Use of ultrasound to place central lines

https://doi.org/10.1053/jcrc.2002.34364Get rights and content

Abstract

Context: Placement of central venous catheters (CVCs) is an integral part of care for the critically ill patient but is associated with significant morbidity when using the traditional landmark method. The use of real-time ultrasound to guide line placement has been developed in hopes of avoiding this morbidity. Objective: The objectives of this article are 2-fold. The first is to determine the relative effectiveness of the use of real-time ultrasound to place CVCs compared with the use of landmarks alone. The second is to discuss the merits of future study to increase the use of this technology. Data Sources: Medline from 1966 to 2001, personal files, 2 prior systematic reviews, and reference lists of selected articles. Study Selection: Studies were included if: (1) study design was a controlled trial, (2) patients required placement of a CVC, (3) the interventions were real-time ultrasound versus standard landmark-guided line placement, and (4) outcomes included at least 1 of failure to place catheter, success of first attempt, number of attempts, time to catheter placement, or complication rate. Data Synthesis: Eighteen trials were identified. Pooled results showed a significant reduction in failure rate (risk difference, −.12, 95% confidence interval [CI], −.18 to −.06), number of attempts (risk reduction, 1.41, 95% CI, 1.15–1.67), and arterial puncture rate (risk difference, −.07, 95% CI, −.10 to −.03). The number of successful venous cannulations on first attempt were higher using ultrasound (risk difference, .24, 95% CI, .08–.39). No difference was found in time to insertion. Significant heterogeneity of study results was found for most analyses. Subgroup analyses suggested that ultrasound improved outcomes most convincingly using external probes, for internal jugular vein cannulation, and when used by clinicians less experienced at line placement. Conclusions: Adoption of real-time ultrasound to guide CVC placement has the potential to improve successful line placement and minimized complications. It can improve patient safety. However, there are significant cost concerns and the reported adverse events are generally minor and easy to treat. Before creating study protocols to increase usage of this technology, both current usage and cost effectiveness should be determined. Copyright 2002, Elsevier Science (USA). All rights reserved.

Section snippets

Objectives

The objectives of this article are 2-fold. The first objective is to update prior excellent reviews5, 6 on the relative effectiveness and safety of the use of real-time ultrasound to place CVCs compared with the use of landmarks alone. The second is to use the results of this review to suggest a potential research agenda on the use of these catheters.

Data sources and settings

To identify relevant studies, Medline was searched from 1966 to 2001 using keywords central venous catheter OR internal jugular vein OR subclavian vein OR femoral vein with the restriction of controlled clinical trial. In addition, the references of selected studies were reviewed and 2 former systematic reviews were identified and references reviewed. Finally, for selected studies the option of related articles was also used to identify further trials of interest.

Study design

The clinical question that

Results

After applying the selection criteria to those studies identified by the search strategy, 18 trials were identified for further evaluation,7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 17 nonblinded, randomized, controlled trials7, 8, 9, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 and 1 quasirandomized trial10 conducted in a cardiac catheterization laboratory that allocated the intervention on an alternate week basis. This last trial was accepted because it was

Cost implications

There is an added cost to using either form of ultrasound to guide line placement. For Doppler ultrasound there is the cost of the Doppler unit that is in the range of $800 US. In addition, it requires special needles to allow the probe to be positioned within them. In the study by Bold et al,7 these needles were priced at $40 to $70 US compared with the standard needles at $3 to $5. Portable ultrasound machines with external probes cost approximately $13,000 US. The external probes need to be

Summary of literature review

In summary, the use of ultrasound guidance for placement of CVCs has been extensively studied in the literature but the studies themselves have some methodologic flaws that may bias results (lack of blinding, varying definition of failure). The heterogeneity of results found makes one more cautious in drawing strong inferences from pooled results. However, taking into account the various subgroup analyses, it appears that the use of external ultrasound probes increases the successful placement

Future study

Ultrasound guidance of central line placement is a technology that clearly improves patient safety. However, it is not clear from this systematic review that the added costs of adopting this technology are justified. For those of us working in the ICU, the decision to use this technology requires better evidence that can only be derived from a large, multicenter, randomized, controlled trial of the use of external ultrasound versus landmarks for insertion of CVCs in high-risk ICU patients with

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