Ultrasound Guidance versus the Landmark Technique for the Placement of Central Venous Catheters in the Emergency Department

Abstract

Objective: To compare ultrasound (US)-guided vs. landmark-guided techniques for central venous access (CVA) in the emergency department. Methods: This was a prospective study of consecutive patients enrolled at a university teaching hospital with an annual census of approximately 100,000. On even days patients had CVA with ultrasonic assistance; patients presenting on odd days had CVA via traditional landmark techniques. Ultrasound users were emergency medicine faculty or residents who completed a one-hour training session. A data collection tool with 17 variables was completed for each central line placed. Variables were compared using the independent t-test, Fisher's exact test, and the nonparametric Mann-Whitney U test. Results: Between August 1, 2000, and February 1, 2001, data for 122 subjects (n = 51 for US, and n = 71 for landmark) were collected. Variables with statistically significant differences are as follows. Mean (ϮSD) time from skin puncture to blood flash was 115 (Ϯ184) seconds for the US group vs. 512 (Ϯ698) seconds for the landmark group (p < 0.0001). The mean number of CVA attempts in the US group was 1.6 (Ϯ1.0) vs. 3.5 (Ϯ2.7) in the landmark group (p < 0.0001). Acute complications were comparable between groups. Comparisons for time, number of CVA attempts, and complications were done specifically for a subset of patients considered to be ''difficult stick'' due to predefined criteria regarding body habitus or vascular disease. Patients considered to be ''difficult sticks'' required a significantly longer amount of time (p < 0.001) for CVA via the landmark technique than patients considered to be ''difficult sticks'' who had CVA with ultrasonic guidance. Time to line placement for the landmark group was 462.7 (Ϯ627) seconds vs. 93.3 (Ϯ176) seconds in the US group. Comparing the same subset also revealed an increase in number of required CVA attempts for the landmark technique group. The number of acute complications in the ''difficult stick'' patients did not show statistical significance (p = 1.00). The landmark group had 60% ''difficult sticks,'' while the ultrasound group had 80%, although the difference was not statistically significant (p = 0.08). Conclusions: Emergency physicians with limited training and experience are able to use ultrasound as an adjunct for central venous access. Ultrasound technology may decrease the number of CVA attempts required to cannulate a central vein and will decrease the amount of time required to cannulate the vein starting from the time when the needle is on the skin, after the ultrasound machine has been set up and turned on. These results are especially true for those patients considered to be ''difficult sticks.''

Effectiveness of a novel training program for emergency medicine residents in ultrasound-guided insertion of central venous catheters

“…Studies are limited to the description of the procedure and the approximate time involved of the course as well as the "how I do it" approach. 11,17,24,25 There is also a higher awareness and promotion of simulation for training purposes to improve patient safety. 26 This small-scale study demonstrates the effectiveness and efficiency of this multimethod training program.…”

“…5 Ultrasound-guided (USG) insertion of CVCs is reported to be the preferred method for difficult cannulations, such as in those patients with obscure surface landmarks or hypotension. [9][10][11][12][13] Several meta-analyses and randomized controlled trials have demonstrated that USG insertion of CVCs is safely performed by emergency physicians with greater success and fewer immediate complications than the traditional landmarking method. 4,9,11,12,[14][15][16][17] National recommendations have been made for USG insertion of CVCs by both the National Quality Forum in the United States and the National Institute of Clinical Excellence in the United Kingdom.…”

Point-of-Care Ultrasonography by Pediatric Emergency Medicine Physicians

“…The literature supports the ability of general emergency physicians to use point-of-care US to improve the care of adult patients by accurately diagnosing time-sensitive and common ED conditions, decreasing patient lengths of stay, 15,[39][40][41] and reducing complications. 15,[42][43][44][45] Furthermore, emergency physicians are able to achieve competency in performing point-of-care US for various indications after completing adequate training. 20,26,[46][47][48] Point-of-care US in pediatric patients by PEM providers has recently been adopted into practice, and the literature is still evolving.…”

History of Emergency Ultrasound

“…There was also no mention of studies such as those published by Plummer et al 7 and Rozycki et al 8,9 that showed the utility and improved outcome of patients with penetrating chest injuries who were evaluated by sonography. Contributions from other emergency physicians in areas such as aorta, 10-13 gallbladder, [14][15][16] renal, 17 pelvic, [18][19][20][21][22] and vascular [23][24][25][26][27][28][29] sonography were also left out. Finally, indications for ultrasound that are specific to emergency medicine such as the sonographic evaluation of the patient presentation of cardiac arrest, hypotension, and undifferentiated shock were not discussed.…”