In the an issue of West JEM, Backlund et al did a survey study of emergency physicians in Colorado with 116 responses asking questions about their use (or lack thereof) bedside ultrasound for central venous access. Quite a few, too many actually, feel uncomfortable using ultrasound for central venous access. 97% of them have ultrasound machines in their department, so it’s not because of a lack of equipment. 77% agree with the statement:”Ultrasound guidance is the preferred method for central venous catheter placement in the emergency department.” So what was it? Well, it’s always the easiest and most obvious answer: their lack of training and, therefore, a lack of comfort level. “47% cite lack of training in UGCVC as a barrier to performing the technique.”
Now, I know what some of you may be thinking – it’s a survey study, it has its response biases, and it’s only from one state, etc etc – well, I actually wonder if the true number of docs who don’t feel comfortable with US-guided central venous access may not be even higher when thinking nationally, or even globally. It is a relatively new technique (an actual guideline for some). And, it has been reviewed quite well in the literature - with reviews, meta-analyses, cochrane database reviews.
Some institutions have US guidance as part of the standard of care when placing central venous lines as it has been shown to decrease complications (including in pediatrics), decrease number of attempts and time to completion, and increase patient satisfaction. It promotes patient safety.
What may complicate things are whether the physicians perform the one versus two-person technique, the static versus dynamic technique, the short axis vs long axis vs oblique axis technique, or with the use of needle guides or not, but there hasnt been great data that enhanced needle tips improve success. All of which have not been truly scientifically shown to have benefit over the other, but every physician who has experience with US guided access does have an opinion on them.
The Anesthesia group has ultrasound as part of their guidelines for central venous access, and you know this will only occur in many other groups.
Why I’m a believer ? – I like to drive with headlights on when Im in the dark. I want to see the vein, how big it is, if trendelenberg will help, where it is in relation to the artery, whether that side of the patient will be successful or if I should check the other side, where the lung is in relation to the vessels, and see exactly where my needle tip is at all times watching it go right into te vein. THAT gives me comfort. Look out for another post where I’ll go through the technique…. in the meantime, take a look at ACEP’s FOCUS ON by a friend of mine that goes through the literature and the technique.
And, it seems that junior residents have increased success when ultrasound is used…. so lets continue to do it, for patient safety and satisfaction if not for anything else