Ultrasound guidance increases the safety and ease of insertion of central venous catheters in patients undergoing elective procedures

Abdul Rehman1, Huma Zeb2, Abid Ullah Khan Niazi2
1Consultant Anesthesiologist; 2Medical Officer

Quaid-e-Azam International Hospital, Islamabad(Pakistan)

 
Correspondence: Dr. Abdul Rehman, Consultant Anesthesiologist, Quaid-e-Azam International Hospital, Islamabad (Pakistan); E-mail: rehman222@hotmail.com; Phone: +92 51 8449100

 

ABSTRACT
Objective: To determine the advantages of ultrasound guided central venous catheter insertion over anatomical land mark techniqueregarding ease of insertion and safety.

Study Design:  Comparative, cross-sectional study

Setting: Quaid-e-Azam Hospital, Islamabad (Pakistan)

Duration: August 2014 to May 2015

Methodology:
Sixty elective patients requiring central venous catheter were selected and randomly divided into two groups, e.g. ultrasound and anatomical landmark groups. Central catheter was inserted under aseptic measures by the same operator. Variables including ease of access, number of attempts, arterial punctures and other complications in both groups were recorded.

Results:
Ultrasound guidance in central catheter insertion resulted in a statistically significant ease of insertion (P = 0.024). while decreasing number of attempts to gain venous access as compared to the anatomical landmark group (p = 0.0453). Two cases of arterial puncture were recorded in the anatomical landmark group while no arterial puncture occurred in the ultrasound group. P <0.05 was considered significant.

Conclusion:
Ultrasonographic guidance for central catheter insertion makes it easy and safe as it allows better identification of vascular structures. It also reduces the rate of complications associated with central catheter insertion and improves the success rate thereby justifies its cost.

Key words: Central catheter; Ultrasound; Landmark technique; Internal jugular vein; CVP

Citation: Rehman A, Zeb H, Niazi AUK. Ultrasound guidance increases the safety and ease of insertion of central venous catheter insertion in patients undergoing elective procedures. Anaesth Pain& Intensive Care 2015;19(4):474-477

 

 
INTRODUCTION
Central Venous Catheterization (CVC) is a relatively common procedure to obtain central venous access for multiple purposes. Some of its uses include providing parenteral nutrition to patients, treatment of intravascular volume depletion, monitoring for hemodynamics, intravenous access (IV) during cardiopulmonary arrest,  hemodialysis, difficult peripheral intravenous access and long-term Intravenous  access for medications such as antibiotics.1,2 The placement of CVC is a blind procedure making it risky and leads to many complications. The risk is enhanced by a number of factors such as obesity, site of attempted access, operator experience, and associated comorbids such as coagulopathy.1 The anatomical landmark technique has traditionally been used for CVC. In order to decrease complications, ultrasound guidance was introduced. Initialstudies have proven that ultrasound guidance can not only improve the rate of success but also decrease repeated attempts for obtaining access to Internal Jugular Vein (IJV), thus leading to reduced rate of complications.1
The use of IJV for cannulation is favored because of its likely better anatomical location as well as the diameter when patients are placed in Trendelenburg position. One of the most common complications of IJV cannulation is the puncture of the internal carotid artery because of its closeness to the IJV.3,4
The advantages of ultrasound guidance include detection of anatomical variations, exact location of the vessel, avoidance of veins with pre-existing thrombosis and thus add to ease in the catheter placement. This technique has now overtaken the previously used blind technique for central venous access due to multiple benefits.3
In Pakistan, use of ultrasound guidance is very limited for the insertion of CVC. No significant local data exists to justify its routine use. Hence this study was designed to document our experience and to encourage its use in IJV cannulation to make it a routine practice.

METHODOLOGY
This study was conducted at Department of Anesthesiology, Quaid-e-Azam International Hospital, Islamabad, after getting approval from hospital ethics committee and informed consent of patients. A total of 60 patients scheduled for elective surgery were included between August 2014 and May 2015 in this prospective, randomized study. Patients with platelet count below 50 thousand/mm3, INR greater than 1.2, (ASA-PS IV)  and those on ventilator were excluded from the study.

The CVC placement was performed by a single experienced anesthetist either using traditional anatomical landmark technique or use of ultrasound guidance.

The anatomical landmark technique: Using aseptic technique while keeping the patient in Trendelenburg position, 1% Lidocaine Solution was injected under the skin at the site of catheter insertion.  Finder Needle was introduced into skin at an angle of 45 degrees to localize and cannulate the vein. After the confirmation of the venous blood, guide wire was passed in the IJV through needle. After removing the needle, catheter was inserted through guide wire. The catheter was secured after removing the wire.

The ultrasound technique: Patient position and preparation was same as used in anatomical technique. A 6.3 MHz transducer (linear convex probe) was attached to the 2D image display of the portable ultrasound machine (Logic Model, GE Health Care USA) and used in this group. IJV was located using ultrasound probe and finder needle was introduced into skin and direction was dictated by the location of vein in ultrasound. This was followed by the placement of the catheter.

