To the Editor
We read with interest the recent discussion about the application of portable ultrasound in facilitating central venous cannulation (CVC).1,2 This discussion has centered around whether portable ultrasound should be routine in CVC, perhaps even with experienced operators. Our university department has had a long experience with ultrasound guidance (UG) in CVC since 1991. Our group reported the superiority of UG over anatomic landmarks (AL) for CVC in a prospective, randomized trial.3 We have since adopted UG as part of our routine practice for CVC, in particular, with our junior anesthesia residents.
We reported a carotid-internal jugular fistula that occurred during CVC with UG.4 This carotid puncture took place with an 18-gauge needle visualized with ultrasound in real time by an experienced operator. This clinical outcome coupled with departmental review prompted a prospective, observational study of our CVC practice.5
Table 1. CABINS
|C||Cardiac: congenital, congestive, rhythm|
|A||Airway: MP score, loose teeth, asthma, COPD|
|B||Bleeding: coagulapathy, ASA, anticoagulants, blood availability|
|I||Intolerances: drug allergies or dislikes|
|N||NPO: full stomach, active GE reflux|
|S||Steroid: prior exposure (including inhaled steroids)|
We studied 462 CVC procedures; cannulation failure with UG was 2.1% vs. 13.8% with AL. Arterial puncture rates averaged 7.0% regardless of technique (p=0.45). The junior operator tended to be more at risk for arterial puncture during CVC with UG. This arterial puncture rate is higher than reported in the original efficacy studies of CVC with UG.3 We attribute this high rate in part to operator experience. We postulated that a clip-on needle guide might lower the arterial puncture rate in CVC with UG, in particular, among junior operators. We evaluated this hypothesis in a prospective, randomized trial that has just been completed. We plan to report our results in abstract format this year at the ASA.
Our preliminary analysis shows a sample size of 429 CVC procedures (needle-guide 47.6%, UG 52.4%) with an arteriotomy rate of 4.7%. The needle-guide appears to minimize the number of attempts required but does not lower the arteriotomy rate. We are currently analyzing our results to delineate the effects of operator experience.
CVC with UG clearly benefits the junior operator, especially in a patient with difficult anatomy or at high risk for bleeding; UG allows the junior operator to conduct CVC with a success rate of a more senior operator.5 The impact of UG on CVC by experienced operators only is a matter of debate. To our knowledge, there is no prospective, randomized trial that has examined the question; opinions depend on operator preference and experience.
Morbidity and mortality from CVC are a national concern. First, the Agency for Healthcare Research and Quality identified CVC with real time UG as one of the top 11 patient safety practices. Secondly, an analysis of the ASA Closed Claims Database reveals 41 claims due to CVC,6 including 14 carotid artery injuries with a 36% mortality (median payment of $60,000), and 9 pneumothoraces with an 11% mortality (median payment of $125,000). What are the next steps to address this national concern? We propose the following two investigations.
1) What is the prevalence of CVC with UG in anesthesia practices across the US? This could be approximated by means of a questionnaire-based study. We are currently designing such a survey to measure practice patterns of CVC with UG by anesthesia providers. A measured baseline national prevalence of UG in CVC would be essential in planning future strategies for improving outcome after CVC.
2) Does CVC with UG offer any benefit over CVC with AL by experienced operators in a non-teaching setting? A prospective, randomized trial of CVC by experienced operators with and without UG would provide the necessary data that would be applicable to the majority of anesthesia practices in the US. If CVC with UG by experienced operators in a non-teaching setting saves time, minimizes complications, and improves outcome, then it should be strongly considered for routine use in CVC practice.
John G. Augoustides, MD
Justin I. Weiner, BA
- Webster TA, Blitt CD. Portable ultrasound facilitates central vascular access: a case for routine use. APSF Newsletter 2002;17:35.
- Overdyk FJ. Ultrasound guidance should not be standard of care. APSF Newsletter 2003;17:55.
- Troianos CA, Jobes DR, Ellison N. Ultrasound-guided cannulation of the internal jugular vein. Anesth Analg 1991;72:823-6.
- Augoustides JG, Jobes DR, Diaz D, Weiner J. Safe internal jugular vein cannulation. J Cardiothorac Vasc Anesth 2002;16:262-3.
- Augoustides JG, Diaz D, Weiner J, et al. Current practice of internal jugular venous cannulation in a university anesthesia department: influence of operator experience on success of cannulation and arterial injury. J Cardiothorac Vasc Anesth 2002;16:567-71.
- Spitellie PH, Bowdle TA, Posner KL, et al. Injuries from central lines: a closed claims analysis. Anesthesiology 2002;96:A1124.