US guidance keeps central catheter placement on target

By Shalmali Pal, staff writer

January 11, 2006 -- SAN FRANCISCO - More than 5 million central venous catheters (CVC) are placed each year in the U.S. intensive care setting. Unfortunately, substantial complication and failure rates are associated with placement. But ultrasound guidance can significantly reduce the negatives associated with this common procedure, according to a presentation this week at the Society of Critical Care Medicine meeting.

The rate of complications -- which include mechanical difficulties, arterial puncture, hemothorax, and catheter-related bloodstream infections -- ranges from 5% to 19% and increases with each needle pass, said Dr. David Feller-Kopman, director of medical procedure services, interventional pulmonology, at Beth Israel Deaconess Medical Center in Boston.

In addition, a 35% failure rate has been noted, especially with the tried-and-true method of landmark-guided puncture, he added.

But "once you've done ultrasound guidance for central line placement, there's no going back," Feller-Kopman said.

The choice of sites -- subclavian, internal jugular, or femoral veins -- is an important component of CVC placement. The Centers for Disease Control (CDC) recommends the subclavian site as the site of choice, with grade 1A evidence, according to Feller-Kopman.

For more on site placement, Feller-Kopman recommended an article by Dr. Kedar Deshpande and colleagues in Critical Care Medicine. Deshpande's group at the Albert Einstein College of Medicine in New York City looked at the risk of central venous catheter infection, with respect to the insertion site, in an intensive care unit population (January 2005, Vol. 33:1, pp. 13-20).

Whichever site is accessed, Feller-Kopman suggested using B-mode ultrasound to identify the vessel and center it on the screen. The skin is then marked and the catheter placed under real-time sonographic guidance. In the internal jugular vein in particular, this method has been shown to reduce the number of entry attempts, complication rates, and procedure time.

Feller-Kopman highlighted a Japanese study out of Kansai Rosai Hospital in Hyogo that compared prepuncture ultrasound in the internal jugular vein cannulation versus landmark-guided puncture. In this research, the right internal jugular vein was cannulated using either respiratory jugular venodilation or prepuncture ultrasound guidance. The authors found that if the landmark could not be established, then the access and success rates were significantly better with ultrasound (Journal of Cardiothoracic and Vascular Anesthesia, October 2002, Vol. 16:5, pp. 572-575).

In addition to technical improvements, ultrasound-guided placement can sharpen operator skills. Feller-Kopman referred to a study done at the University of Pittsburgh School of Medicine that found sonography improved the success rate of subclavian venous catheterization performed by less experienced operators (Critical Care Medicine, April 1995, Vol. 23:4, pp. 692-697).

Finally, in the femoral artery, ultrasound guidance can improve the chance of success with the first placement attempt and help distinguish between arteries and veins, he said.

Doppler can be used but does have several disadvantages, Feller-Kopman stated. These include a greater learning curve than 2D ultrasound, longer insertion times, and higher costs. He cited a meta-analysis by Daniel Hind and colleagues from the U.K. that ultimately supported the use of 2D ultrasonography for central venous cannulation.

For more on Doppler versus real-time ultrasound guidance, Feller-Kopman suggested that his audience read another meta-analysis by Dr. Adrienne Randolph and colleagues (Critical Care Medicine, December 1996, Vol. 24:12, pp. 2053-2058).

Feller-Kopman rounded out his talk by mentioning a few other drawbacks of ultrasound-guided line placement, including initial start-up costs to purchase the equipment and supplies such as gel and sheaths. For more information on the finances of ultrasound-guided line placement, he referred attendees to a study done in the U.K. on the cost-effectiveness of this technique.

Also, providers should check with their local billing experts on reimbursement rates for ultrasound guidance, which are generally around $20 (technical component) and $17 (professional component). In addition, time for proper training is required. However, Feller-Kopman stressed that ultrasound guidance serves as an "outstanding" education tool for line placement.

By Shalmali Pal staff writer
January 11, 2006

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Copyright © 2006


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