Comparative Analysis of Ultrasound Guided Central Venous Catheterization Compared to Blind Catheterization

Abstract

Central venous catheterization is performed by the landmark method and ultrasound guided method. The purpose of the study was to compare the success, average number of attempts, average time to return of blood, and complication rate between the two methods.

This was a prospective study done in the Intensive Care Unit of the Acibadem Sistina Clinical Hospital, in Skopje. There were 400 patients in need of central venous catheter and they were prospectively randomized in two groups. The patients randomized in the examined-ultrasound group underwent real-time ultrasound-guided catheterization and the patients randomized in the control-landmark group were catheterized using the landmark method. Internal Jugular, Subclavian and Femoral vein were catheterized in both groups. The Overall success, success on the first attempt, time to the return of blood, number of attempts and complications at the moment of catheterization such as arterial puncture, pneumothorax and hematoma formation were the main outcome measures.

The catheterization using the landmark method was successful in 90.5% of patients, 60.5% of which during the first attempt. The cannulation using real-time ultrasound guidance was successful in 98% of patients with a first pass success of 77%. The complication rate with the landmark method was 14.5% versus 4% with real-time ultrasound guidance p<0.05(p=0.0008).

Real-time ultrasound guidance improves success, decreases number of attempts, decreases average time to the return of blood and reduces mechanical complications rate.

Full text

MASA
МАНУ
CONTRIBUTIONS. Sec. of Med. Sci., XXXVIII 2, 2017
ПРИЛОЗИ. Одд. за мед. науки, XXXVIII 2, 2017
ISSN 1857-9345
UDC: 616.14-089.819.1
ABSTRACT
Introduction:
Central venous catheterization is performed by the landmark method and ultrasound guided meth-
od. The purpose of the study was to compare the success, average number of attempts, average
time to return of blood, and complication rate between the two methods.
Material and Methods:
This was a prospective study done in the Intensive Care Unit of the Acibadem Sistina Clinical
Hospital, in Skopje. There were 400 patients in need of central venous catheter and they were
prospectively randomized in two groups. The patients randomized in the examined-ultrasound
group underwent real-time ultrasound-guided catheterization and the patients randomized in the
control-landmark group were catheterized using the landmark method. Internal Jugular, Subclavian
and Femoral vein were catheterized in both groups. The Overall success, success on the rst attempt,
time to the return of blood, number of attempts and complications at the moment of catheterization
such as arterial puncture, pneumothorax and hematoma formation were the main outcome measures.
Results:
The catheterization using the landmark method was successful in 90.5% of patients, 60.5% of
which during the rst attempt. The cannulation using real-time ultrasound guidance was success-
ful in 98% of patients with a rst pass success of 77%. The complication rate with the landmark
method was 14.5% versus 4% with real-time ultrasound guidance p<0.05(p=0.0008).
Conclusion:
Real-time ultrasound guidance improves success, decreases number of attempts, decreases average
time to the return of blood and reduces mechanical complications rate.
Key words: Landmark, ultrasound, central venous cauterization
Corresponding author: Darko Sazdov, mail:dr.sazdov@gmail.com
1 Clinical Hospital Acibadem-Sistina, Skopje, Department for Intensive Care
2 University Clinic for Traumatology, Orthopedics, Anesthesia, Reanimation and Intensive Care, Skopje
3 European Eye Hospital, Skopje
Darko Sazdov
1
, Marija Jovanovski Srceva
2
, Zorka Nikolova Todorova
3
COMPARATIVE ANALYSIS OF ULTRASOUND GUIDED CENTRAL VENOUS
CATHETERIZATION COMPARED TO BLIND CATHETERIZATION
INTRODUCTION
Central venous catheters (CVC) are reserved for
patients in the intensive care unit, in the operating
theatre, at medical or surgical wards, in elective or
urgent procedures [1], as a part of everyday medical
practice [2, 3]. In the United States, over 5 million
central venous catheters are placed every year [4].
For CVC placement usually internal jugular
vein (on the neck) [5], subclavian vein (under the
clavicle) [6] and femoral vein (under the inguinal
ligament) [6] are used depending on the situa-
tion, need, indication and patient characteristics.
The preferred vein is punctured either by using
the landmark method (when external anatomical
landmarks are used) or by using ultrasound (US).
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108 Darko Sazdov
After the return of the venous blood from the tar-
geted vessel a guidewire is passed through the
needle, the needle is removed and the catheter is
placed over the guidewire into the vein – Seldinger
technique [9].
