Ultrasound-guided vs ultrasound-assisted central venous catheterization

Introduction

Ultrasound (US) significantly facilitates central venous catheterization, reducing the percentage of failure, the percentage of accidental arterial puncture, and the percentage of complications (haematoma, haemothorax, pneumothorax). Nonetheless, it is not clear whether US guidance (USG) (so-called 'dynamic' or 'real-time' US techniques: that is, venipuncture under direct US control) may be better than US assistance (USA) (so-called 'static' or 'indirect' US techniques: that is, US imaging of the vein, with or without skin marking, and then blind venipuncture).

Methods

From February 2005 to September 2006, our CVC Team adopted the following protocol for internal jugular vein (IJV) catheterization: (a) both IJVs were evaluated to assess position, dimensions, and other features known to affect the risk of catheterization; (b) then, a decision was made whether to continue with USA or USG; (c) the IJV was accessed via the low lateral Jernigan approach; (d) after two failed USA attempts, USG venipuncture was adopted; (d) when IJVs were not available, USG venipuncture of other central veins was the second choice; and (e) fluoroscopy was used only in paediatric patients, but all patients had a postoperative chest X-ray to rule out pneumothorax and malposition.

Results

In 20 months, 821 central venous catheters (CVCs) were inserted in adults (181 short-term CVC + 218 tunnelled + 316 ports) and in paediatric patients (age range 20 days–13 years, average 5.5 years: 20 short-term + 84 tunnelled + two ports). In adults, the procedure started as USA in 522 and as USG in 299 cases: a shift from USA to USG was necessary in 8%. USG was the first choice in all paediatric cases. The IJV was successfully cannulated in most adult patients, with very few exceptions (innominate vein in 12 cases, axillary vein in two cases, femoral vein in one case, all by USG). In one paediatric patient, the CVC was inserted in the subclavian vein, via a supraclavicular USG approach. Complications were: failure 0%; pneumothorax 0%; haemothorax 0%; accidental arterial puncture 1.1% (1.7% USA vs 0.3% USG); haematoma 0.4% (only for USA); malposition (0.8%, exclusively with the left IJV).

Conclusion

In conclusion, (a) we had a minimal incidence of complications, (b) USG was associated with a relevant reduction of the risk of accidental arterial puncture and haematoma, if compared with USA, and (c) choosing the left IJV was associated with a higher risk of malposition.