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Rapid Responses: Rapid Responses published:
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Ultrasound for central venous cannulation.
- Paul Jefferson, David R. Ball (18 August 2003)
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Statistically correct, not clinically relevant
- Stuart M White (2 September 2003)
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Paul Jefferson, Consultant anaesthetist Dumfries and Galloway Royal Infirmary DG1 1SY, David R. Ball
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The meta-analysis provides further evidence supporting the use of ultrasound for central venous cannulation [1]. The critical care world has been reluctant to embrace this technology. In 2000 we sent a questionnaire to critical care units in the UK [2]. Less than a quarter of units used ultrasound for central venous cannulation, and of these only 11% used it routinely. Half of the units used ultrasound sub-optimally by identifying the internal jugular vein prior to blind cannulation rather than using continuous real-time guidance. In 1999, Scott [3] predicted that ‘early in the next millenium… ultrasound guidance will be a prerequisite before and during central venous cannulation.’ The current situation is far removed from this ideal and it will be interesting to see if the apathy towards ultrasound guidance changes. REFERENCES [1] Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C et al. Ultrasonic locating devices for central venous cannulation: meta -analysis. BMJ 2003;327:361-4. [2] Jefferson P, Ogbue MN, Hamilton K.E.StC, Ball DR. A survey of the use of portable ultrasound for central vein cannulation on critical care units in the UK. Anaesthesia 2002;57:365-8. [3] Scott DHT. In the country of the blind, the one-eyed man is king. Br J Anaesth 1999;82:820-1. Competing interests: None declared |
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Stuart M White, Consultant Anaesthetist Dept. Anaesthesia, Brighton and Sussex University Hospitals, Eastern Road, Brighton, BN2 5BE
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Hind et al. concluded that locating central venous catheters under two-dimensional ultrasound guidance ‘is quicker and safer than the landmark method in both adults and children’1. This statement is indeed the statistically valid conclusion of their meta-analysis, but one does have to ask whether the extra 12 seconds required for successful cannulation of the internal jugular vein (the only approach for which this statement holds true) by the landmark method is of any clinical relevance, or is even the actual case once the practical realities of locating an unused, operational ultrasound machine are factored in. Whether one method is safer than the other may be a question of training. Personally, my training in central venous cannulation by the landmark method consisted of the ‘see one, do one, teach one’ approach, modified by clinical experience, whereas my training in two-dimensional ultrasound guided cannulation involved a whole day of lectures and practical workshops. One has to ask whether complications using the landmark method could be reduced if only practitioners were correctly trained in the first instance. There are any number of criticisms that can be made of NICE’s guidance concerning ultrasound-guided central venous cannulation2,3. Nevertheless, visualisation of venous anatomy should be considered in potentially ‘difficult’ patients. However, papers such as this which proscribe a quasi-legal standard of care based on poor conclusions, have the effect of further undermining the admirable aim of promoting patient safety. References. 1. Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C, Thomas S. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 2003;327:361-4 2. White SM. Legal considerations of clinical guidelines. JRSM 2003;96:254 3. White SM. Not NICE advice. Anaesthesia 2003;58:295-6 Competing interests: None declared |
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