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Abstract
A short cut review was carried out to establish whether ultrasonic guidance reduces the complication rate during central line placement in the emergency department. Altogether 349 papers were found using the reported search, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.
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Report by Joel Dunning, RCS Research Fellow Checked by James Williamson, Clinical Fellow
Clinical scenario
You are evaluating a 90 kg acutely dyspnoeic diabetic woman in the emergency department. She has a history of left ventricular failure and was an inpatient only two weeks ago with a small myocardial infarction. Her BP is only 90/50 and you feel that she is a high risk patient with poor peripheral venous access who may need high dependency care possibly with inotropes, and you therefore decide that a central line would be of great benefit. Your department has just bought a handheld USS probe and you wonder whether it is worth having a go with this rather than your usual blind landmark technique.
Three part question
In [patients in the emergency department requiring a central line] is [USS guidance better than blind landmark techniques] at [reducing the complications of insertion]?
Search strategy
Medline 1966-07/03 using the OVID interface. [(exp Ultrasonography/ OR ultrasound.mp) AND (exp Catheterization, Central Venous/ OR central venous catheter.mp OR central line.mp)] LIMIT to human AND English
Search outcome
Altogether 349 papers were found of which two represented the best evidence. This included a meta-analysis and an additional paper. In addition a second meta-analysis not indexed on Medline was identified by cross referencing (table 5).
Comment(s)
Two meta-analyses were identified in this area and only one additional paper could be found that neither meta-analysis included. Both meta-analyses provide strong evidence that USS guided placement significantly reduces complications during catheter placement, number of attempts at insertion and reduction in the number of attempts at insertion for both neck and femoral line insertion. In addition and the NICE meta-analysis provides evidence that insertion time is quicker although this evidence is less convincing. NICE also imply that if used regularly the cost implication could be as little as £10 per patient although they acknowledge a projected £29 million cost for initial NHS implementation for equipment and training.
CLINICAL BOTTOM LINE
There is good evidence that USS guided placement of central lines reduces the complication rate associated with this procedure.
Report by Joel Dunning, RCS Research Fellow Checked by James Williamson, Clinical Fellow