Introduction: Central venous catheters (CVCs) are widely used in critically ill patients as they help facilitate volume resuscitation, administration of vasopressors, renal replacement therapy, and hemodynamic monitoring.... [ view full abstract ]
Introduction:
Central venous catheters (CVCs) are widely used in critically ill patients as they help facilitate volume resuscitation, administration of vasopressors, renal replacement therapy, and hemodynamic monitoring. Traditionally, central venous cannulation was achieved by the use of anatomical landmarks. Common immediate complications of CVC placement include bleeding, arterial puncture, pneumothorax, and line misplacement. Landmark-guided complication rates may be as high as 20%1 and failure rates as high as 35%.2 Ultrasound-guided CVC placement has both reduced complication rates and increased success rates.3-7 As a result, ultrasound-guided CVC placement has become recognized as the standard of care by many medical organizations. However, nearly 60% of hospitals, mostly those in low and middle income countries, have limited access to ultrasound machines and thus rely more on landmark-guided CVC placement.
Objectives:
1. To develop and implement an ultrasound-based curriculum consisting of 3 components: didactic sessions, hands-on training, and competency assessment for the placement of ultrasound-guided internal jugular CVCs.
2. To perform a prospective, randomized controlled trial comparing landmark (LM)-guided to ultrasound (US)-guided placement of CVCs in a resource poor setting.
Methods:
Internal medicine residents at Roosevelt Hospital, a public hospital in Guatemala City, participated in an ultrasound-based curriculum including: didactic sessions, hands-on training, and a competency assessment. Resident competency was assessed by the use of a pre-test and post-test consisting of 10 multiple choice questions.
An observational study was then adapted from the original randomized controlled study due to limitations in ultrasound machine access. Success and complication rates of landmark-guided and ultrasound-guided CVCs placed over a 4 week period were recorded and compared.
Results:
Competency assessment scores improved from 62% (SD 0.165) on the pre-test to 82% (SD 0.151) on the post-test (p<0.001).
Success rates improved from 63% in the landmark group to 90% in the ultrasound group (p=0.102). Complication rates improved from 40% in the landmark group to 30% in the ultrasound group (p=0.565).
Conclusions, Limitations, and Future Work:
An ultrasound-based curriculum improved resident competency assessment scores, suggesting increased understanding of the technique.
CVC placement success rates increased and total complication rates decreased with US-guidance, consistent with published literature. However, as this was a pilot study, it was not adequately powered to detect a statistically significant improvement with the use of ultrasound. Therefore, residents at Roosevelt Hospital plan to continue data collection for this study.
Implications:
While public hospitals in developing countries have limited funding to enhance diagnostic and therapeutic infrastructure, the World Health Organization states that ultrasound is a cost effective and safe way to bridge this gap. Therefore, many experts agree that ultrasound access should be available at public hospitals in developing countries.8 With further data collection, Roosevelt Hospital will experience first-hand, the benefits of the use of ultrasound, highlighting the value of investing in an ultrasound machine.
Resources:
1. Bernard R, Stahl W. Subclavian Vein Catheterizations. Annals of Surgery. 1971;173(2):184-200.
2. Sznajder J, Zveibil F, Bitterman H, Weiner P, Bursztein S. Central Vein Catheterization. Failure and Complication Rates by Three Percutaneous Approaches. Survey of Anesthesiology. 1986;30(4):196.
3. Karakitsos D, Labropoulos N, De Groot E, et al. Real-time ultrasound-guided catheterization of theinternal jugular vein: a prospective comparison with the landmark technique in critical care patients. Crit Care. 2006;10(6):R162.
4. Denys B, Uretsky B, Reddy P. Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external landmark-guided technique. Circulation. 1993;87(5):1557-1562.
5. Gilbert T, Seneff M, Becker R. Facilitation of internal jugular venous cannulation using an audio-guided Doppler ultrasound vascular access device. Critical Care Medicine. 1995;23(1):60-65.
6. Leung J, Duffy M, Finckh A. Real-Time Ultrasonographically-Guided Internal Jugular Vein Catheterization in the Emergency Department Increases Success Rates and Reduces Complications: A Randomized, Prospective Study. Annals of Emergency Medicine. 2006;48(5):540-547.
7. Mallory D. Ultrasound guidance improves the success rate of internal jugular vein cannulation. A prospective, randomized trial. CHEST. 1990;98(1):157.
8. Mindel S. (1997) Role of imagery in the developing world. Lancet 1997;350:426-429.
Use of ultrasound in Graduate Medical and Continuing Education , Point of Care ultrasound in health care delivery to underserved populations
