Interactive Cardiovascular and Thoracic Surgery 3:523-527(2004)
© 2004 European Association of Cardio-Thoracic Surgery
Best evidence topic - Cardiac general |
Does ultrasound-guided central line insertion reduce complications and time to placement in elective patients undergoing cardiac surgery
Anthony Espinet* and
Joel Dunning*
Department of Cardiothoracic Surgery, Freeman Hospital, Freeman Road, Newcastle-upon-Tyne NE7 7DN, UK
* Corresponding authors. Tel./fax: +44-780-154-8122
anthony.espinet{at}nuth.northy.nhs.uk joeldunning{at}doctors.org.uk
Received May 17, 2004;
accepted May 18, 2004
 |
Abstract
|
|---|
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether ultrasound probe central line placement reduced complications and time to placement in patients undergoing coronary artery bypass grafting surgery. Altogether, 193 papers were found from Medline using the reported search of which 6 papers presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses and comments were tabulated. We conclude that in patients with a potentially difficult central line insertion, the ultrasound technique reduces complications and time to insertion. However, in those patients where no difficulty is predicted, there is no evidence that the ultrasound technique confers any advantage.
Key Words: Evidence-based medicine; Central venous catheterisation; Review; Cardiac surgery; Ultrasonography
|
1. Introduction
|
|---|
A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].
|
2. Clinical scenario
|
|---|
You are a consultant anaesthetist inserting a central line in a patient undergoing elective coronary artery bypass grafting (CABG). A junior colleague asks you why you are not following the NICE guidelines which state that you should always use an ultrasound probe when placing a central line. You reply that you do more than 250 central line placements per year and that your complication rate is very low and that an ultrasound scan would just slow down the start of the operation. Your junior colleague then asks "if you did have a complication, couldn't a lawyer criticise you for not using an ultrasound probe in all your cases?" You are unsure how to respond to this and therefore you resolve to look up the evidence for use of ultrasound-guided central line placement in elective cardiac surgical patients.
|
3. Three-part question
|
|---|
In [patients undergoing elective cardiac surgery, requiring a central line] does the use of the [ultrasound guided central line placement technique] reduce [time to insertion and incidence of complications].
|
4. Search strategy
|
|---|
Medline 1966–March 2004 using the OVID interface. [exp ultrasonography OR ultrasound] AND [exp catheterisation, central venous OR central venous catheter.mp OR central line.mp] LIMIT to [Maximally sensitive RCT filter OR Review, academic.pt]
|
5. Search outcome
|
|---|
Using the reported search 193 papers were found from Medline of which 5 papers presented the best evidence to answer the clinical question. This included one meta-analysis, which was used to formulate the NICE guidelines, which we also reviewed [2–7]. These papers are presented in Table 1.
|
6. Discussion
|
|---|
The NICE guidelines, together with their meta-analysis [2,7] reported in the BMJ, recommend the routine usage of a 2D ultrasound technique for the insertion of all central lines, including those in elective settings. However, these recommendations were based on papers from a very wide range of specialities, including studies in emergency medicine, intensive care, oncology, cardiac arrest and paediatrics. In addition it is interesting that no anaesthetists were present at the guideline development stage for these recommendations. It therefore seems that these recommendations do not seem to be based on patients similar to those in the elective cardiac surgical setting.
We identified 4 papers that studied cardiac surgical patients. These were all identified by the NICE systematic review. Sulek et al. [3] studied 120 patients for elective abdominal, vascular or cardiothoracic surgery using a 2D ultrasound technique versus a landmark approach (apex of the sternocleidomastoid triangle). They found that complications were about 50% less in the ultrasound group compared to the landmark approach, and the time to placement of the guidewire with ultrasound guidance was also less, but this was neither clinically nor statistically significant. However, details of the patient population were not provided and we are unsure how many of the patients had cardiac surgery or how difficult the central line placements were perceived to be.