Data collection: For all the patients, their demographic characteristics such as age, gender and indications for CVC, were recorded. The measured outcomes were the ease of insertion, arterial puncture and number of attempts. Various complications such as carotid artery puncture, hematoma formation,pneumothorax, hemothorax and incorrect position of catheter were noted. Postprocedure chest x-ray films were taken to confirm the location of catheter tip and to assess any complication.

Statistical analysis: SPSS 19 was used to analyze data. Two independent groups were selected and all variable were analyzed. Independent sample t-test was applied that showed the p value of all these variables and p value < 0.05 was considered statistically significant.

RESULTS
A total of 60 patients were assessed in this study. Mean age of our patients was 53 years and range was 18-81 years.

In case of anatomical technique, significant difficulty was faced while insertion in nearly half of cases but with ultrasound guidance vast majority of cases were easily done. Thus a statistically significant association(p value =0.024 of ease of insertion was found using ultrasound technique (Table 1).

Table 1: Comparison of ease of insertion in two groups
Ease of insertion Central Catheter Insertion Total P Value
With Ultrasound Without Ultrasound
Easy 26 (86%) 17 (56.7%) 43 (71.7%) 0.024
Moderate difficulty 4 (13.3%) 10 (33.3%) 14 (23.3)
Very difficult 0 (0%) 3 (10%) 3 (5%)
There were two cases of arterial puncture in anatomical landmark group, but none occurred in ultrasound group. There were no other complications seen in both groups.

The catheter was placed in first attempt in 25 (83.3%) patients using the ultrasound technique, only 5 (17%) insertions required a second attempt and none required a third attempt. However, in anatomically landmark technique 17 (56.7%) insertions were done in first attempt and one third (33.3%) required a second attempt. Another 10% required third attempt. Here a statistically significant statistical relationship was found (p-value = 0.0453) (Table 2).

Table 2: Comparison of number of attempts in two groups
Number of Attempts Central Catheter Insertion Total P Value
With Ultrasound Without Ultrasound
First attempt 25 (83.3%) 17 (56.7%) 42 (70%) 0.0453
Second attempt 5 (16.7%) 10 (33.3%) 15 (25%)
Third attempt 0 (0%) 3 (10%) 3 (5%)
Total 30 30 60
 
DISCUSSION
This study clearly demonstrates the superiority of ultrasound assisted cannulation as compared to the traditional landmark technique. The advent of ultrasonography has changed the overall technique of the placement of CVCs in both the internal jugular and femoral veins.  Recently, it has been embraced with fervor across the medical fraternity as a diagnostic and therapeutic aid.3
On the contrary, some studies show that the use of ultrasound had no effect on the rate of complication and in reducing the number of attempts in CVC placement.4 In contrast, our study showed significantly decreased incidence of complications.

Many studies have compared the ultrasound technique to the landmark technique. A number of studies have concluded that the overall complication rate was higher in the landmark group than in the ultrasound-guided group (p < 0.01). The number of attempts for successful placement were significantly higher in the landmark group accompanied by a significantly increased access time.5-8 Our study showed similar results.

As ultrasound machines have become portable and convenient to carry, their use has become more feasible for common use. The vascular structures are identified with ease. More accurate needle placement results in safer and more successful procedures. Appropriate training is vital for proper placement of IJV catheter so that the safety of patients can be ensured.8
In critically ill patients, difficulties in obtaining venous access may occur in up to one quarter of patients.8-11 In our study about 30% insertions were moderate to very difficult, although this study was done in patients undergoing an elective procedure. So ultrasound guidance can be very helpful in critically ill patients where insertion is more challenging. Our study showed that vast majority of CVC was easily done using ultrasound guidance. Several benefits of ultrasound include regular and reliable access to the IJV, patient satisfaction, reduced risk for acquiring infections and decreased arterial damage.

The skill of the physician in placing the IJV catheter is an important factor in determining the success of catheter placement. A number of studies show that in 54% cases the carotid artery can partly cover the IJV and 5.5% of the time the IJV can lie medial to the carotid artery.12,13,14 Hence, it becomes imperative to locate the vessel with ultrasound. Our study also proved that ultrasound guidance can eliminate complication of carotid artery puncture during CVC.

One study also shows that ultrasound guidance for CVC may be beneficial in emergency with higher anticipated success rates and lower complications.15 This will require further studies in emergency settings. Another study confirms that although ultrasound equipment is costly but the benefits of decreased complication rate and lesser time in success to cannulate the patients can justify its cost.16 Studies done earlier provide satisfactory proof to support the concept that ultrasound-guided CVC is cost-effective.17-19 Our study was limited but it also shows safety of ultrasound guidance.

No extensive local published material is currently available to see the benefits of ultrasound guidance in IJV cannulation.20,21 So this study can motivate our local physicians to adopt this technique for enhanced patient safety.

CONCLUSION
Using ultrasonographic guidance makes central venous catheter insertion easy and safe as it allows better identification of vascular structures. It also reduces the rate of associated complications and improves the success rate thereby justifies its cost. Availability of ultrasound at every institution should be mandatory so physicians can use it in their routine clinical practice.

