BMJ  2003;327:361 (16 August), doi:10.1136/bmj.327.7411.361

Paper

Ultrasonic locating devices for central venous cannulation: meta-analysis

¹ School of Health and Related Research (ScHARR), Regent Court, Sheffield S1 4DA, ² Fourth Hurdle Consulting, London WC1R 4QA, ³ Royal Liverpool University Hospital, Liverpool L7 8XP, ⁴ Sheffield Teaching Hospitals NHS Trust, Royal Hallamshire Hospital, Sheffield S10 2JF, ⁵ Department of Academic Radiology, University of Sheffield, Northern General Hospital, Sheffield S5 7AU

Abstract

Objectives To assess the evidence for the clinical effectiveness of ultrasound guided central venous cannulation.

Data sources 15 electronic bibliographic databases, covering biomedical, science, social science, health economics, and grey literature.

Design Systematic review and meta-analysis of randomised controlled trials.

Populations Patients scheduled for central venous access.

Intervention reviewed Guidance using real time two dimensional ultrasonography or Doppler needles and probes compared with the anatomical landmark method of cannulation.

Data extraction Risk of failed catheter placement (primary outcome), risk of complications from placement, risk of failure on first attempt at placement, number of attempts to successful catheterisation, and time (seconds) to successful catheterisation.

Data synthesis 18 trials (1646 participants) were identified. Compared with the landmark method, real time two dimensional ultrasound guidance for cannulating the internal jugular vein in adults was associated with a significantly lower failure rate both overall (relative risk 0.14, 95% confidence interval 0.06 to 0.33) and on the first attempt (0.59, 0.39 to 0.88). Limited evidence favoured two dimensional ultrasound guidance for subclavian vein and femoral vein procedures in adults (0.14, 0.04 to 0.57 and 0.29, 0.07 to 1.21, respectively). Three studies in infants confirmed a higher success rate with two dimensional ultrasonography for internal jugular procedures (0.15, 0.03 to 0.64). Doppler guided cannulation of the internal jugular vein in adults was more successful than the landmark method (0.39, 0.17 to 0.92), but the landmark method was more successful for subclavian vein procedures (1.48, 1.03 to 2.14). No significant difference was found between these techniques for cannulation of the internal jugular vein in infants. An indirect comparison of relative risks suggested that two dimensional ultrasonography would be more successful than Doppler guidance for subclavian vein procedures in adults (0.09, 0.02 to 0.38).

Conclusions Evidence supports the use of two dimensional ultrasonography for central venous cannulation.

Introduction

Around 200 000 procedures for central venous access are performed in the NHS each year.¹ Catheters are inserted for several reasons, including haemodynamic monitoring, delivery of blood products and drugs (for example, chemotherapy and antibiotics), haemodialysis, total parenteral nutrition, and management of perioperative fluids. These procedures are performed in a wide range of locations within the hospital and at various insertion sites on the body by medical and, increasingly, nursing staff.

Central venous access is commonly attempted at the internal jugular vein, subclavian vein, femoral vein, or arm veins. Safe puncture of a central vein (venepuncture) is traditionally achieved by passing the needle along the anticipated line of the vein using anatomical landmarks on the skin's surface (the landmark method).

Central venous cannulation can be unsafe: death is possible but rare.² Less serious, but still costly for patient discomfort, clinician time, and NHS resources are the varying rates for failure and complications from central venous cannulation. Anomalies in anatomy and thrombosed veins may cause failure.

The rates, risks, and consequences of complications arising from central venous cannulation vary across patient groups. Infants, obese patients, and those with short necks are more difficult to access. Patients with clotting problems, ventilated patients, and those undergoing emergency pacing procedures may have more serious consequences from a complication associated with venepuncture.² Repeated catheterisation (as in patients requiring chemotherapy or haemodialysis) is a significant risk factor for the formation of thrombus.³

Ultrasound devices may be used to locate a vein in two ways. Real time ultrasonography generates a two dimensional grey scale image of the vein and surrounding tissues. Continuous wave Doppler ultrasonography generates an audible sound from flowing venous blood, with no information on depth of the vessel. We systematically reviewed randomised controlled trials for evidence of the effectiveness of two dimensional ultrasound guidance and Doppler ultrasound guidance in patients undergoing central venous catheterisation.

Methods

We searched 15 electronic bibliographic databases from inception to October 2001. The search strategy is available on bmj.com and elsewhere.⁴ Inclusion criteria were: clinical effectiveness of two dimensional ultrasound guidance or Doppler ultrasound guidance for the placement of central venous lines; comparison of ultrasonography with the landmark method or the surgical cut-down procedure; inclusion of one or more of several outcomes—number of failed catheter placements, number of complications from catheter placement, risk of failure at first attempt, number of attempts to successful catheterisation, and time (seconds) to successful catheterisation. Only English language papers were selected.

Allocation concealment and the method of generation of the allocation sequence were recorded, to assess the potential for selection bias. We also recorded whether an intention to treat analysis was performed.

The numbers of catheters and patients were abstracted as reported, as were data on mechanical complications. The numbers of patients with complications were pooled for meta-analysis. The numbers of catheter placements, rather than the numbers of patients, were pooled for analysis. Data for adults and children were pooled separately, as were alternative insertion sites.

Results

We identified 27 trials. None reported allocation concealment. Three were excluded because the method of allocation was unclear and the trials were not described as randomised, and two were excluded because they had inadequate methods for generation of allocation sequence. Two prospective trials were rejected because vessels were located by Doppler ultrasound guidance followed by blind venepuncture. Two trials were rejected because they were reported in abstract form only. We therefore included 18 studies in our review.