Vucevic et al. [4] studied 40 patients (divided into predicted easy or difficult cannulation) needing central vein cannulation for cardiac surgery or in ITU using the SMART needle Doppler ultrasound versus a landmark approach (lateral to carotid pulse at the level of the cricoid cartilage). The SMART needle technique utilises a small ultrasonic probe sited within the needle, which detects the motion of blood within the vessel as an audible signal. The needle is advanced in the direction of the loudest venous sound intensity (blowing low frequency venous sound as compared to the pulsatile high-pitched arterial sound) until it enters the vein. Vucevic found that the combined incidence of complications were the same in both methods (1 out of 20) and the time to placement of the cannula into the vein was greater in the difficult group (322 versus 167 s) using the landmark approach, but this was not clinically significant. Gratz et al. [5] studied 41 patients for cardiothoracic or major vascular surgery needing central venous cannulation using the SMART needle Doppler ultrasound versus the landmark approach (apex of SCM triangle). He found that there was no difference in complications between the ultrasound and landmark approach (0 out of 20) and the time to cannulations was longer in the landmark group than in the ultrasound group (226 versus 109 s) but this was not clinically significant. However, we were unable to determine how many patients were for cardiac surgery, whether these patients were elective or urgent and what was the experience or seniority of the anaesthetist performing the procedure. Troianos et al. [6] studied a much larger group of 160 patients for cardiothoracic surgery using a 2D ultrasound probe versus landmark approach (apex of SCM triangle). He found that the incidence of complications was higher in the landmark group (8.4%) versus the ultrasound group (1.4%) but this was not statistically significant  The time to cannulation was also greater in the landmark group (61 s) versus the ultrasound group (117 s) but this was not clinically or statistically significant. Unfortunately, we are not provided with details of the number of patients who had thoracic surgery in that group, the patient demographics nor the clinical experience of the person cannulating the vein.
Thus while these studies appear to show some benefit in using the 2D ultrasound probe in predicted difficult insertions to reduce the incidence of complications and time to placement of the central line, there is insufficient evidence to recommend that the probe be used for all cases of central line insertion, especially if taking into account the expertise and skill of the operator.
|
7. Clinical bottom line
|
|---|
In patients with a potentially difficult central line insertion, the ultrasound technique reduces complications and time to insertion. However, in those patients where no difficulty is predicted, there is no evidence that the ultrasound technique confers any advantage.
doi:10.1016/j.icvts.2004.05.006
|
References
|
|---|
- Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact Cardiovasc Thorac Surg. 2003;2:405–409[Abstract/Free Full Text]
- Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C, Thomas S. Ultrasonic locating devices for central venous cannulation: meta-analysis. Br Med J (BMJ). 2003;327(7411):361–364
- Sulek CA, Blas ML, Lobato EB. A randomized study of left versus right internal jugular vein cannulation in adults. J Clin Anesth. 2000;12(2):142–145[Medline]
- Vucevic M, Tehan B, Gamlin F, Berridge JC, Boylan M. The SMART needle. A new Doppler ultrasound-guided vascular access needle. Anaesthesia. 1994;49(10):889–891[Medline]
- Gratz I, Afshar M, Kidwell P, Weiman DS, Shariff HM. Doppler-guided cannulation of the internal jugular vein: a prospective, randomized trial. J Clin Monit. 1994;10:185–188[Medline]
- Troianos CA, Jobes DR, Ellison N. Ultrasound-guided cannulation of the internal jugular vein. A prospective, randomized study. Anesth Analg. 1991;72(6):823–826[Free Full Text]
- National Institute for Clinical Excellence. Guidance on the use of ultrasound locating devices for placing central venous catheters. NICE Technical report number 49; September 2002.
This article has been cited by other articles:
|
|
|
|
 
A. Verma, S. Mohan, and S. S. Baijal
Central Venous Catheter in the Sigmoid Sinus
Anesth. Analg.,
April 1, 2007;
104(4):
1002 - 1003.
[Full Text]
[PDF]
|
|
|
|
|
Top
Abstract
1. Introduction