C. J. Lee1, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada
Introduction: Real-time ultrasound guidance for the placement of central venous catheters (CVCs) is purported to increase placement success and to reduce complications but in whose hands? This meta-analysis assesses all available evidence comparing landmark-guided (LG) to ultrasound-guided (UG) CVC insertion in regards to success, safety/complications and the experience of the operator placing the CVC.
Methods: A comprehensive literature search of Medline, PubMed, and the Cochrane Central Register of Controlled Trials was performed. 17 prospective, randomized controlled trials were identified which compared UG with LG techniques of CVC placement and specified operator experience. Data were extracted on study design, study size, operator experience, rate of successful catheter placement, number of attempts to success, and rate of accidental arterial puncture. A meta-analysis was constructed to analyze the data.
Results: 17 trials with a total of 3,686 subjects were included. 1,684 CVCs were placed by LG, and1,822 by UG. Among the UG group, 910 subjects were placed by junior operators (<5 years experience), and 912 by senior operators. In the LG group, 754 subjects were placed by junior operators and 930 by senior operators. UG CVC insertion was associated with 14% increase in the likelihood of successful CVC placement by junior operators (risk ratio (RR), 1.14; 95% CI, 1.08-1.21) and a 8% increase in senior operators (RR 1.08; 95% CI, 1.02-1.14). The mean number of needle attempts until CVC placement was lower in the UG placement group (Standard difference in means -0.85; 95% CI, -1.18 to -0.51) however no significant difference was seen between junior and senior operators. UG was associated with a 49% decrease in the likelihood of accidental arterial puncture among junior operators (RR 0.51; 95% CI, 0.28-0.95 and an 86% decrease in senior operators (RR 0.14; 95% CI, 0.07-0.26). Statistically significant difference between junior and senior operators was only observed in regards to accidental arterial puncture (p=0.004).
Conclusion: UG CVC placement in adult patients is effective in improving overall success rate and decreasing the number of attempts until cannulation and arterial puncture rate regardless of operator experience level. Accidental arterial punctures during UG CVC were lower in both groups, but a significantly higher benefit was observed among senior operators compared to junior operators. UG SVC improves success rate, efficiency, and safety in regards to CVC placement, even among those most comfortable or confident in traditional landmark guided techniques.
