Systematic review: is real-time ultrasonic-guided central line placement by ED physicians more successful than the traditional landmark approach?

Abstract

Introduction: 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:

Patients: Adults requiring emergent CVC placement except during cardiopulmonary resuscitation.

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

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

Analysis: 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).

Conclusion: 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.