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Ultrasonographic Guidance for Internal Jugular Vein Cannulation: An Educational Imperative, A Desirable Practice Alternative
IMAGING/EDITORIAL
Ultrasonographic Guidance for Internal Jugular Vein Cannulation: An Educational Imperative, A Desirable Practice Alternative Alfredo Sabbaj, MD Jerris R. Hedges, MD, MS
From the Department of Emergency Medicine (Sabbaj, Hedges), and the Dean’s Office, School of Medicine (Hedges), Oregon Health & Science University, Portland, OR.
0196-0644/$-see front matter Copyright © 2006 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2006.04.015
SEE RELATED ARTICLE, P. 540. [Ann Emerg Med. 2006;48:548-550] In this issue of Annals, Leung et al1 present data comparing real-time ultrasonographic guidance and the traditional landmark technique for the insertion of internal jugular vein catheters in an emergency department (ED) setting. All operators completed a 2-hour training session before the start of the study. Ultrasonography-guided insertion of internal jugular lines was associated with higher successful insertion and lower complication rates than the traditional landmark technique. Catheterization of the internal jugular vein was successful in 61 of 65 (93%) patients in the ultrasonographic group and in 51 of 65 (78.5%) in the landmark group. There was also a higher first attempt success rate with ultrasonography, 50 of 61 (82%), than with the landmark technique, 36 of 51 (70.6%). Time intervals to venipuncture and successful insertion were not significantly different. Finally, the study revealed that the ultrasonographyguided group had fewer complications than the landmark technique: 3 (4.6%) versus 11 (16.9%). Given these results, the authors suggest that in EDs with ultrasonography available, ultrasonography-guided insertion of internal jugular vein catheters should become the standard of care.1 Catheterization of the internal jugular vein is one of the more common central venous approaches used in the ED but also one of the more challenging because of variable deep and surface anatomy and the proximity of important structures (eg, carotid artery, cervical plexus, apex of the lung). The frequency of complications for the internal jugular vein approach to central venous catheterization is as high as 11.8%.2 Techniques that enhance procedural performance and improve patient safety with internal jugular vein catheterization are clearly desirable. This commentary briefly reviews the development of ultrasonographic guidance for internal jugular vein catheterization, emphasizes the contributions of Leung et al,1 notes factors that may limit the universal application of ultrasonographic guidance, and reflects on the next steps in the development of a practice standard for internal jugular vein catheterization. 548 Annals of Emergency Medicine
Legler and Nugent3 first described the use of ultrasonography for localizing the internal jugular vein before catheterization in 1984. In 1986, Yonei et al4 described the technique of 2-dimensional real-time ultrasonography, and in 1997 Hudson and Rose5 reported on 2-dimensional ultrasonography-guided internal jugular venous access in the ED. Since then, there have been at least 4 key articles in the emergency medicine literature addressing ultrasonographic guidance for central venous catheterization.6-9 Like the study by Leung et al,1 these studies report greater success using ultrasonography versus landmark guidance for venous access.6-9 Articles in the anesthesiology, critical care, nephrology, and surgery literature have cited similar results. The current ED study adds to previous studies because it is large (130 patients, 13 providers), prospective, randomized, used real-time imaging, and focused only on catheterization of the internal jugular vein. The benefits of ultrasonographic guidance are convincing, but in this study, as in previous studies, there were some significant limitations. Critically ill patients who couldn’t consent were excluded, along with blunt trauma patients. Although the study found no increase in time to catheterization with ultrasonography, insertion times did not include setup of the ultrasonographic machine. Several practice guidelines already recommend ultrasonography use for central line placement. A meta-analysis report for the Agency for Healthcare Research and Quality in 2001 suggested that real-time ultrasonographic guidance could reduce complication rates but cautioned that benefits “may not accrue until after the initial [ultrasonography] learning period for operators already experienced in the landmark techniques.”10 This report states that the greatest benefit “may apply to the novice or inexperienced operator and for all operators in high-risk situations.” However, the author also noted that there “are no studies comparing the impact of central venous access insertion with ultrasound guidance on overall patient outcomes (eg, mortality, length of stay).” Another meta-analysis, commissioned by the British National Institute for Clinical Excellence, included 18 clinical trials (1,646 participants).11,12 Internal jugular vein access with Volume , . : November
