The Role of Ultrasound in Central Line Placement
Search Strategy: Your Ultrasound guru hands you a randomized controlled trial evaluating common complications of central venous cannulation as background information. Determined to find information directly related to ultrasound-guided placement, however, you turn to PUBMED entering the search terms “ultrasound” (255,264 citations) then central venous cannulation (9,094 citations) which you then combine (722 citations). Fortunately the 23rd citation is a RCT by Milling of one versus two operator US-guided placement of IJ which looks relevant, so you select “Related Articles” and obtain 104 citations of which #4 is the Milling article below, #47 the Miller article, and #69 the Denys article.
The first year and a half of your residency is just complete and you’ve found new confidence handling critically ill patients in the ED since you just came off your procedure-laden month on the Cardiothoracic ICU. Serendipitously, a septic patient presents to the ED and you begrudgingly sign up for the nursing home patient with reported anorexia. The strong odor of urine noted upon entering the room suggests urinary tract infection.
The “surviving sepsis campaign” is in full force today and a central line is warranted in this patient. The attending thinks he’s hot because he can “cannulate a spaghetti noodle in a dark room” under ultrasound and brusquely says “I don’t care where you put it, but do it under ultrasound.” The teaching resident rolls his eyes and asserts he can hit this easily with the blind or landmark subclavian approach.
Unfortunately, as he begins to assist you, a Level 1 trauma arrives and you immediately find yourself alone with a nurse. On the way out the door the teaching resident suggests you just do a femoral line since it is quickest. The sepsis nurse groans with angst. As you contemplate your approach the nurse places a 25 gauge IV and starts pushing fluid which stabilizes your patient for a brief time. You exit the room in search of a computer terminal to do a PUBMED search for central venous line insertion, ultrasound, and outcomes.
Population: ED patients requiring central line access
Intervention: Ultrasound guided central line placement
Comparison: Non-ultrasound guided central line placement (blind approach)
Outcome: Iatrogenic complications (arterial cannulation, pneumothorax), time-to-central access, total ED length-of-stay, infectious complications
First years: Complications of Femoral and Subclavian Venous Catheterization in Critically Ill Patients, A Randomized Controlled Trial, JAMA 2001; 286: 700-707.
Second years: Ultrasound-assisted Cannulation of the Internal Jugular Vein: A Prospective Comparison to the External Landmark-Guided Technique. Circulation 1993; 87: 1557-1562.
Third years: Ultrasound Guidance versus the Landmark Technique for the Placement of Central Venous Catheters in the Emergency Department. Acad EM 2002; 9: 800-805.
Fourth years: Randomized, Controlled Trial of Point-of-Care Limited Ultrasonagraphy Assistance of Central Venous Cannulation: The Third Sonography Outcome Assessment Program (SOAP-3) Trial, Crit Care M 2005; 33: 1764-1769.
Article 1: Complications of Femoral and Subclavian Venous Catheterization in Critically Ill Patients: A Randomized Controlled Trial. JAMA 2001; 286:700-707
Article 2: Ultrasound-Assisted cannulation of the internal jugular vein. A prospective comparison to the external landmark-guided technique. Circulation 1993; 87:1557-1562
Article 3: Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Acad EM 2002; 9:800-805
Article 4: Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program(SOAP-3) Trial Crit Care Med 2005; 33: 1764 –1769
The evidence on ultrasound-guided central venous cannulation is limited. To date, SOAP-3 represents the best evidence but has limited internal validity in that one investigator performed almost half of the US-guided procedures. More importantly, the study lacks external validity in that nearly every other ED in the United States (and probably the world) lacks the high-caliber, US-specific training this particular urban teaching hospital offers. Future trials should assess US-guided central line placement in less US-friendly institutions among a more heterogeneous clinician group while assessing physician acceptance and skill maintenance.