However, both techniques have some de-
gree of risks for failure and complications. The
landmark method can have a failure rate of 35%
and an overall complication rate of 26% [7, 8].
Different modalities of ultrasound, among other
efforts, have been used in an attempt to reduce
the complication rate and increase the success
rate of central venous catheterization [4, 10, 11].
Ultrasound can be used as static or dynamic. When
static ultrasound is used the targeted vein is visu-
alized on the US monitor and the skin is marked
for the puncture site. The actual catheterization is
performed blindly as with the landmark method.
When dynamic ultrasound is used the whole pro-
cedure is guided by ultrasound control from skin
puncture to guidewire placement [10]. The use of
ultrasound enables visualization of the targeted
venous vessel and its anatomical relationship with
the surrounding structures and with the needle for
catheterization. It allows detection of anatomical
variations like vein and artery transposition and
overlap. The use of ultrasound also, enables vi-
sualization of the correct position of the vein, its
size, patency and eventual thrombosis, which is
especially useful in patients with difcult anatom-
ical characteristics (morbid obesity, cachexia, and
scars on the skin at the puncture site). This allows
the practitioner to choose the best skin puncture
site [11].
Recommendations on the use of ultrasound
for central venous catheterization have been made
by many medical societies and government agen-
cies like the Agency for Healthcare Research and
Quality, the National Institute for Health and Clin-
ical Excellence in the UK, the American Society
of Echocardiography and the Society of Cardio-
vascular Anesthesiologists [10, 12]. Despite these
recommendations, the use of ultrasound for cen-
tral venous catheterization remains low [13]. We
have been using the ultrasound guided method in
our intensive care unit for two years now.
The purpose of this study was to compare
the success rate between ultrasound guided and
landmark based central venous catheterization.
In addition, the study included an analysis of the
average number of attempts, average time to the
return of blood, and the occurrence of mechanical
complications (arterial puncture, pneumothorax
and hematoma formation).
MATERIAL AND METHODS
This was a prospective study done during the
period of 2015 and 2016 in the general intensive
care unit at the Acibadem, Sistina Clinical Hospital
in Skopje. After the approval by the ethical board
at our hospital, a patient consent was obtained.
Four hundred adult (18-70 years old) patients, with
an indication for central venous catheterization
were enrolled for the study. Patients were random-
ly (computer generated randomization) divided
into two groups, group A (n=200) included patients
where for the CVC placement the ultrasound meth-
od was used and group B (n=200) included patients
who underwent CVC insertion with the landmark
technique. For both groups of patients, the internal
jugular, subclavian and femoral veins were used
to get access to the central venous circulation. The
placement of the CVC for each group was done
by the same experienced team and under sterile
technique (sterile cap, mask and gown).
The success rate, time to venous blood return,
and mechanical complications were recorded for
both groups.
A maximum of three attempts were allowed at
the catheter site. An unsuccessful attempt was de-
clared when after skin puncture, needle advance-
ment and needle withdrawal there wasn’t a return
of venous blood from the targeted vein. After three
unsuccessful attempts the procedure was termi-
nated at the given site and declared unsuccessful.
Time was measured from skin puncture to return
of venous blood. Mechanical complications like
arterial puncture, pneumothorax and hematoma
were recorded. A pulsatile ow of bright red blood
from the needle was a sign of arterial puncture.
In such cases the needle was withdrawn from the
skin and manual pressure was applied until hemo-
stasis was achieved. Hematoma formation on the
skin access site bigger than 1 cm in diameter was
recorded. A radiographic examination of the lungs
was made 6 hours after the procedure to check the
catheter’s position and check for pneumothorax.
All patients with subcutaneous emphysema,
undergoing radiation therapy, skin inammation
at the insertion site, fractured clavicle, cardiac
arrest, urgent patients, and patients with raised
intracranial pressure were excluded.
LANDMARK TECHNIQUE
For the landmark method, the site for cath-
eterization was chosen by the doctor doing the
procedure depending on patient characteristics,
anatomical landmarks, indication for catheteriza-
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COMPARATIVE ANALYSIS OF ULTRASOUND GUIDED CENTRAL VENOUS CATHETERIZATION ...
tion, and his/hers experience. The rst choice for
landmark based central venous catheterization in
our institution are the subclavian and jugular veins,
while femoral vein is the second choice [14-16].
Anatomical landmarks for internal jugular
vein catheterization were the medial border of the
sternocleidomastoid muscle and the pulsations of
the carotid artery. Subclavian vein was catheterized
1 centimeter below the junction of the medial and
the lateral two thirds of the clavicle bone, and the
femoral vein was catheterized two centimeters be-
low the inguinal ligament and 1 centimeter medial
of the palpable pulsations of the femoral artery [6].