Sabbaj & Hedges 2-dimensional ultrasonography was more effective than the landmark technique in adults, with lower technical failure rates (overall and on the first attempt), a reduction in complications, and faster access. The National Institute for Clinical Excellence committee recommended that 2-dimensional imaging ultrasonographic guidance be the preferred method for internal jugular vein catheterization for adults and children in “elective situations.” The committee also suggested that 2-dimensional imaging ultrasonographic guidance be considered in most clinical situations in which internal jugular line insertion is necessary, whether the situation is elective or an emergency. Finally, the report also stated that although 2-dimensional ultrasonographic imaging guidance in internal jugular line placement may eventually become the routine method for placing these lines, the landmark method would remain important in some circumstances, ie, emergency situations, when ultrasonographic equipment or expertise might not be immediately available. Consequently, the National Institute for Clinical Excellence Committee thought it important that operators maintain their ability to use the landmark method and that the method continue to be taught alongside the 2dimensional ultrasonography-guided technique. Since the original National Institute for Clinical Excellence study in 2002, a follow-up survey evaluating the impact of the report on anesthesiologists and their implementation of ultrasonography for internal jugular line placement was published.13 The survey demonstrated that anesthesiologists were polarized in their opinion of the National Institute for Clinical Excellence recommendations for elective situations, with 41% of respondents disagreeing and 36% agreeing with them. Given a similar spectrum of ultrasonography-guided internal jugular vein catheterization training and experience for practicing emergency physicians, it is likely that emergency physicians would have equally polarized opinions, should ultrasound guidance be a priori labeled as a standard of care. Those with training and experience in this adjunct will likely embrace it (given the appropriate patient and practice scenario), whereas those without the training and experience will question whether adding ultrasonography to their practice will translate to improved outcomes in their hands. Clinical practice is changed through a combination of clinical reports, controlled studies, consensus opinions, and educational programs. The clinical studies have been done and appropriate practice guidelines have been promulgated, but educational and logistical hurdles remain before a practice paradigm shift and the universal use of ED ultrasonography. Even if ultrasonographic machines become universally available, tens of thousands of emergency physicians must be formally trained to use ultrasonography guidance for jugular line placement. Landmark-guided internal jugular line placement skills will remain useful in extreme time-critical situations when acquiring and starting up the ultrasonographic machine may incur delay. There will be other instances in which the landmark technique will also be needed, given the potential for equipment Volume , . : November
Ultrasonographic Guidance for Internal Jugular Vein Cannulation failure, temporary location of the machine outside of the ED, or simultaneous need for the same machine within the ED. The study by Leung et al1 strengthens the rationale for programs to provide training in ultrasonography such that residents and staff become facile in image-guided procedures. Efforts to extend this training to hospitals without emergency medicine residency programs must also be dramatically increased. Five years ago, the American College of Emergency Physicians produced guidelines for ultrasonographic training and indications for use by emergency physicians and noted the potential role of ultrasonography for augmenting procedures.14 The study by Leung et al1 provides further evidence of improved patient care. It adds more justification for the significant economic and educational investments that are required. As emergency physicians acquire additional training and experience, ultrasonography-guided venous catheterization will become increasingly applied. Ultrasonography-guided internal jugular line placement will undoubtedly become the rule (rather than the exception) in relatively stable ED patients, but for the reasons outlined in this commentary, it is premature to universally accept the technique as the “new standard of care” for the ED. Supervising editor: Richard M. Levitan, MD Funding and support: The authors report this study did not receive any outside funding or support. Publication dates: Available online June 14, 2006. Reprints not available from the authors. Address for correspondence: Jerris R. Hedges, MD, MS, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098; 503-494-8220, fax 503-494-3400; E-mail [email protected].
