We thank Pivalizza et al.
for their comments on the Practice Guidelines for Central Venous Access.1
We acknowledge that data from nonanesthesiologist practitioners were used in our analysis for the utility of real-time ultrasound; however, at this time there is insufficient published evidence that directly assesses whether anesthesiologists perform the task of catheter insertion better – or differently – than physicians in other specialties.
Pivalizza et al.
are correct that the meta-analytic data report heterogeneity for successful internal jugular (IJ) line insertion when using real-time ultrasound guidance as compared with the landmark technique. However, other Category A1 outcomes, such as first-attempt success rate, reduced access time, and decreased rate of arterial puncture, are homogeneous. Regarding hemothorax and pneumothorax, the few randomized controlled trials reporting these outcomes demonstrated lower frequencies for real-time ultrasound.2
In addition to the cited randomized controlled trials, we took into consideration studies with observational findings showing high rates of success when using ultrasound.4–8
Regarding the survey information, Pivalizza et al. neglected to note that more than 75% of the expert consultants agreed, and less than 10% disagreed, that real-time ultrasound should be used with the IJ. Although 48.2% of the randomly selected members agreed, less than 29% disagreed. These findings likely represent a gap in practice between expert practitioners and the random sample of American Society of Anesthesiologists members.
The value and enhanced safety that real-time ultrasound affords is most likely because the operator can look beneath the skin at the anatomy and the relationship of the IJ to the carotid artery. Significant anatomic variation in the relationship of the IJ to the carotid artery has been documented9–12
: 1–5% of the time, the IJ lies medial to the carotid; 3–18% of IJ veins are absent or thrombosed; and in more than half of patients, 50–75% of the surface of the vein overlies the carotid.9–12
These anatomic variables cannot be ascertained via
the landmark approach. Using real-time ultrasound, one can see the anatomy and direct the needle away from the carotid artery.13
Regarding “studies not being scored by traditional methods to assess for bias and scientific rigor,” we use a standard analytical (statistical) approach, and our review process and basic classification system has been in place for more than 20 yr. The review procedures we have in place to control for bias surpass most, if not all, other literature assessment methods in use today.
The American Society of Anesthesiologists guidelines are consistent with other organizations in recommending real-time ultrasound. The Society of Cardiovascular Anesthesiologists, along with the American Society of Echocardiography, recently published their own guidelines, recommending “that properly trained clinicians use real-time ultrasound during IJ cannulation whenever possible to improve cannulation success and reduce the incidence of complications associated with the insertion of large-bore catheters.”14
In 2001, the Agency for Healthcare Research and Quality identified the use of real-time ultrasound guidance during central venous catheter insertion as one of the patient safety practices with the greatest strength of supporting evidence.15
Other societies and organizations have also recommended it.†16
Within our specialty, the Society of Cardiovascular Anesthesiologists, the Society of Critical Care Anesthesiologists, and the Society of Pediatric Anesthesia have endorsed the American Society of Anesthesiologists guidelines.1
We are delighted that the American Society of Anesthesiologists House of Delegates approved these recommendations and hope the members of our specialty will embrace these enhanced safety practices.
We thank Keegan and Mueller for their thoughtful and informative letter detailing the potentially grave risks associated with removal of central venous catheters. In our guidelines, we were explicitly focused on the events and practices to improve safety at the time of central venous catheter placement. Their letter serves to remind all of us that there is a comprehensive set of considerations for maintenance and access of indwelling central lines. Although these issues were beyond the scope of our endeavor, we will add them to the list of potential topics to be included in a future update to the guidelines.
