landmark methods. All entail added expense for the instrument, associated supplies, maintenance, and training.

This review shows that ultrasonographic guidance improves the rate of successful cannulation. An intuitive alternative to routine use would be to use guidance only if the landmark method fails, in high-risk patients, or in patients for whom difficult cannulation is anticipated. An even more important finding is that ultrasonographic guidance is associated with lower complication rates. The authors show that these guidance methods can, on average, spare 1 complication in 7 patients. The actual effect on patient care is more elusive because many complications, such as most arterial punctures and catheter malpositions, do not cause important adverse consequences. Large-scale studies that examine actual morbidity and costs are necessary to determine the real cost-effectiveness of the technique.

For both the landmark and ultrasonography-guided methods, training and experience are required to master and maintain proficiency. If routine use of some of these techniques becomes the norm, what effect would this have for future operators who receive all or most of their training using real-time guidance? Perhaps lack of experience with landmark methods would render them less adroit in emergency or other situations in which catheterization is necessary but ultrasonography instruments are unavailable.

James A. Kruse, MD
Wayne State UniversityDetroit, Michigan, USA