Use of Real-Time Imaging Modalities for Placement of Central Venous Access Devices
ABSTRACT:
The Association for Vascular Access has identified that use of the landmark technique for placement of central venous access devices is associated with preventable, potentially serious patient complications. To that end, AVA strongly advocates the use of ultrasound guidance or other real-time imaging modality for all non-emergent central vascular access procedures, including insertion of peripherally-inserted central catheters (PICCs), and all vascular access devices placed into the vessels of the deep vasculature of all extremities, the neck, and the trunk.
BACKGROUND:
Each year more than 5 million central venous access devices (CVADs) are placed in the United States7. These CVADs are used to deliver a variety of fluids and medications inappropriate for peripheral administration because of chemical properties of infusates, peripheral vessel condition, hemodynamic monitoring or duration of therapy. Historically the vast majority of CVADs were placed with clinicians relying on external anatomical landmarks to localize insertion sites for
cannulation. In many instances, these practices persist despite the relatively low cost and often ready availability of portable ultrasound in many institutions22.
Unfortunately, complication rates associated with insertion of CVADs utilizing landmark techniques has been demonstrated in the literature to exceed 15%7. Complications associated with these procedures include pneumothorax, hemothorax, hydrothorax, hematoma formation,
chylothorax, arterial puncture, nerve damage, malposition, localized infection, and catheter-related bloodstream infection. Moreover, research indicates greater than 50% of adult patients have anatomical variation in arterial and venous structures of the neck9 and similar variations are known to exist among vessels in the upper extremities, especially the cephalic and brachial veins. Deep veins used for cannulation most often share a connective tissue sheath known as the venae comitantes with arteries and nerves, putting patients at risk for complications from imprecise venipuncture attempts like compartment syndrome and Chronic Regional Pain Syndrome (also known as Reflex Sympathetic Dystrophy).
Since 2001, multiple professional organizations have recommended a change from landmark technique to ultrasound guidance for placement of CVADs18, 19. The Agency for Healthcare Research and Quality (AHRQ) and U.S. Centers for Disease Control and Prevention (CDC) both support the use of ultrasound guidance for elective CVAD placement procedures. The AHRQ states “real-time US guidance for CVAD insertion, with or without Doppler assistance, improves catheter insertion success rates, reduces the number of venipuncture attempts prior to successful placement, and reduces the number of complications associated with catheter insertion.”8
Complications associated with central venous catheterization increase with multiple percutaneous venipuncture attempts, especially when more than two attempts are made at venipuncture5, 6. A large body of data demonstrates that ultrasound guidance during central
catheterization can minimize complications related to multiple venipunctures by simply eliminating multiple venipunctures1-4. In the acute care setting, the least-experienced operators, i.e., junior medical house physicians are often the clinicians charged with placement of CVADs. This lack of experience and training is also associated with increased rates of catheter-related bloodstream infections.1, 19, 20 Offering ultrasound guidance for venipuncture could reduce the number of cannulation attempts and improve operator outcomes.
Benefits of ultrasound guidance for CVAD placement have been realized across the continuum of care. While the majority of the clinical literature discusses its benefits for non-emergent
insertions, there is precedent for its use in emergent settings as well, with identified improvements in successful first-attempt cannulation, reduced time to successful insertion, and lower rates of insertion-associated and post-insertion complications16,20.
Moreover, a cogent argument for ultrasound guidance can be offered from a cost-benefit analysis as well. Economic modeling showed that using ultrasound to place CVADs in all three most-commonly cannulated sites (Internal Jugular, Subclavian, and Femoral veins) would save £2000 (UK) for every 1,000 procedures performed even factoring in the costs of purchasing ultrasound machines and training clinical personnel21. These results were replicable in both adult and pediatric patients. POSITION STATEMENT:
The Association for Vascular Access (AVA) supports the use of real time imaging guidance for placement of all non-emergent CVADs. This endorsement extends to all clinicians who place CVADs in all care settings, and to all types of access devices. In addition, vascular access clinicians of all disciplines must demonstrate mastery of these psychomotor skills by meeting the objective criteria for use within their employing institutions, obtaining appropriate ongoing education and training on the equipment in use in their institutions, demonstrating ongoing competency with these procedures as set forth by institutional policy, and meeting the criteria for licensure and practice in the locale(s) in which they are licensed.
