Use of ultrasound to place central lines

CONTEXT: Placement of central venous catheters (CVCs) is an integral part of care for the critically ill patient but is associated with significant morbidity when using the traditional landmark method. The use of real-time ultrasound to guide line placement has been developed in hopes of avoiding this morbidity. OBJECTIVE: The objectives of this article are 2-fold. The first is to determine the relative effectiveness of the use of real-time ultrasound to place CVCs compared with the use of landmarks alone. The second is to discuss the merits of future study to increase the use of this technology. DATA SOURCES: Medline from 1966 to 2001, personal files, 2 prior systematic reviews, and reference lists of selected articles. STUDY SELECTION: Studies were included if: (1) study design was a controlled trial, (2) patients required placement of a CVC, (3) the interventions were real-time ultrasound versus standard landmark-guided line placement, and (4) outcomes included at least 1 of failure to place catheter, success of first attempt, number of attempts, time to catheter placement, or complication rate. DATA SYNTHESIS: Eighteen trials were identified. Pooled results showed a significant reduction in failure rate (risk difference, -.12, 95% confidence interval CI], -.18 to -.06), number of attempts (risk reduction, 1.41, 95% CI, 1.15-1.67), and arterial puncture rate (risk difference, -.07, 95% CI, -.10 to -.03). The number of successful venous cannulations on first attempt were higher using ultrasound (risk difference,.24, 95% CI,.08-.39). No difference was found in time to insertion. Significant heterogeneity of study results was found for most analyses. Subgroup analyses suggested that ultrasound improved outcomes most convincingly using external probes, for internal jugular vein cannulation, and when used by clinicians less experienced at line placement. CONCLUSIONS: Adoption of real-time ultrasound to guide CVC placement has the potential to improve successful line placement and minimized complications. It can improve patient safety. However, there are significant cost concerns and the reported adverse events are generally minor and easy to treat. Before creating study protocols to increase usage of this technology, both current usage and cost effectiveness should be determined.