REFERENCES 1. Leung J, Finckh A, Duffy M. Real-time ultrasonography-guided internal jugular vein catheterization in the emergency department increases success rates and reduces complications: a randomized, prospective study. Ann Emerg Med. 2006;48:540547. 2. McGee D, Gould MK. Preventing complications of central venous catheterizations. N Engl J Med. 2003;348:1123-1133. 3. Legler D, Nugent M. Doppler localization of the internal jugular vein facilitates central venous catheterization. Anesthesiology. 1984;60:481-482. 4. Yonei A, Nonoue T, Sari A. Real-time ultrasonic guidance for percutaneous puncture of the internal jugular vein. Anesthesiology. 1986;64:830-831. 5. Hudson PA, Rose JS. Real-time ultrasound guided internal jugular vein catheterization in the emergency department. Am J Emerg Med. 1997;15:79-82. 6. Miller A, Roth BA, Mills TJ, et al. Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Acad Emerg Med. 2002;9:800-805. 7. Hrics P, Wilber S, Blanda MP, et al. Ultrasound-assisted internal jugular vein catheterization in the ED. Am J Emerg Med. 1998;16: 401-403.
Annals of Emergency Medicine 549
Ultrasonographic Guidance for Internal Jugular Vein Cannulation 8. Hilty W, Hudson P, Levitt AM. Real-time ultrasound guided femoral vein catheterization during cardiopulmonary resuscitation. Ann Emerg Med. 1997;29:331-336. 9. Milling T, Holden C, Melniker L, et al. Randomized controlled trial of single-operator vs. two-operator ultrasound guidance for internal jugular central venous catheterization. Acad Emerg Med. 2006;13:245-247. 10. Rothschild JM. Ultrasound guidance of central vein catheterization. In: Shojania KG, Duncan BW, McDonald KM, et al, eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices: AHRQ Publication 01-E058: Evidence Report/ Technology Assessment, Number 43. Rockville, MD: Agency for Healthcare Research and Quality, US Department of Health and Human Services; 2001. 11. National Institute for Clinical Excellence. Guidance on the Use of
Sabbaj & Hedges Ultrasound Locating Devices for Placing Central Venous Catheters. London, England: NICE; 2002. NICE Technology Appraisal No. 49. 12. Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices for central venous catheterization: meta-analysis. BMJ. 2003;327:361-367. 13. Howard S. A survey measuring the impact of the NICE guidance 49: the use of ultrasound locating devices for placing central venous catheters. Abacus International Survey, July 2004. Available at http://www.abacusint.com/downloads/ CVC_Placement_Abacus_International.pdf. Accessed May 26, 2006. 14. American College of Emergency Physicians. American College of Emergency Physicians Policy Statement: Emergency Ultrasound Guidelines. Dallas, TX: American College of Emergency Physicians; 2001.
NEW RESIDENT FELLOWS ANNOUNCED Kalev Freeman, MD, PhD, of Boston Medical Center; Anna Olson, MD, of Denver Health Medical Center; and Spencer G. Nabors, MD, MPH, of Kings County Hospital, have been selected as Annals of Emergency Medicine Resident Fellows for 2006-2007. Dr. Freeman is entering his senior year as a resident at Boston University School of Medicine’s emergency medicine residency program. He received his MD from the University of Colorado School of Medicine and his PhD in molecular, cellular, and developmental biology from the University of Colorado.
Dr. Olson is entering her senior year as a resident at the Denver Health Residency in Emergency Medicine program. She received her MD from Upstate Medical University, State University of New York at Syracuse, NY.
Dr. Nabors is entering his third year of combined residency in Emergency Medicine and Internal Medicine at SUNY Downstate, College of Medicine. He received his MD from SUNY Downstate School of Medicine. He also received his MPH in health policy and management from Columbia University and an MA in Philosophy with a concentration in Bio-Clinical Ethics from New York University.
Drs. Freeman, Olson, and Nabors took the place of Resident Fellow Troy E. Madsen, MD, at the conclusion of his term in October 2006.
