Ultrasonography can aid central venous cannulation

EDITOR—Murphy in his editorial highlights problems with temporary cardiac pacing where the service is provided by doctors in training with inadequate supervision.1 An essential component of temporary pacing is obtaining central venous access. The failure rate for this intervention remains notable. Murphy suggests involving anaesthetists or intensivists to help resolve this problem.

There are other ways to address this important issue rather than increasing the workload of another department. The first would be to increase the involvement of consultant physicians from the current level of only 14%. Failure rates for central venous cannulation are related to the experience of the operator, with failure rates almost double in inexperienced hands.2

The second is to move from a landmark guided technique for central venous cannulation to an ultrasound guided technique. A meta-analysis comparing ultrasound guidance with a landmark technique for central venous cannulation suggested that ultrasound guidance significantly reduced the rates of failures and complications and the need for multiple attempts at placement.3 The benefits may be more obvious in patients with difficult central venous access.4

Better training in general medicine is required

EDITOR—Temporary transvenous cardiac pacing is a life saving procedure and an important skill for emergency physicians to have.1 It is often a poorly taught procedure with potentially life threatening complications. It should not be embarked on without due care, attention, and training. When possible, waiting and observing more stable patients overnight until the permanent pacemaker list is much more desirable. But potentially deskilling the frontline may have equally disastrous consequences, as would transferring potentially unstable patients to other centres.

If trainees in general medicine are not to expected to perform temporary pacing, then should the same be said …