Ultrasound guidance may improve rates of successful central venous cannulation

1. Ultrasound (US)-guided techniques reduced the odds of central venous cannulation (CVC) failure by almost 75% compared to techniques using landmark identification alone.

2. The odds of accidental arterial puncture using US-guidance were about 1/3 the odds of puncture when using landmarks alone.

Evidence Rating: 1 (Excellent)

Study Rundown: While CVCs are often an essential component of care for seriously ill pediatric patients, deep vein catheterization in children is technically challenging and can result in several significant complications, including arterial punctures, hematomas, hemothorax, etc. This meta-analysis evaluated the effectiveness of US-guided techniques in reducing the number of cannulation failures and arterial punctures compared to the traditional anatomic landmark technique. Results of the pooled analysis show US guidance significantly reduced the odds of central venous cannulation failure by almost 75%. Furthermore, rates of arterial punctures were more than 60% lower when using ultrasound guidance compared to landmarks. This study is limited by potential publication bias among the studies analyzed, which could lead to falsely lower odds of cannulation failures and artieral punctures. Results of this meta-analysis suggest that the use of ultrasound for central venous catheter insertion in the pediatric population is superior to using anatomical landmarks alone.

Click to read the study, published today in Pediatrics

Relevant reading: Ultrasonographic anatomic variations of the major veins in paediatric patients

In-depth [meta-analysis]: Researchers analyzed 23 studies (12 randomized control trials) with a total of 3995 CVC placements (1852 US-guided) found via PubMed and Embase databases. Of the studies included in the analysis, 19 utilized the real-time US, 3 used the US-guide prelocation technique and 1 looked at both techniques. 15 studies looked at procedures done in the operating room, 3 were conducted in the pediatric intensive care unit, 3 were in multiple settings, 1 was done in the emergency department, and 1 study did not include setting information. Results show cannulation failure was significantly less in the US group compared to the the landmarks group (9.1% and 19.2% respectively; OR=0.27; 95% CI 0.17-0.43, P<.00001). US-guidance was found to reduce failure rates regardless of which vein was cannulated (internal jugular vs. femoral). Rates of arterial puncture were also significantly lower in procedures utilizing US-guidance compared to landmark identification alone (5.4% and 8.4%, respectively; OR=0.34, 95% CI 0.21-0.55, p<.0001). Only the subgroup analysis of randomized control trials that looked at real-time US-guidance versus landmarks demonstrated heterogeneity for the primary outcome of cannulation failure (5.3% and 25% respectively; OR=0.16, 95% CI 0.04-0.56, P=.004), likely due to 1 study which found a higher failure rate with the former technique.

Image: PD

©2018 2 Minute Medicine, Inc. All rights reserved. No works may be reproduced without expressed written consent from 2 Minute Medicine, Inc. Inquire about licensing here. No article should be construed as medical advice and is not intended as such by the authors or by 2 Minute Medicine, Inc.