ROCKstars – Case 1: US-Guided Central Venous Access (CIV)

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An elderly patient is in the RIH Critical Care bay with severe sepsis and needs central access.  Luckily, Drs. Adam “Hyperechoic” Haag and Eddie “Rule ‘Em Out” Ruhland are on shift.  They settle on the right Internal Jugular vein, but traditional sternocleidomastoid muscle (SCM) and clavicular bone landmarks are not apparent.  So a linear-array probe is correctly placed transversely over the triangle formed by the bifurcation of the SCM, to where the IJ and Carotid are seen in parallel…but there is some sort of hyperechoic, noncompressible mass…

They identify the thrombus, and instead find the Femoral vein, where CIV access is successfully achieved on the first attempt with no immediate complications.  The use of US to guide this procedure changed this patient’s course and potentially saved a complication.  

But exactly how much safer, faster, and more reliable is US-guided CIV placement?

THE ISSUE

  • Vascular access is critical in emergent situations
  • Body habitus, dehydration, poor perfusion, anatomical abnormalities, or history of IVDU can cause difficulties and delays when using landmark-based techniques
  • Complications of CIV placement include arterial puncture, excessive bleeding, vessel laceration, pneumothorax, hemothorax, and necessitation of multiple attempts
  • US guidance was identified in 2001 by United States Agency for Healthcare Research and Quality as one of the top 11 means of increasing patient safety, but this was based on one study of subclavian lines at one large urban center (1)

The “SOAP-3” Trial (2005)

  • A concealed, randomized, controlled study of 201 patients
  • Studies dating back to the 1990s in EM and Anesthesia (4) had demonstrated the efficacy of ultrasound-guidance, but this was the first study in the ED setting comparing the anatomical landmark method, the static “quick look” US-guided method, and dynamic “real time” US-guided method
  • In the “quick look” group, US was used to identify landmarks, the skin was marked, and the catheter was placed without real-time US guidance
  • EM residents and Attendings passed a 1h training course, then placed 10 CIVs with dynamic US guidance to qualify to participate

RESULTS

Dynamic

US Guidance

Static

US Guidance

Anatomical Landmarks Method
Overall Success 98% 82% 64%
First-Attempt Success

(OR vs LM)

5.8 3.4
Avg # of Attempts 1.7 1.6 3.2
Avg Total Sec 30 20 150
Complications 2 2 8

DISCUSSION

  • Dynamic guidance is superior but requires the most training
  • Static guidance is vastly superior to Landmark, and while slightly inferior to Dynamic, it requires less training
  • 10% of the study patients had “extremely narrow” (<5mm) IJs bilaterally, which could explain the inferior performance of the LM technique, even with experienced practitioners
  • All the complications were arterial punctures, and these were not statistically significant

References

  1. Agency for Health Care Research and Quality (AHRQ). Evidence Report/Technology Assessment: Number 43. Making Health Care Safer. A Critical Analysis of Patient Safety Practices: Summary 2001. 2007.
  1. Milling, et al. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial.  Critical Care Medicine, 2005, Aug;33(8); 1764-9.
  1. Sulek et al.  A Randomized Study of Left versus Right Internal Jugular Vein Cannulation in Adults.  J Clin Anesth, 2000, Mar; 12(2): 142-5
  1. www.sonoguide.com/line_placement.html

2 thoughts on “ROCKstars – Case 1: US-Guided Central Venous Access (CIV)

  1. Why was femoral vein the next site of clinician choice when there is clear evidence that IJ or Axillary approaches under US are more appropriate for the patient? Femoral catheters will need to be changed within a few days, guaranteeing the patient of another invasive procedure that could have been avoided. L)IJ would have been another site. Don’t place device on clinician insertion preference over beat site for patient!

  2. Very nice. Interestingly, there’s a relevant NEJM article, released today, about complications of the three common approaches to central venous catheters. The crazy thing is that they didn’t break down whether lines were placed with ultrasound guidance vs landmarks in their analysis of mechanical complications. It looks like almost 30% of the IJ lines were not placed with US, and the grand majority of femoral and subclavians were not placed with US.

    They also summarize that “the overall risk of mechanical, infectious, and thrombotic complications of grade 3 or higher was similar among the three insertion sites, which suggests that an ideal site for central venous catheter insertion does not exist when all types of complications are considered to be of equal concern.” (Emphasis mine.) Obv expected length of insertion, patient anatomy, operator expertise, and other factors should come into consideration for any individual patient, and as the authors suggest, “Decisions regarding the choice of insertion site should therefore be considered on a case-by-case basis.”

    The conclusion may have been significantly different if ultrasound guidance was factored in. Definitely fodder for discussion. And more study. (With stratification for ultrasound guided placement.)

    Abstract: http://www.nejm.org/doi/full/10.1056/NEJMoa1500964?query=featured_home

    Nice post!

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