550 Annals of Emergency Medicine
Volume , . : November
Ultrasonographic Guidance for Internal Jugular Vein Cannulation: An Educational Imperative, A Desirable Practice Alternative Alfredo Sabbaj, MD Jerris R. Hedges, MD, MS
From the Department of Emergency Medicine (Sabbaj, Hedges), and the Dean’s Office, School of Medicine (Hedges), Oregon Health & Science University, Portland, OR.
0196-0644/$-see front matter Copyright © 2006 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2006.04.015
SEE RELATED ARTICLE, P. 540. [Ann Emerg Med. 2006;48:548-550] In this issue of Annals, Leung et al1 present data comparing real-time ultrasonographic guidance and the traditional landmark technique for the insertion of internal jugular vein catheters in an emergency department (ED) setting. All operators completed a 2-hour training session before the start of the study. Ultrasonography-guided insertion of internal jugular lines was associated with higher successful insertion and lower complication rates than the traditional landmark technique. Catheterization of the internal jugular vein was successful in 61 of 65 (93%) patients in the ultrasonographic group and in 51 of 65 (78.5%) in the landmark group. There was also a higher first attempt success rate with ultrasonography, 50 of 61 (82%), than with the landmark technique, 36 of 51 (70.6%). Time intervals to venipuncture and successful insertion were not significantly different. Finally, the study revealed that the ultrasonographyguided group had fewer complications than the landmark technique: 3 (4.6%) versus 11 (16.9%). Given these results, the authors suggest that in EDs with ultrasonography available, ultrasonography-guided insertion of internal jugular vein catheters should become the standard of care.1 Catheterization of the internal jugular vein is one of the more common central venous approaches used in the ED but also one of the more challenging because of variable deep and surface anatomy and the proximity of important structures (eg, carotid artery, cervical plexus, apex of the lung). The frequency of complications for the internal jugular vein approach to central venous catheterization is as high as 11.8%.2 Techniques that enhance procedural performance and improve patient safety with internal jugular vein catheterization are clearly desirable. This commentary briefly reviews the development of ultrasonographic guidance for internal jugular vein catheterization, emphasizes the contributions of Leung et al,1 notes factors that may limit the universal application of ultrasonographic guidance, and reflects on the next steps in the development of a practice standard for internal jugular vein catheterization. 548 Annals of Emergency Medicine
Legler and Nugent3 first described the use of ultrasonography for localizing the internal jugular vein before catheterization in 1984. In 1986, Yonei et al4 described the technique of 2-dimensional real-time ultrasonography, and in 1997 Hudson and Rose5 reported on 2-dimensional ultrasonography-guided internal jugular venous access in the ED. Since then, there have been at least 4 key articles in the emergency medicine literature addressing ultrasonographic guidance for central venous catheterization.6-9 Like the study by Leung et al,1 these studies report greater success using ultrasonography versus landmark guidance for venous access.6-9 Articles in the anesthesiology, critical care, nephrology, and surgery literature have cited similar results. The current ED study adds to previous studies because it is large (130 patients, 13 providers), prospective, randomized, used real-time imaging, and focused only on catheterization of the internal jugular vein. The benefits of ultrasonographic guidance are convincing, but in this study, as in previous studies, there were some significant limitations. Critically ill patients who couldn’t consent were excluded, along with blunt trauma patients. Although the study found no increase in time to catheterization with ultrasonography, insertion times did not include setup of the ultrasonographic machine. Several practice guidelines already recommend ultrasonography use for central line placement. A meta-analysis report for the Agency for Healthcare Research and Quality in 2001 suggested that real-time ultrasonographic guidance could reduce complication rates but cautioned that benefits “may not accrue until after the initial [ultrasonography] learning period for operators already experienced in the landmark techniques.”10 This report states that the greatest benefit “may apply to the novice or inexperienced operator and for all operators in high-risk situations.” However, the author also noted that there “are no studies comparing the impact of central venous access insertion with ultrasound guidance on overall patient outcomes (eg, mortality, length of stay).” Another meta-analysis, commissioned by the British National Institute for Clinical Excellence, included 18 clinical trials (1,646 participants).11,12 Internal jugular vein access with Volume , . : November