For the jugular and subclavian vein catheter-
ization the patients were placed in Trendelenburg
position of 15 degrees and for femoral vein cath-
eterization patients were placed in a horizontal
position. The skin at the entry site was disinfected
with 2% solution of chlorhexidine or 1% solution
of betadine and was covered with sterile drape.
The catheterization needle attached to a 5ml sy-
ringe with 2ml physiological solution was slowly
advanced to the expected position of the target-
ed vein with continuous aspiration applied with
the syringe clip. After the return of the venous
blood in the syringe the needle guide was inserted
and the procedure was nished according to the
Seldinger’s technique [9].
US METHOD
The jugular vein was the rst choice for ultra-
sound guided central venous catheterization and
the subclavian and femoral veins were the second
choice [10]. An ultrasound exam was done before
the procedure to determine the vein’s position, its
caliber and patency [17].
For the jugular vein catheterization, the ultra-
sound probe was applied on the lateral aspect of
the neck. For the subclavian vein the probe was
placed on the anterolateral aspect of the thorax 1
centimeter below the clavicle and for the femoral
vein on the anterolateral aspect of the femoral
region 2 centimeters below the inguinal ligament
[6, 12]. A non-compressible vein (thrombosis) or
a vein diameter below 0.5cm was an indication
to use the same vein at the contralateral side or
to use a different central vein for catheterization.
Patient preparation and positioning was the
same as for patients in the landmark group.
For the ultrasound guided catheterization, an
ultrasound machine General Electric e-Logic and
a linear transducer 5 to 10 MHz was used. Asepsis
was achieved with sterile gel and sterile cover for
the probe, Figure 1. Figure 2 and Figure 3 show
Figure 3. Short axis out-of-plane view of the subclavian vein
and the needle Signicant anatomic structures are marked:
PM-pectoralis muscle, n-branches of plexus brachialis, C-clav-
icle, pleura, SCA-subclavian vein, SCA-subclavian artery, the
arrow shows the needle before entering the blood vessel.
Figure 2. Short axis out-of-plane view of the jugular vein and
the needle; the arrow is pointing at the needle seen as a hy-
perechoic dot on the ultrasound screen inside the lumen of the
jugular vein; SCM-sternocleidomastoid muscle; IJV-Internal
Jugular Vein; CA-carotid artery.
Figure 1. Ultrasound guided catheterization of the jugular vein
with a short axis out-of-plane approach
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110 Darko Sazdov
the monitor image of the short axis out of plane
view of the targeted vessel and the needle.
The ultrasound probe was applied in a 90-de-
gree angle to the long axis of the targeted vessel
and the needle for catheterization was inserted at
the middle of the long axis of the probe to achieve
a short axis out of plane approach [10]. With this
approach the needle is shown as a hyperechoic dot
on the US-monitor while the venous and arterial
vessels are shown as hypoechoic oval and circular
structures with well-dened borders. The vein is
centered into the middle of the screen with slight
movement of the probe and the needle was care-
fully advanced under ultrasound guidance until
the anterior wall is punctured and venous blood
is aspirated in the syringe connected to it. After
documenting the return of the venous blood the
Seldinger’s technique for catheterization was used.
RESULTS
The study included 400 patients divided into
two groups. The average age of the patients in
the ultrasound group was 59.3 years and the av-
erage age of the patients in the landmark group
was 59.2 years. The statistical difference between
the groups for the average age is not signicant.
(Table 1) Male and female patients were equally
represented in both groups. Both groups were ho-
mogenous regarding gender and age.
In the ultrasound group the jugular vein was
catheterized in 41% of patients, the subclavian
vein in 35.5% and the femoral vein in 23.5% of
the patients.
The most commonly accessed vein in the
landmark group was the subclavian vein in 45.5%
of patients. The jugular vein was catheterized in
43%, while the femoral vein was accessed in
11.5% of patients.
The difference between the groups for vein
representation is statistically signicant for the
subclavian and femoral vein p<0.05 (p=0.0416,
and p=0.0016) (Table 2).
In the ultrasound group 196/200 (98%) of
patients were successfully catheterized with the
ultrasound guided catheterization while the land-
mark method was successful in 181/200 (90.5%)
of patients. The difference test was statistically
signicant for p<0.05 (p=0.0013).
In the ultrasound group the success on rst
attempt was 77% which was a signicant increase
from 60.5% achieved in the landmark group
p<0.05 (p=0.0032).
