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Original Article

A survey of the use of 2D ultrasound guidance for insertion of central venous catheters by UK consultant paediatric anaesthetists

Tovey, G.1; Stokes, M.1

Author Information
European Journal of Anaesthesiology (EJA): January 2007 - Volume 24 - Issue 1 - p 71-75
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Abstract

Introduction

In 2002, the National Institute for Clinical Excellence (NICE) published guidance on the use of ultrasound locating devices for placing central venous catheters (CVCs) [1]. This document stated that 2D imaging ultrasound guidance was the preferred method for insertion of CVCs into the internal jugular vein in adults and children in elective situations and should be considered in most clinical circumstances requiring CVC insertion. It also recommended that all those involved in placing CVCs using 2D ultrasound guidance should undertake appropriate training to achieve competence.

The evidence base for the use of 2D ultrasound in the paediatric population is small. The NICE guidelines were produced on the findings of three studies by Alderson and colleagues [2] and Verghese and colleagues [3,4]. To date, only one further randomized-controlled trial comparing ultrasound guidance with the landmark technique for insertion of CVC in children has been published [5]. The results of this trial conflicted with previous studies by showing higher success rates and lower complication rates using the landmark technique. In 2002, Asheim and colleagues published a prospective non-comparative study of an ultrasound-guided technique for CVC placement in 42 consecutive infants and children with a 100% success rate and 0% complication rate [6].

The NICE guidance has medico-legal implications for anaesthetists and hospital trusts regarding the provision and use of 2D ultrasound equipment. Failure to follow the guidelines could be criticized should complications occur. Purchase of ultrasound equipment and training of personnel is costly and the validity of the guidance has been challenged [5]. The purpose of this survey was to explore the availability, training and use of ultrasound devices by consultant paediatric anaesthetists in the UK.

Methods

In February 2005, after a local pilot study, a confidential questionnaire was posted to all UK members of the Association of Paediatric Anaesthetists of Great Britain and Ireland. The questionnaire consisted of 11 questions with tick-box responses and an option to add further comments (Appendix). The purpose of the questionnaire was to assess the availability of 2D ultrasound devices in the workplace and their use for insertion of CVCs in elective paediatric theatre cases. Information was also obtained about the training undertaken, influence of the NICE guidance and use of ultrasound when supervising trainees.

Results

A total of 262 out of 415 questionnaires were returned giving a response rate of 63%. Of those responding, 212 (81%) inserted paediatric CVCs. Table 1 details the numbers of lines inserted annually by respondents. Ultrasound devices were available in the workplace of 216 (82%) paediatric anaesthetists. The average number of ultrasound devices available per department was two with a range of 0–27 (Table 2). For elective paediatric theatre cases, 176 anaesthetists had experience inserting internal jugular central venous lines, 86 had experience inserting subclavian lines and 180 had experience inserting femoral lines. Of these anaesthetists, 45 (26%) with access to an ultrasound device always used it when inserting internal jugular lines. This figure was reduced at 9 (10%) for those inserting subclavian lines and 14 (8%) for those inserting femoral lines. The regularity with which ultrasound devices were used is illustrated in Figures 1–3. The majority (74%) of anaesthetists had received training in the use of 2D ultrasound locating devices. This training occurred in the workplace for 78% with the remaining 22% attending external courses. Demonstration by colleagues was the sole method of training for 22% of respondents.

Table 1
Table 1:
Number of paediatric central venous catheters inserted annually.
Table 2
Table 2:
Number of 2D ultrasound devices available in the workplace.
Figure 1.
Figure 1.:
Frequency of use of 2D ultrasound guidance when inserting internal jugular CVC in elective paediatric theatre cases.
Figure 2.
Figure 2.:
Frequency of use of 2D ultrasound guidance when inserting subclavian CVC in elective paediatric theatre cases.
Figure 3.
Figure 3.:
Frequency of use of 2D ultrasound guidance when inserting femoral CVC in elective paediatric theatre cases.

The NICE guidelines had influenced the clinical practice of 107 (55%) respondents. Nobody reported being unaware of the guidelines. Of the consultants who supervised trainees inserting CVCs on paediatric lists, 70% used 2D ultrasound guidance and 43% stated that they were more likely to use ultrasound guidance with trainees than if working alone.

Discussion

Whilst all anaesthetists are aware of the NICE guidance on the use of ultrasound when inserting CVCs there is not total compliance amongst those surveyed. One of the problems encountered was the non-availability of 2D ultrasound devices within the workplace of 18% of respondents. Some commented that publication of the NICE guidelines had helped to persuade National Health Service (NHS) trusts to release funds to purchase ultrasound equipment. Use of ultrasound in young infants requires a paediatric probe which was unavailable in some institutions. The average number of ultrasound machines available in each workplace was two; these are often shared between both the operating department and intensive care units making availability and accessibility an issue. One consultant commented that they would change their practice when or if more devices were purchased. In many hospital trusts securing funds for investment in equipment can be a difficult and lengthy process; one respondent reported submitting a business case for 3 years without success.