Sabbaj & Hedges 2-dimensional ultrasonography was more effective than the landmark technique in adults, with lower technical failure rates (overall and on the first attempt), a reduction in complications, and faster access. The National Institute for Clinical Excellence committee recommended that 2-dimensional imaging ultrasonographic guidance be the preferred method for internal jugular vein catheterization for adults and children in “elective situations.” The committee also suggested that 2-dimensional imaging ultrasonographic guidance be considered in most clinical situations in which internal jugular line insertion is necessary, whether the situation is elective or an emergency. Finally, the report also stated that although 2-dimensional ultrasonographic imaging guidance in internal jugular line placement may eventually become the routine method for placing these lines, the landmark method would remain important in some circumstances, ie, emergency situations, when ultrasonographic equipment or expertise might not be immediately available. Consequently, the National Institute for Clinical Excellence Committee thought it important that operators maintain their ability to use the landmark method and that the method continue to be taught alongside the 2dimensional ultrasonography-guided technique. Since the original National Institute for Clinical Excellence study in 2002, a follow-up survey evaluating the impact of the report on anesthesiologists and their implementation of ultrasonography for internal jugular line placement was published.13 The survey demonstrated that anesthesiologists were polarized in their opinion of the National Institute for Clinical Excellence recommendations for elective situations, with 41% of respondents disagreeing and 36% agreeing with them. Given a similar spectrum of ultrasonography-guided internal jugular vein catheterization training and experience for practicing emergency physicians, it is likely that emergency physicians would have equally polarized opinions, should ultrasound guidance be a priori labeled as a standard of care. Those with training and experience in this adjunct will likely embrace it (given the appropriate patient and practice scenario), whereas those without the training and experience will question whether adding ultrasonography to their practice will translate to improved outcomes in their hands. Clinical practice is changed through a combination of clinical reports, controlled studies, consensus opinions, and educational programs. The clinical studies have been done and appropriate practice guidelines have been promulgated, but educational and logistical hurdles remain before a practice paradigm shift and the universal use of ED ultrasonography. Even if ultrasonographic machines become universally available, tens of thousands of emergency physicians must be formally trained to use ultrasonography guidance for jugular line placement. Landmark-guided internal jugular line placement skills will remain useful in extreme time-critical situations when acquiring and starting up the ultrasonographic machine may incur delay. There will be other instances in which the landmark technique will also be needed, given the potential for equipment Volume , . : November
Ultrasonographic Guidance for Internal Jugular Vein Cannulation failure, temporary location of the machine outside of the ED, or simultaneous need for the same machine within the ED. The study by Leung et al1 strengthens the rationale for programs to provide training in ultrasonography such that residents and staff become facile in image-guided procedures. Efforts to extend this training to hospitals without emergency medicine residency programs must also be dramatically increased. Five years ago, the American College of Emergency Physicians produced guidelines for ultrasonographic training and indications for use by emergency physicians and noted the potential role of ultrasonography for augmenting procedures.14 The study by Leung et al1 provides further evidence of improved patient care. It adds more justification for the significant economic and educational investments that are required. As emergency physicians acquire additional training and experience, ultrasonography-guided venous catheterization will become increasingly applied. Ultrasonography-guided internal jugular line placement will undoubtedly become the rule (rather than the exception) in relatively stable ED patients, but for the reasons outlined in this commentary, it is premature to universally accept the technique as the “new standard of care” for the ED. Supervising editor: Richard M. Levitan, MD Funding and support: The authors report this study did not receive any outside funding or support. Publication dates: Available online June 14, 2006. Reprints not available from the authors. Address for correspondence: Jerris R. Hedges, MD, MS, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098; 503-494-8220, fax 503-494-3400; E-mail [email protected].