The trials included a total of 1646 people scheduled for central venous catheterisation. Ten studies investigated two dimensional ultrasound guidance compared with the landmark method and six investigated Doppler ultrasound guidance compared with the landmark method. One trial investigated two dimensional ultrasound guidance compared with blind venepuncture preceded by ultrasound guidance. One trial, with three arms, investigated two dimensional ultrasound guidance compared with Doppler ultrasound guidance and the landmark method. No studies compared two dimensional ultrasound guidance as a single procedure against surgical cut-down. Nine trials described adequate methods for generation of allocation sequence within the randomisation process. Two trials did not indicate an intention to treat analysis.

Quantitative data synthesis
Two dimensional ultrasound guidance was more effective for all five outcomes for internal jugular vein procedures in adults (table 1). Limited evidence suggested two dimensional ultrasound guidance reduced the relative risk of failed catheter placements by 86% in the subclavian vein and 71% in the femoral vein. Three studies of this comparison for procedures on internal jugular veins in infants had relatively small sample sizes but suggested that ultrasonography was significantly more effective.

View this table: [in this window] [in a new window]   Table 1 Summary of significance of outcome measures for two dimensional (2-D) ultrasound guidance compared with landmark method for catheterisation

 

For internal jugular vein procedures, Doppler ultrasound guidance significantly improved the chance of successful cannulation overall and on the first attempt (table 2). However, for cannulation of the subclavian vein, results significantly favoured the landmark method for relative risk of failed catheter placements and the mean number of seconds to successful catheterisation. Only one study of this comparison in infants was found (for internal jugular vein procedures), and this was too small to achieve statistical significance. No studies of this comparison in femoral vein procedures were identified for adults or infants.

View this table: [in this window] [in a new window]   Table 2 Summary of significance of outcome measures for Doppler ultrasound guidance compared with landmark method for catheterisation

 

In the absence of studies comparing two dimensional ultrasonography with Doppler ultrasonography in adults, we made an indirect comparison of the two estimated relative risks. The ratio of relative risks for the primary outcome, failed catheter placements, was 0.36 (0.11 to 1.19) in favour of two dimensional ultrasonography for internal jugular vein procedures and 0.09 (0.02 to 0.38) for subclavian vein procedures.

Discussion

Our systematic review shows a clear benefit from two dimensional ultrasound guidance for central venous access compared with the landmark method. These results are similar to a previously published meta-analysis: however, that study inappropriately pooled the results from trials of both Doppler ultrasound guidance and two dimensional ultrasound guidance.⁵ The evidence presented here favours the use of two dimensional ultrasound guidance for cannulation of the subclavian vein, with Doppler ultrasound guidance less successful and more time consuming than even the landmark method. It also proved more successful than Doppler ultrasound guidance or the landmark method when the internal jugular vein of infants was cannulated, the image aiding the navigation of diminutive anatomy; although this evidence came from only one study.

Potential benefits to health care providers are improvements in efficiency and reductions in costs of dealing with complications. To be weighed against this are the implications of advocating ultrasound guidance for central venous cannulation, such as a potential for deskilling in the landmark method that may be required in some emergency situations. Guidance from the National Institute for Clinical Excellence in this area states that it is important that "operators maintain their ability to use the landmark method and that the method continues to be taught alongside the 2-D ultrasound guided technique."⁶ Financial and logistical implications for the NHS are provision of sufficient ultrasound machines and staff training.

Economic modelling indicated that using ultrasound guidance for venepuncture in central venous access was likely to save £2000 ($3249; €2840) of NHS resources for every 1000 procedures.⁴ The model incorporated the inevitable costs of purchasing machines and training staff. The net resource saving was attributable to savings from the need to treat fewer complications and notional savings from less time spent by clinicians and nurses achieving successful cannulation and dealing with complications, with all the implications for reduced use of expensive time in theatres and intensive care units. Although wider use of two dimensional ultrasound guidance for central venous access is unlikely to achieve hard cash savings for the NHS, the opportunity cost savings are genuine and relevant.

What is already known on this topic Hundreds of thousands of central venous lines are placed in patients every year in NHS hospitals Complication and failure rates vary, and deaths have been reported What this study adds Catheterisation under two dimensional ultrasound guidance is quicker and safer than the landmark method in both adults and children Two dimensional ultrasound guidance is more effective than Doppler ultrasound guidance for more difficult procedures

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This is an abridged version; the full version is on bmj.com

Additional references appear on bmj.com

Contributors: See bmj.com

Funding: The UK National Coordinating Centre for Health Technology Assessment programme funded the study.

Competing interests: RMcW has received honorariums from Sonosite for lecturing at training days.

References

1. Elliot TSJ, Faroqui MH, Armstrong RF, Hanson GC. Guidelines for good practice in central venous catheterization. J Hosp Infect 1994;28: 163-76.[CrossRef][Web of Science][Medline]
2. Callum KG, Whimster F. Interventional vascular radiology and interventional neurovascular radiology: a report of the National Confidential Enquiry into Perioperative Deaths. Data collection period 1 Apr 1998 to 31 Mar 1999. London, NCEPOD, 2000.
3. Trottier SJ, Veremakis C, O'Brien J, Auer AI. Femoral deep vein thrombosis associated with central venous catheterization: results from a prospective, randomized trial. Crit Care Med 1995;23: 52-9.[CrossRef][Web of Science][Medline]
4. Calvert N, Hind D, McWilliams RG, Thomas SM, Beverley C, Davidson A. The effectiveness and cost-effectiveness of ultrasound locating devices for central venous access: a systematic review. Health Technol Assess 2003:7(12).
5. Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med 1996;24: 2053-8.[CrossRef][Web of Science][Medline]
6. National Institute for Clinical Excellence. Guidance on the use of ultrasound locating devices for placing central venous catheters. London: NICE, 2002. [NICE Technology Appraisal No 49.]

(Accepted June 18, 2003)

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