Systematic review: is real-time ultrasonic-guided central line placement by ED physicians more successful than the traditional landmark approach?
BACKGROUND
The superiority of ultrasonic-guided compared with landmark-guided central venous catheter (CVC) placement is not well documented in the Emergency Department.


OBJECTIVE
To systematically review the literature comparing success rates between ultrasonic- and landmark-guided CVC placement by ED physicians.


METHODS
PubMed and EMBASE databases were searched for randomised controlled trials from 1965 to 2010 using a search strategy derived from the following PICO formulation:


METHODS
Adults requiring emergent CVC placement except during cardiopulmonary resuscitation.


METHODS
CVC placement using real-time ultrasonic guidance. Comparator: CVC placement using anatomical landmarks.


RESULTS
Comparison of success rates of CVC placement between ultrasonic- versus landmark-guided techniques.


METHODS
Success rates between CVC placement methods using a Forest Plot (95% CI) calculated by Review Manager Version 5.0.


RESULTS
Search identified 944 articles of which 938 were excluded by title/abstract relevance, two not randomised, one cardiac arrest, one no landmark control, one success rate not calculated. A single study of 130 patients (65 ultrasonic- vs 65 landmark-guided) selected for internal jugular vein placement remained. Successful internal jugular CVC was significantly (p=0.02) more likely in the ultrasound-guided (93.9%) compared with landmark-guided (78.5%) techniques with an OR of 1.2 (95% CI 1.0 to 1.4). Complications rates were significantly (p=0.04) lower in ultrasonic (4.6%) versus landmark (16.9%) technique, OR=3.7 (95% CI 1.1 to 12.5).


CONCLUSIONS
Only one single high quality study illustrating that ED ultrasound- versus landmark-guided internal jugular catheter placement had higher success rates with lower complication rates.
Department of Emergency Medicine, Kings County Hospital/State University of New York Downstate Medical Center, Brooklyn, New York 11203, USA.
Ninfa
N
Mehta
Walter Wallace
WW
Valesky
Allysia
A
Guy
Richard
R
Sinert
D061605:Administration, Intravenous / Q000379:methods; D000328:Adult; D059925:Anatomic Landmarks; D002405:Catheterization, Central Venous / Q000379:methods* / Q000706:statistics & numerical data; D004635:Emergency Medicine / Q000379:methods*; D004636:Emergency Service, Hospital; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D018084:Ultrasonography, Interventional