Stephen M. Rupp, M.D.,* Jeffrey L. Apfelbaum, M.D., Richard T. Connis, Ph.D., David G. Nickinovich, Ph.D.; on behalf of the American Society of Anesthesiologists Task Force on Central Venous Access. *Virginia Mason Medical Center, Seattle, Washington. email@example.com
1. American Society of Anesthesiologists Task Force on Central Venous Access, Rupp SM, Apfelbaum JL, Blitt C, Caplan RA, Connis RT, Domino KB, Fleisher LA, Grant S, Mark JB, Morray JP, Nickinovich DG, Tung A: Practice guidelines for central venous access: A report by the American Society of Anesthesiologists Task Force on Central Venous Access. ANESTHESIOLOGY 2012; 116:539–73
2. Cajozzo M, Quintini G, Cocchiera G, Greco G, Vaglica R, Pezzano G, Barbera V, Modica G: Comparison of central venous catheterization with and without ultrasound guide. Transfus Apher Sci 2004; 31:199–202
3. Karakitsos D, Labropoulos N, De Groot E, Patrianakos AP, Kouraklis G, Poularas J, Samonis G, Tsoutsos DA, Konstadoulakis MM, Karabinis A: Real-time ultrasound-guided catheterisation of the internal jugular vein: A prospective comparison with the landmark technique in critical care patients. Crit Care 2006; 10:R162
4. Wigmore TJ, Smythe JF, Hacking MB, Raobaikady R, MacCallum NS: Effect of the implementation of NICE guidelines for ultrasound guidance on the complication rates associated with central venous catheter placement in patients presenting for routine surgery in a tertiary referral centre. Br J Anaesth 2007; 99:662–5
5. Augoustides JG, Horak J, Ochroch AE, Vernick WJ, Gambone AJ, Weiner J, Pinchasik D, Kowalchuk D, Savino JS, Jobes DR: A randomized controlled clinical trial of real-time needle-guided ultrasound for internal jugular venous cannulation in a large university anesthesia department. J Cardiothorac Vasc Anesth 2005; 19:310–5
6. Brederlau J, Greim C, Schwemmer U, Haunschmid B, Markus C, Roewer N: Ultrasound-guided cannulation of the internal jugular vein in critically ill patients positioned in 30 degrees dorsal elevation. Eur J Anaesthesiol 2004; 21:684–7
7. Hatfield A, Bodenham A: Portable ultrasound for difficult central venous access. Br J Anaesth 1999; 82:822–6
8. Lamperti M, Cortellazzi P, D'Onofrio G, Subert M, Falcone C, Filippini G, Caldiroli D: An outcome study on complications using routine ultrasound assistance for internal jugular vein cannulation. Acta Anaesthesiol Scand 2007; 51:1327–30
9. Troianos CA, Kuwik RJ, Pasqual JR, Lim AJ, Odasso DP: Internal jugular vein and carotid artery anatomic relation as determined by ultrasonography. ANESTHESIOLOGY 1996; 85:43–8
10. Gordon AC, Saliken JC, Johns D, Owen R, Gray RR: US-guided puncture of the internal jugular vein: Complications and anatomic considerations. J Vasc Interv Radiol 1998; 9:333–8
11. Maecken T, Grau T: Ultrasound imaging in vascular access. Crit Care Med 2007; 35(5 Suppl):S178–85
12. Lichtenstein D, Saïfi R, Augarde R, Prin S, Schmitt JM, Page B, Pipien I, Jardin F: The Internal jugular veins are asymmetric. Usefulness of ultrasound before catheterization. Intensive Care Med 2001; 27:301–5
13. Turba UC, Uflacker R, Hannegan C, Selby JB: Anatomic relationship of the internal jugular vein and the common carotid artery applied to percutaneous transjugular procedures. Cardiovasc Intervent Radiol 2005; 28:303–6
14. Troianos CA, Hartman GS, Glas KE, Skubas NJ, Eberhardt RT, Walker JD, Reeves ST, Councils on Intraoperative Echocardiography and Vascular Ultrasound of the American Society of Echocardiography: Guidelines for performing ultrasound guided vascular cannulation: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2011; 24:1291–318
15. Rothchild JM: Ultrasound guidance of central vein catheterization. In: Making Health Care Safer: A critical analysis of patient safety practices. Rockville: AHRQ Publications; 2001:245–55
16. National Institute for Clinical Excellence (NICE): Guidance on the Use of Ultrasound Locating Devices for Placing Central Venous Catheters. London: NICE; 2002
© 2012 American Society of Anesthesiologists, Inc.