Conflict of interest: None declared by the authors

Author contribution:
AR:  conducted the clinical procedures; review and revision of the manuscript

HZ & AULN: Literature search, manuscript preparation

REFERENCES
  1. Civetta JM, Taylor RW, Kirby RR. Critical Care. 3rd Philadelphia: Lippincott-Raven; 1997.
  2. Shoemaker W, Ayres S, Grenvik A, et al. Textbook of Critical Care. 4th Philadelphia: WB Saunders; 2000.
  3. Maguire R. Imaging in chronic pain: May the force be with US. Anesth Pain & Intensive Care. 2015;19(3):219-221.
[Free full text]
  1. Soliman M, Ismail K. A comparison between ultrasound guided-central venous line placement and an anatomical landmark technique. Crit Care. 2007; 11 (Suppl 2): P160.
[Free full text] doi:  10.1186/cc5320
  1. Turker G, Kaya FN, Gurbet A, Aksu H, Erdogan C, Atlas A. Internal jugular vein cannulation: an ultrasound guided technique versus a landmark-guided technique. Clinics. 2009;64(10):989–992.
[PubMed] [Free full text]
  1. Malloy DL, McGee WT, Shawker TH, Brenner M, Bailey KR, Evans RG, et al.Ultrasound guidance improves the success rate of internal jugular vein cannulation: a prospective, randomized trial. Chest. 1990;98:157-160 .
[PubMed] [Free full text]
  1. Dennys BG, Uretsky BF, Reddy PS.Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external landmark-guided technique. Circulation. 1993;87(5):1557-1562.
[PubMed]
  1. Karakitsos D, Labropoulos N, De Groot E, Patrianakos AP, Kouraklis G, Poularas J, et al. Real-time ultrasound-guided catheterization of the internal jugular vein: A prospective comparison with the landmark technique in critical care patients. Crit Care. 2006;10(6): R162.
[PubMed] [Free full text]
  1. Fields JM, Piela NE, Au AK, Ku BS. Risk factors associated with difficult venous access in adults ED patients. Am J Emerg Med. 2014 Oct;32(10):1179-82.
[PubMed] doi: 10.1016/j.ajem.2014.07.008. Epub 2014 Jul 30.
  1. Sebbane M, Claret PG, Lefebvre S, Mercier G, Rubenovitch J, Jreige R, et al. Predicting peripheral venous access difficulty in emergency department using body mass index and a clinical evaluation of venous accessibility. J Emerg Med. 2013 Feb;44(2):299-305.
[PubMed] doi: 10.1016/j.jemermed.2012.07.051. Epub 2012 Sep 13.
  1. Lininger RA. Pediatric peripheral i.v insertion success rates. Pediatric Nurs. 2003;29:351-354.
[PubMed]
  1. Gordon AC, Saliken JC, Johns D, Owen R, Gray RR. US-guided puncture of the internal jugular vein: complications and anatomic considerations. J Vasc Interv Radiol. 1998;9(2):333-8.
[PubMed]
  1. Troianos CA, Kuwik RJ, Pasqual JR, Lim AJ, Odasso DP. Internal jugular vein and carotid artery anatomic relation as determined by ultrasonography. Anesthesiology. 1996;85(1):43-8.
[PubMed] [Free full text]
  1. Denys BG. Uretsky BF. Anatomical variations of internal jugular vein location: impact on central venous access. Critical Care Medicine 1991;19(12):1516-9.
[PubMed]
  1. Mehta N, Valesky WW, Guy A,Sinert R. Is Real-time Ultrasonic-Guided Central Line Placement by EDPhysicians More Successful Than the Traditional Landmark Approach? Emerg Med J. 2013;30(5):355-359.
[PubMed]
  1. Augoustides JG, Diaz D, Weiner J, Clarke C, Jobes DR.Current practice of internal jugular venous cannulation in a university anesthesia department: influence of operator experience on success of cannulation and arterial injury. J Cardiothorac Vasc Anesth. 2002;16:567-571.
[PubMed]
  1. Bold RJ, Winchester DJ, Madary AR, Gregurich MA, Mansfield PF.Prospective, randomized trial of Doppler-assisted subclavian vein catheterization. Arch Surg. 1998;133;1089-1093.
[PubMed]
  1. Calvert N, Hind D, McWilliams R, Davidson A, Beverley CA, Thomas SM.Ultrasound for central venous cannulation: economic evaluation of cost-effectiveness. Anaesthesia. 2004;59:1116-1120.
[PubMed]
  1. Gayle JA, Kaye AD. Ultrasound-Guided central venous cannulation: Current recommendations and guidelines. Anesthesiology News.2012; June. 1-6
  2. Akhtar MI, Hamid M. Ultrasound guided central venous access; a review of literature. Anaesth Pain & intensive Care. 2015;19(3):317-322.
[Free full text]
  1. Riaz A, Khan RAS, Salim F. Ultrasound Guided Internal Jugular Venous Cannulation: Comparison with Land-Mark Technique. J College of Phy & Surg. 2015;25(5):315-319.
[PubMed] doi: 05.2015/JCPSP.315319.