Ultrasonic locating devices for central venous cannulation: meta-analysis
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7411.361 (Published 14 August 2003) Cite this as: BMJ 2003;327:361
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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
Competing interests: No competing interests
Statistically correct, not clinically relevant
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
Competing interests: No competing interests