PRACTICE IMPLICATIONS:
While incorporating ultrasound guidance into CVAD insertion procedures improves outcomes for both patients and clinicians, additional didactic and clinical training is required to achieve
proficiency with its use during vascular access procedures. Dr. David Feller-Kopman, MD, FCCP states “clearly there is some aspect of gaining a procedural skill that is numbers based.”7 Physician professional organizations recommend that learners participate in two to four hours of didactic training, a like amount of laboratory training, and should perform between 10 and 25 proctored examinations when establishing proficiency with ultrasound-guided vascular access procedures. A retrospective review of the clinical practice of experienced vascular access clinicians demonstrated that they were identified as having achieved mastery of these techniques after between 30 and 50 ultrasound guided CVAD placement procedures10.
In some instances, pending availability, fluoroscopy (with or without contrast) may prove to be a superior imaging method as the entire vessel may be viewed throughout the procedure. This is
especially true if patients are known to have vascular anomalies, have a history of previous CVADs, or if placement using ultrasound has been unsuccessful. Fluoroscopic guidance may not be consistent with the scope of practice for Registered Nursing in many states in the U.S., as its activation may be considered a medical act. Many states require either separate endorsement or education and licensure as an Advanced Practice Registered Nurse for nurses to independently operate fluoroscopy
equipment.
Infrared imaging systems are entering the marketplace and may gain greater adoption in the future, but there is currently nothing in the clinical literature demonstrating their merits for central venous access procedures. Because these devices have a limited viewing depth (6 – 8 mm. from the surface of the skin) they may be an alternative to ultrasound guidance in locating more superficial veins and arteries and offer a hands-free method of imaging these superficial vessels.23
SUMMARY:
The reduction of insertion-associated and post insertion complications and increased success rates in the placement of CVADs supports the use of ultrasound guidance or other real-time imaging modality during insertion procedures11 - 15. The use of imaging techniques during the assessment of patients prior to cannulation assists in the identification of optimal insertion sites, and may decrease the number of venipuncture attempts, thus reducing the risk of insertion related complications. REFERENCES:
1. Gualtieri E, Deppe SA, Sipperly ME, Thompson DR. Subclavian venous catheterization: greater success rate for less experienced operators using ultrasound guidance. Crit Care Med. 1995; 23:692-697.
2. Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med.1996; 24:2053-2058.
3. Mallory DL, McGee WT, Shawker TH, et al. Ultrasound guidance improves the success rate of internal jugular vein cannulation. A prospective, randomized trial. Chest. 1990; 98:157-160.
4. Gilbert TB, Seneff MG, Becker RB. Facilitation of internal jugular venous cannulation using an audio-guided Doppler ultrasound vascular access device: results from a prospective dual-center, randomized, crossover clinical study. Crit Care Med. 1995; 23:60-65.
5. Eisen LA, Narasimhan M, Berger JS, et al. Mechanical complications of central venous catheters. J Intensive Care Med. 2006; 21:40-46.
6. McGee WT. Central venous catheterization: better and worse. J Intensive Care Med 2006; 21; 51.
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8. Agency for Healthcare Research and Quality. Making health care safer: a critical analysis of patient safety practices. 2001. http://www.ahrq.gov/clinic/ptsafety/. Accessed December 1, 2007.
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19. CDC. Guidelines for the prevention of intravascular catheter-related bloodstream infections. MMWR 2002;51:1-29.
20. National Institute for Health and Clinical Excellence (National Health Service UK). NICE Guideline: TA49 Central venous catheters - ultrasound locating devices: Guidance. 2005 Ed., available online at http://www.nice.org.uk/guidance/index.jsp?action=download&o=32461 Accessed January 13, 2008.
21. Calvert N, Hind D, McWilliams RG, Thomas SM, Bererley C, Davidson A. The effectiveness and cost-effectiveness of ultrasound locating devices for central venous access: a systematic review and economic evaluation. Health Technology Assessment, 2003; Vol. 7: No. 12; available online at http://www.ncchta.org/execsumm/summ712.htm Accessed January 13, 2008.
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23. Luminetx Corporation Product Literature, Luminetx Vein Viewer. Available online at http://luminetx.com/Healthcare/VeinViewer/FAQ/Clinical/tabid/85/Default.aspx Accessed January 13, 2008.