The average number of attempts for successful
catheterization in the ultrasound group was 1.25
(standard deviation=0.511), and in the landmark
group it was 1.52 (Standard deviation=0.810).
There was a statistically signicant difference in
the average number of attempts between groups
for p<0.05 (t-test=4.009, p=0.000074).
On the average 13.6 seconds (standard devi-
ation=11.6) were needed from skin puncture to
blood return in the ultrasound group. The time was
signicantly increased in the landmark group 20.1
(standard deviation=20.3) due to the increased
number of attempts and increased complication
rate (t=3.85, p=0.000139) (Table 3).
DISCUSSION
Central venous catheterization is commonly
performed in the intensive care unit. According to
the study on prevalence of infection in the Euro-
pean intensive care units, 78% of patients have a
central venous access device [18]. Central venous
catheters are placed for uid and medication ad-
ministration, pacing, hemodialysis and for hemo-
dynamic monitoring [19].
Traditionally for the landmark method, visi-
ble and palpable external landmarks with known
relation with the targeted vessel are used to de-
termine the puncture site on the skin [6]. This
method is associated with complications that re-
sult in increased morbidity, longer hospital stay,
increased expenses and mortality [4]. Nine percent
of patients have abnormal central venous anatomy
that makes central venous catheterization difcult
and increase the risk of failure and complications
[20]. The percent of failure with the landmark
method can be as high as 35% [8]. Complications
are usually divided to early which occur during
the catheterization and are mostly mechanical and
late mostly infective and thrombotic in nature.
The frequency of mechanical complications range
between 5% and 19% [7]. Most common compli-
cation during jugular and femoral vein catheter-
ization is arterial puncture. Pneumothorax is the
most common complication during subclavian
vein catheterization [4].
The use of direct ultrasound for central ve-
nous catheterization enables direct visualization
of the targeted vein and surrounding structures
before and during the catheterization. Studies
show increased success and reduced complica-
tion rate with the use of direct ultrasound [17,
19, 21]. Some studies report that two dimension-
al ultrasound offers minimal advantage in safety
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COMPARATIVE ANALYSIS OF ULTRASOUND GUIDED CENTRAL VENOUS CATHETERIZATION ...
and quality during central venous catheterization
of the subclavian vein (lower percent of arterial
puncture and hematoma) and femoral vein (higher
rst pass success) [11]. The results of our study
show that the ultrasound guided method is supe-
rior for central venous catheterization in intensive
care patients compared to the landmark method.
The overall success with the landmark method
was 90.5% which is in concordance with other
reports where the overall success ranges between
85% and 100% [8, 17, 19, 21, 22]. In our study,
in 60.5% of the patients the catheterization was
achieved in the rst attempt. The incidence of
arterial puncture with the landmark method was
8%, while the incidence of hematoma formation
and pneumothorax was 16% and 3.955% respec-
tively. The incidence of these complications in the
literature ranges between 10.6%-13% for arterial
puncture [19, 23, 24], hematoma formation 4%-
8.4% [19, 23] and pneumothorax 1%-6.6% [25-
27]. The higher rate of hematoma formation in our
study appears as a result of the lower threshold of
hematoma reporting of 1cm in diameter.
The use of dynamic ultrasound resulted in
higher overall success, the higher rst pass suc-
cess, shorter average time to the return of blood,
the lower average number of attempts and the
lower percent of mechanical complications, arteri-
al puncture, pneumothorax and hematoma. These
results correspond with other reports on the effect
of dynamic ultrasound on the central venous cath-
eterization [10, 17, 19, 21, 28-30]. The study by
Karakitsos et al. (19) reports an overall success of
100% using ultrasound and 94.5% with the land-
mark technique. Fragou et al. [17] also achieved a
success of 100% in the ultrasound group whereas
Table 1. Average patient’s age and side of the catheterization.
