Letters to the Editor: Letters & Announcements
To the Editor:
Bailey et al. (1) provide important yet disappointing information regarding the current central venous catheter insertion safety practices of cardiac anesthesiologists. The majority of respondents did not use objective venous verification techniques.
Although ultrasonography is very useful in aiding inexperienced practitioners in locating the internal jugular vein without reliance on surface landmarks, highly experienced practitioners are confident using surface landmarks and thus the usefulness of ultrasonography is diminished, unless one puts a critical value on venous versus arterial verification. Zero risk of significant complications should be our goal because it is possible and our duty (2).
I am chairman of the oversight committee for invasive procedures for a large VA medical center and suggest that the reason why more anesthesiologists at VA hospitals use ultrasonography is that there are fewer obstacles to establishing hospital-wide clinical protocols. We instituted a successful hospital-wide central venous catheterization policy 6 yr ago mandating venous verification by real time ultrasonography, tubing manometry, or fluoroscopy. As part of the policy, we recommend the use of ultrasound for the performance of the procedure because of its benefits for those with limited experience.
As the survey suggests, many health care institutions are already instituting protocols for safety in vascular access procedures. I expect this to eventually become a hospital performance measure. Anesthesiologists cannot simply choose to ignore the public's expectation of absolute safety because we are safer than others. If anesthesiologists do not want a particular narrow approach imposed on them, then they need to write the central venous catheterization safety protocol themselves and formally put it into practice. That approach will protect the patient and themselves.
Rick Bjerke, MD, FASE
Department of Anesthesiology
University Drive C
University of Pittsburgh
1. Bailey PL, Glance LG, Eaton MP, Parshall B, Mcintosh S. A survey of the use of ultrasound during central venous catheterization. Anesth Analg 2007;104:491–7
2. Bjerke R, Mangione M, Oravitz T. Major arterial injury need not be a risk of central venous catheterization. Anesth Analg 2004; 98:SCA1–134