Imaging/original researchReal-Time Ultrasonographically-Guided Internal Jugular Vein Catheterization in the Emergency Department Increases Success Rates and Reduces Complications: A Randomized, Prospective Study
Introduction
Central venous catheterization is a common and important procedure in the emergency department (ED). It allows resuscitation for intravascular fluid depletion and access for vasoactive medications and antibiotics, and it provides a means for hemodynamic monitoring and pacing.1, 2 At times, it may be the only form of intravenous access. The internal jugular, subclavian, and femoral veins are commonly used for central venous access. Femoral vein catheterization has always been an attractive method of obtaining central venous access in the ED because it is possible in the vast majority of patients, is suitable for many indications, and is associated with a low complication rate during insertion. However, disadvantages include the inability to perform invasive hemodynamic monitoring and the higher risks of thromboembolic and infectious complications.3 Therefore, central venous access by the internal jugular vein or subclavian vein may be preferred in the ED setting.
However, there are well-documented risks and complications associated with internal jugular vein and subclavian vein catheterization, especially in the urgent or emergency situation.1, 2 Complications for internal jugular vein catheters include carotid artery puncture, hematoma, pneumothorax, brachial plexus injury, and hemothorax.3 The complication rate for central venous catheters (subclavian, internal jugular, femoral) inserted using the traditional landmark technique ranges from 0.5% to 10%.2, 4, 5 In ED patients specifically, the mechanical complications rate (pneumothorax, hematoma, line misplacement, hemothorax) has been quoted as between 10% and 15%.5 Unsuccessful insertion may occur in up to 20% of cases.4 The rates vary, depending on operator experience and patient comorbidities such as coagulopathy and hemodynamic instability.2, 6 Anomalies in anatomy may cause the operator to pass the needle in an inappropriate direction, or the landmark method may fail if the vein has thrombosed.6
Studies in anesthetic, cardiac, and intensive care settings have shown that ultrasonographic guidance for the insertion of central lines, particularly through the internal jugular vein, can lead to a decrease in the number of attempts to successful puncture, a decrease in the rate of complications, and in some cases, a faster insertion time.6, 7, 8, 9, 10, 11, 12, 13, 14, 15 However, there are only limited studies in the literature about ultrasonographically guided central venous access in the ED.1, 16, 17, 18 One study involving catheterization of the internal jugular vein suggested that single-needle-pass punctures and successful venipunctures were improved with ultrasonography, but the study was not randomized and the sample size was small.17 The other larger study by Miller et al,1 based in the ED, was not specific for internal jugular vein catheterization.
The purpose of this study was to determine whether real-time ultrasonographic guidance could improve the success rate, decrease the number of attempts and time to successful puncture, and decrease the number of complications compared to the landmark technique for the insertion of internal jugular vein catheters in an ED setting.
Section snippets
Study Design and Setting
This was a prospective, randomized, clinical trial performed in the ED of a major tertiary teaching hospital with approximately 36,000 presentations a year. The study was approved by the hospital’s ethics committee.
Selection of Participants
All patients presenting to the ED between August 2003 and May 2005 who required central venous access as part of their treatment were considered for the study. Patients were enrolled by the emergency physician or registrar treating or supervising the patient. The sample was not
Characteristics of Study Subjects
One hundred thirty patients were enrolled in the study; 65 (50%) patients were randomized to the landmark technique and 65 (50%) patients to the ultrasonographic method. The clinical variables and reasons for insertion of the internal jugular vein catheter in both groups are summarized in Table 1, Table 2.
Main Results
The statistical analysis of success rates assumes patients were a simple random sample from the population of potential patients. Given the potential for physicians to induce a cluster
Limitations
There were several limitations to our study. Our study was not blinded, introducing the risk of bias on the part of the operator. Because it was obviously not possible to have a blinded technique, an attempt was made to reduce bias by having the patient enrolled in the study before randomization and the operator chosen before the insertion technique was known.
Assembly bias may have occurred because our sample was nonconsecutive.
With regard to access times, we attempted to standardize the
Discussion
There are only a few studies in the literature about ultrasonographically guided central venous access in the ED.1, 16, 17, 18 Hudson and Rose 16 described 2 patients in whom ultrasonography was used to establish central access through the internal jugular vein in the ED. Hrics et al 17 evaluated the use and success of ultrasonographically assisted central venous catheterization of the internal jugular vein in the ED setting. There were 40 attempts at internal jugular vein catheters in 34
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Supervising editor: Richard M. Levitan, MD
Author contributions: AF conceived the study. JL, AF, and MD designed the trial. JL was responsible for data collection, and MD analyzed the data. JL drafted the manuscript, and MD contributed substantially to its revision. MD takes responsibility for the paper as a whole.
Funding and support: This study did not receive any outside funding or support.
Reprints not available from the authors.