The NICE guidance does not dictate how ultrasound guidance should be used when inserting CVCs. Many respondents commented that they use ultrasound to identify the presence and location of a patent vein prior to scrubbing up for cannulation. Patency can be a problem when veins have been previously cannulated and some anaesthetists commented that they were more likely to use ultrasound under these circumstances and for cases where they anticipated difficulty. Inserting a CVC under ultrasound guidance requires training and practice, and some anaesthetists reported a reduced success rate compared with the landmark technique. This survey found that 26% of consultant paediatric anaesthetists had never been trained in the use of ultrasound locating devices. Other respondents suggested that the use of ultrasound guidance should be a core skill for anaesthetic trainees and that it was an excellent teaching tool.

Implementation of the NICE guidance is not yet universal amongst paediatric anaesthetists. Whilst some would not consider inserting a neckline without ultrasound guidance, others disregard the guidelines or use ultrasound only as a defence strategy.

There is limited and conflicting evidence available from randomized clinical trials in the paediatric population [2-5]. At the time of writing (January 2006), NICE have proposed that there is insufficient new evidence to justify a full review appraisal of the guidance [7]. Further work in the paediatric field would be beneficial to give additional weight to the NICE guidance.

Acknowledgements

The authors wish to thank all those who responded to the questionnaire. Thanks also to members of the anaesthetic department at Birmingham Children's Hospital who participated in the pilot phase.

Appendix: Questionnaire to assess use of 2D ultrasound guidance by Consultant Paediatric Anaesthetists when inserting central venous catheters

(1) On average, how many paediatric CVCs do you insert per year?

0

1–10

11–50

>50

(2) Are 2D ultrasound devices available within your workplace for use when inserting CVCs?

Yes How many?…..

No

Don't know

If you do not insert paediatric CVCs or have answered ‘No’ to Q2 you do not need to proceed with any further questions.

(3) How often do you use 2D ultrasound guidance when inserting an internal jugular central venous line for an elective paediatric theatre case?

Always

Usually (>50% of the time)

Sometimes (<50% of the time)

Never/Rarely

I do not insert IJV lines

(4) How often do you use 2D ultrasound guidance when inserting a subclavian central venous line for an elective paediatric theatre case?

Always

Usually (>50% of the time)

Sometimes (<50% of the time)

Never/Rarely

I do not insert subclavian lines

(5) How often do you use 2D ultrasound guidance when inserting a femoral central venous line for an elective paediatric theatre case?

Always

Usually (>50% of the time)

Sometimes (<50% of the time)

Never/Rarely

I do not insert femoral lines

(6) Where did you receive your training in the use of 2D ultrasound locating devices for insertion of CVCs?

Within the workplace Please go to Q7

Outside the workplace Please go to Q8

Never received training Please go to Q9

(7) What type of training in the use of 2D ultrasound have you undertaken?

Demonstration by companies

Demonstration by companies colleagues

In house training day

(8) What type of training in the use of 2D ultrasound have you undertaken?

Manufacturers training course

Other external training course

(9) Has the introduction of the NICE guidelines on the use of ultrasound locating devices for placing CVCs influenced your clinical practice?

Yes

No

Not aware of guidelines

(10) Do you use 2D ultrasound guidance when supervising trainees inserting CVCs?

Yes Please go to Q11

No Please skip Q11

Do not work with trainees Please skip Q11

(11) Are you more likely to use ultrasound guidance when supervising trainees inserting CVCs than if you were working alone?

Yes (more likely)

No (less likely)

No difference

References

1. National Institute for Clinical Excellence. Guidance on the use of ultrasound locating devices for placing central venous catheters. Technology Appraisal Guidance No. 49. September 2002. www.nice.org.uk
2. Alderson PJ, Burrows FA, Stemp LI et al. Use of ultrasound to evaluate internal jugular vein anatomy and to facilitate central venous cannulation in paediatric patients. Br J Anaesth 1993; 70: 145–148.
3. Verghese ST, McGill WA, Patel RI et al. Ultrasound guided internal jugular venous cannulation in infants: a prospective comparison with the traditional palpation method. Anesthesiology 1999; 91: 71–77.
4. Verghese ST, McGill WA, Patel RI et al. Comparison of three techniques for internal jugular venous cannulation in infants. Paediatr Anaesth 2000; 10: 505–511.
5. Grebenik CR, Boyce A, Sinclair ME et al. NICE guidelines for central venous catheterization in children. Is the evidence base sufficient? Br J Anaesth 2004; 92: 827–830.
6. Asheim P, Mostad U, Aadahl P. Ultrasound-guided central venous cannulation in infants and children. Acta Anaesth Scand 2002; 46: 390–392.
7. National Institute for Clinical Excellence. Review of NICE Technology Appraisal Guidance No. 49, ultrasound locating devices for placing central venous catheters. Proposal to move guidance to the static list. September 2005. www.nice.org.uk
Keywords:

CATHETERIZATION, CENTRAL VENOUS; ULTRASONOGRAPHY; PAEDIATRICS

© 2007 European Society of Anaesthesiology