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We read Dunning’s BET report with great interest.1 As Dunning himself acknowledges, most of the available literature concerns the insertion of central venous catheters (CVCs) by anaesthetists (and also electively). However, we have found that this data does not necessarily apply to the critically-ill emergency setting, as illustrated by the study looking at emergency medicine physicians2 where the ultrasound did not reduce the complication rate.
The literature does not distinguish between potentially life-threatening complications and those with unwanted side-effects. An extra attempt or prolonged time for insertion, whilst unpleasant, has a minimal impact on the patient’s eventual outcome. However, a pneumothorax could prove fatal to a patient with impending cardio-respiratory failure. Some techniques – for example, high internal jugular vein – have much lower rates of pneumothorax. Furthermore, some techniques use an arterial pulsation as a landmark. Such techniques can minimise the adverse effect of an arterial puncture as pressure can be applied directly to the artery.
We also share Dunning’s doubt in the National Institute for Clinical Excellence (NICE) guidance’s claim that the cost-per-use of an ultrasound could be as low as £10.3 NICE’s economic analysis model assumed that the device is used 15 times a week. This would mean sharing the device with another department, clearly unsatisfactory for most emergency situations. The cost per complication prevented would be even greater. (£500 in Miller’s study, assuming 2 fewer complications per 100 insertions).
Finally, the NICE guidance is that “appropriate training to achieve competence” is undertaken. We are sure that the authors would concur that the clinical scenario given would not be the appropriate occasion to “have a go” with a new device for the first time.
In conclusion, we believe that far more important than ultrasound-guided CVC insertion, is the correct choice of insertion site to avoid those significant risks, which the critically-ill patient would not tolerate.
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