Group B
Ultrasound
(n=200)
Group A
Control group
(n=200) t - value p value
Age
(M/±SD) 59.3 ± 12.42767 59.2 ± 12.83163 -0.06729 0.94638
Right side
(Number, %) 136 / 68% 168 / 84%
p=0.0002
Left side
(Number, %) 64 / 32% 32 / 16%
Table 2. Vein representation in both groups
Central vein Control Ultrasound
Count Percent (%) Count Percent (%)
Jugular vein 86 43.0 82 41
Subclavian vein 91 45.5 71 35.5
Femoral vein 23 11.5 47 23.5
overall 200 100 200 100
Table 3. Results of the punctures and complications in the study groups
Group B
Ultrasound-Guided
(n=200)
Group A
Landmark
(n=200)
p value
Success
Number / percent 196 / 98% 181 / 90.5% 0.0013
First attempt success
Number / percent 154 / 77% 121 / 60.5% 0.0032
Average number of attempts
(M/±SD) 1.25 ± 0.511 1.52 ± 0.810 t=4.009
p=0.000074
Average time
(M/±SD) 13.6 ± 11.6 20.1 ± 20.3 t=3.85
p=0.000139
Arterial puncture
Number / percent 2 / 1% 16 / 8% p=0.0007
Pneumothorax
Number / percent 0 / 0% 7 / 3.955% p=0.0259
Hematoma
Number / percent 8 / 4% 20 / 10% p=0.018694
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112 Darko Sazdov
the success in the landmark group was 87.5%.
Prabhu et al. [19] got a success rate of ultrasound
catheterization of 98.2% compared to 89.1% of
the landmark group. Regarding the complications,
the study by Karakitsos [19] reports an arterial
puncture of 1.1%, hematoma of 0.4% and pneu-
mothorax of 0% compared to 10.6%, 8.4% and
2.4% respectively, with the landmark technique.
Neither arterial puncture nor pneumothorax were
recorded in the ultrasound group in the study by
Fragou et al. [17] as in our study.
All doctors in the study had a similar experi-
ence with the ultrasound method so a conclusion
regarding the inuence of experience on the suc-
cess and complication rate during this procedure
could not be made. The short axis out of plane
approach was used in all catheterizations. During
this approach the needle tip is not always seen so
there is a greater risk of damage of deeper struc-
tures (10, 31). Even so, no pneumothorax was
seen in our patients.
CONCLUSION
Ultrasound guidance during the central ve-
nous catheterization in intensive care patients
increases overall, and the rst pass success com-
pared to the landmark method. At the same time
the average time for return of the blood and the
average number of attempts, as well as the arterial
puncture, pneumothorax and hematoma formation
are signicantly reduced.
Competing interests
The authors declare that they have no com-
peting interests.
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114 Darko Sazdov
СПОРЕДБЕНА АНАЛИЗА НА УЛТРАЗВУЧНО ВОДЕНА ЦЕНТРАЛНА
ВЕНСКА КАТЕТЕРИЗАЦИЈА НАСПРОТИ СЛЕПА КАТЕТЕРИЗАЦИЈА
Дарко Саздов
1
, Марија Јовановски Срцева
2
, Зорка Николова Тодорова
3
1
Клиничка болница Аџибадем-Систина, Скопје, Оддел за Интензивно Лекување
2
Универзитетска Клиника за Трауматологија Ортопедија Анестезија Реанимација
и Интензивно Лекување, Скопје
3
Европска Очна Болница, Скопје
Резиме
Вовед:
Централна венска катетеризација секојдневно се спроведува со слепа или ултразвучно водена
метода. Целта е да се споредат успехот, просечното време до добивање крв, просечниот број обиди,
и механичките компликации при катетеризација меѓу овие две методи.
Материјал и Методи:
Во проспективна студија беа вклучени 400 возрасни пациенти од единицата за интензивно
лекување (ЕИЛ) во Клиничката болница Аџибадем Систина, Скопје. Пациентите во испитуваната
група беа катетеризирани со ултразвучно водена метода. Кај пациентите во контролната група цен-
трален венски катетер беше поставен со помош на надворешни обележја т.н.слепа катетеризација.
Кај двете групи пациенти беа пунктирани внатрешната југуларна, потклучната и феморалната вена
и следени, успешноста, времето од боцкање на кожата до добивање крв, бројот на убоди до успешна
катетеризација и појава на компликации во моментот на катетеризација.
Резултати:
Катетеризацијата со помош на слепата метода беше успешна кај 90,5% од пациентите, и тоа
кај 60,5% при првиот обид, а успешноста со ултравучно водената метода беше 98% и тоа 77% при
првиот обид. Компликации во контролната група се среќаваат кај 14,5% пациенти, наспроти 4%
во испитуваната група што претставува статистички сигнификантна разлика за p<0.05 (p=0.0008)
Заклучок:
Ултразвучно водената метода за пристап до централната венска циркулација во интензивна нега,
ја зголемува успешноста, го намалува бројот на обиди и потребното време за катетеризација како
и механичките компликации асоцирани со оваа постапка.
Клучни зборови: Слепа катетеризација, ултразвук, централна венa
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