REFERENCES 1. Leung J, Finckh A, Duffy M. Real-time ultrasonography-guided internal jugular vein catheterization in the emergency department increases success rates and reduces complications: a randomized, prospective study. Ann Emerg Med. 2006;48:540547. 2. McGee D, Gould MK. Preventing complications of central venous catheterizations. N Engl J Med. 2003;348:1123-1133. 3. Legler D, Nugent M. Doppler localization of the internal jugular vein facilitates central venous catheterization. Anesthesiology. 1984;60:481-482. 4. Yonei A, Nonoue T, Sari A. Real-time ultrasonic guidance for percutaneous puncture of the internal jugular vein. Anesthesiology. 1986;64:830-831. 5. Hudson PA, Rose JS. Real-time ultrasound guided internal jugular vein catheterization in the emergency department. Am J Emerg Med. 1997;15:79-82. 6. Miller A, Roth BA, Mills TJ, et al. Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Acad Emerg Med. 2002;9:800-805. 7. Hrics P, Wilber S, Blanda MP, et al. Ultrasound-assisted internal jugular vein catheterization in the ED. Am J Emerg Med. 1998;16: 401-403.
Annals of Emergency Medicine 549
Ultrasonographic Guidance for Internal Jugular Vein Cannulation 8. Hilty W, Hudson P, Levitt AM. Real-time ultrasound guided femoral vein catheterization during cardiopulmonary resuscitation. Ann Emerg Med. 1997;29:331-336. 9. Milling T, Holden C, Melniker L, et al. Randomized controlled trial of single-operator vs. two-operator ultrasound guidance for internal jugular central venous catheterization. Acad Emerg Med. 2006;13:245-247. 10. Rothschild JM. Ultrasound guidance of central vein catheterization. In: Shojania KG, Duncan BW, McDonald KM, et al, eds. Making Health Care Safer: A Critical Analysis of Patient Safety Practices: AHRQ Publication 01-E058: Evidence Report/ Technology Assessment, Number 43. Rockville, MD: Agency for Healthcare Research and Quality, US Department of Health and Human Services; 2001. 11. National Institute for Clinical Excellence. Guidance on the Use of
Sabbaj & Hedges Ultrasound Locating Devices for Placing Central Venous Catheters. London, England: NICE; 2002. NICE Technology Appraisal No. 49. 12. Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices for central venous catheterization: meta-analysis. BMJ. 2003;327:361-367. 13. Howard S. A survey measuring the impact of the NICE guidance 49: the use of ultrasound locating devices for placing central venous catheters. Abacus International Survey, July 2004. Available at http://www.abacusint.com/downloads/ CVC_Placement_Abacus_International.pdf. Accessed May 26, 2006. 14. American College of Emergency Physicians. American College of Emergency Physicians Policy Statement: Emergency Ultrasound Guidelines. Dallas, TX: American College of Emergency Physicians; 2001.
NEW RESIDENT FELLOWS ANNOUNCED Kalev Freeman, MD, PhD, of Boston Medical Center; Anna Olson, MD, of Denver Health Medical Center; and Spencer G. Nabors, MD, MPH, of Kings County Hospital, have been selected as Annals of Emergency Medicine Resident Fellows for 2006-2007. Dr. Freeman is entering his senior year as a resident at Boston University School of Medicine’s emergency medicine residency program. He received his MD from the University of Colorado School of Medicine and his PhD in molecular, cellular, and developmental biology from the University of Colorado.
Dr. Olson is entering her senior year as a resident at the Denver Health Residency in Emergency Medicine program. She received her MD from Upstate Medical University, State University of New York at Syracuse, NY.
Dr. Nabors is entering his third year of combined residency in Emergency Medicine and Internal Medicine at SUNY Downstate, College of Medicine. He received his MD from SUNY Downstate School of Medicine. He also received his MPH in health policy and management from Columbia University and an MA in Philosophy with a concentration in Bio-Clinical Ethics from New York University.
Drs. Freeman, Olson, and Nabors took the place of Resident Fellow Troy E. Madsen, MD, at the conclusion of his term in October 2006.
550 Annals of Emergency Medicine
Volume , . : November