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USS guidance reduces the complications of central line placement in the Emergency Department

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]?

Clinical Scenario

You are evaluating a 90kg acutely dyspnoeic diabetic woman in the emergency department. She has a history of left ventricular failure and was an inpatient 2 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.

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 2 represented the best evidence. This included a meta-analysis and additional paper. In addition a second meta-analysis not indexed on Medline was identified by cross referencing.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
NICE guidelines,
2002,
UK
Systmatic review of the literature 20 RCTs evaluating ultrasound guidance for central line placement found Only 2 were performed in the emergency room setting, with 7 in ITU, and the remainder in elective scenarios Only 4 studies were clearly performed by non anaesthetistsSystematic review and meta analysisRecommendationsUse of 2-D USS should be considered in most clinical situations where a central line is necessary electively or in an emergencyGrades of recommendation not provided Few studies on non anaesthetist personnel in the emergency department
Meta-analysis of relative risks of various clinical outcome measuresNo. failed catheter placements RR: 0.16 (0.09 0.3)

No. complications odds: 0.36 (0.17 0.36) risk of failure RR: 0.59 (0.39 0.88)

Number of fewer attempts RR:1.62 (2.57 0.67)

No. seconds saved 76 (96 63) secs

No of arterial punctures saved 90 per 1000 patients
Cost effectivenessThe extra cost is likely to be about 10 patient, although the machines cost 7000-15000 initially
Randolph AG et al,
1996,
USA
8 randomised controlled studies identified from Medline search from 1966 to 1995 Studies were using operators with low experience but no studies were in the emergency departmentMeta-analysisMeta-analysis of the relative risk of various clinical variablesCentral line placement failure 0.32 (0.18 - 0.55)

Complications during catheter placement 0.22 (0.10 - 0.45)

Need for multiple catheter placement attempts 0.60 (0.45 - 0.79)
Medline search only, no systematic review Poor search strategy
Miller AH et al,
2002,
USA
122 emergency medical patients designated as 'difficult insertions' randomised to the Landmark technique (n=71) or 2-D USS guidance technique (n=51) Difficult patients defined as peripheral vascular disease, coagulopathy, obesity, abnormal anatomy, or history of intravenous drug misuseCohort studyTime from needle touching skin to successful flashbackLandmark group 463 secs +/- 627 secs

USS group 93secs +/- 176 secs

p<0.0001
The insertion time may only represent a small amount of the total time taken to set up an USS guided central line insertion
Number of attemptsLandmark group 3.54+/-2.7

USS group 1.55+/-1

p<0.0001
ComplicationsLandmark group 14%

USS group 12%

p=0.780

Comment(s)

Two meta-analyses were identified in this area and only 1 additional paper could be found in this area 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.

References

  1. National Institute for Clinical Excellence. Guidance on the use of ultrasound locating devices for placing central venous catheters. Technology appraisal guidance No.49 2002 (Accessed 03/02/03)
  2. Randolph AG, Cook DJ, Gonzales CA et al. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med 1996;24:2053-8.
  3. Miller AH, Roth BA, Mills TJ et al. Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the Emergency Department Acad Emerg Med 2002;9:800-5.