Impact of ultrasonography on central venous catheter insertion in intensive care

Gopal B Palepu, Juneja Deven, M Subrahmanyam, S Mohan, Gopal B Palepu, Juneja Deven, M Subrahmanyam, S Mohan

Abstract

Background and aims: The insertion of central venous catheters (CVCs) is an integral part of the management of critically ill patients. We aimed to study the impact of ultrasonography (USG) on CVC insertion in intensive care.

Setting and design: A prospective study of 450 patients requiring CVC in the intensive care unit (ICU) of a tertiary care hospital.

Methods and materials: The patients were randomized into two groups: to have CVC insertion with USG-guidance or with the anatomic landmark technique (ALT). Data were collected on patient demographics; operator experience; and method, site and side of insertion. Outcome measures included successful insertion of CVC, number of attempts needed and complications.

Results: Internal jugular vein (IJV) cannulation was successful in 177/194 patients (91.2%) using ALT and in 200/205 patients (97.6%) using USG guidance, a significant difference of 6.4% (P = 0.006). Using ALT, 72.7% of cannulations could be accomplished in the first attempt as compared with 84.4% with USG guidance (P = 0.004). The overall complication rate was 28/399 (7%), with 19 (9.8%) complications in the ALT group and 9 (4.4%) in the USG group (age-, sex-, and operator-adjusted OR = 0.35, 95% CI: 0.13-0.96; P = 0.03). For subclavian vein catheterization, the success rate was 26/28 (92.9%) in the ALT group and 17/17 (100%) in the USG group (P = 0.52). Using ALT, 71.4% cannulation could be accomplished in the first attempt as compared with 82.4% under USG guidance (P = 0.49). The overall complication rate was 6/45 (13.3%), with 4 (14.3%) complications in the ALT group and 2 (11.8%) in the USG group (P > 0.99).

Conclusions: Real-time USG guidance improves success rates, reduces the number of attempts and decreases the complications associated with CVC insertion, especially for the IJV, and should become the standard of care in intensive care.

Conflict of interest statement

Conflict of Interest: None declared.

Figures

Figure 1
Figure 1
Insertion of a CVC in the right IJV using the anatomical landmark technique. The image shows the position of the needle with respect to the clavicular (CH-SCM) and sternal (SH-SCM) heads of the sternocleidomastoid muscle. H indicates the head end of the patient
Figure 2
Figure 2
Insertion of a CVC in the right IJV under USG guidance. The image shows the position of the USG transducer and needle with respect to the clavicular head of the sternocleidomastoid muscle (CHSCM). H indicates the head end of the patient
Figure 3
Figure 3
Insertion of a CVC in the right subclavian vein under USG guidance. The images shows the position of the USG transducer and needle with respect to the clavicle (Cl). H indicates the head end of the patient
Figure 4
Figure 4
USG shows the location of the right IJV in relation to the carotid artery (CA), thyroid and trachea (TR). M indicates medial and L indicates lateral
Figure 5
Figure 5
CONSORT diagram. CVC - central venous catheters, ALT - anatomical landmark technique, USG - ultrasound, IJV - internal jugular vein, SCV - subclavian vein, FV - femoral vein

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