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Systematic review: is real-time ultrasonic-guided central line placement by ED physicians more successful than the traditional landmark approach?
  1. Ninfa Mehta,
  2. Walter Wallace Valesky,
  3. Allysia Guy,
  4. Richard Sinert
  1. Department of Emergency Medicine, Kings County Hospital/State University of New York Downstate Medical Center, Brooklyn, New York, USA
  1. Correspondence to Dr Richard Sinert, Department of Emergency Medicine, Kings County Hospital, 451 Clarkson Ave., Brooklyn, NY 11203, USA; nephron1{at}


Introduction The superiority of ultrasonic-guided compared with landmark-guided central venous catheter (CVC) placement is not well documented in the Emergency Department.

Objective To systematically review the literature comparing success rates between ultrasonic- and landmark-guided CVC placement by ED physicians.

Methods PubMed and EMBASE databases were searched for randomised controlled trials from 1965 to 2010 using a search strategy derived from the following PICO formulation: Patients: Adults requiring emergent CVC placement except during cardiopulmonary resuscitation.

Intervention CVC placement using real-time ultrasonic guidance. Comparator: CVC placement using anatomical landmarks. Outcome: Comparison of success rates of CVC placement between ultrasonic- versus landmark-guided techniques. Analysis: Success rates between CVC placement methods using a Forest Plot (95% CI) calculated by Review Manager Version 5.0.

Results Search identified 944 articles of which 938 were excluded by title/abstract relevance, two not randomised, one cardiac arrest, one no landmark control, one success rate not calculated. A single study of 130 patients (65 ultrasonic- vs 65 landmark-guided) selected for internal jugular vein placement remained. Successful internal jugular CVC was significantly (p=0.02) more likely in the ultrasound-guided (93.9%) compared with landmark-guided (78.5%) techniques with an OR of 1.2 (95% CI 1.0 to 1.4). Complications rates were significantly (p=0.04) lower in ultrasonic (4.6%) versus landmark (16.9%) technique, OR=3.7 (95% CI 1.1 to 12.5).

Conclusion Only one single high quality study illustrating that ED ultrasound- versus landmark-guided internal jugular catheter placement had higher success rates with lower complication rates.

  • Ultrasound
  • central venous catheterisation
  • internal jugular vein
  • vascular access
  • vascular-arterial
  • resuscitation
  • clinical care
  • clinical management
  • intensive care

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  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.