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Central venous catheterization is a common procedure, but can potentially result in serious complications. Previous studies have shown that inexperienced trainees have lower success rates than experienced operators. Little is known about the efficacy of ultrasound (US) guidance in central venous catheter (CVC) insertion by inexperienced trainees.
A prospective, observational study, performed in a Japanese training hospital. All patients who were inserted CVCs by inexperienced trainees (postgraduate year 1 to 6) between 1 June 2008 and 31 October 2009 were included. The following parameters were evaluated: the rate of successful insertions, the incidence of complications, the site of CVC insertion, the method of US use, and the postgraduate year of the trainees. We defined success of CVC insertion if a trainee completes catheterization without complication and personnel exchange. We compared the success rate and the complication rate with both insertion sites and US techniques; Group SA (surface anatomy) underwent CVC insertion using the landmark technique, Group indirect-ultrasound (iUS) using ultrasound image-based skin surface marking, and Group direct-US (dUS) using real-time ultrasound guidance. The chi-test was used for analysis and P < 0.05 was considered statistically significant.
In total 593 CVCs were inserted, 527 via the internal jugular vein (IJV), and 66 via the subclavian vein (SV). The IJV approach includes 52 patients (9.9%) in Group SA, 145 patients (27.5%) in Group iUS, and 330 patients (62.6%) in Group dUS. The SV approach, on the other hand, consisted of 26 patients (39.4%) in Group SA, and 40 patients (60.6%) in Group dUS. The success rate of CVC insertion of the IJV approach linearly rose in Group SA, Group iUS and Group dUS (76.9%, 81.4%, 88.2%, P = 0.033), but in the SV approach there is no significant difference between Group SA and Group dUS (76.9%, 75.0%, P = 0.83). Five patients who underwent real-time US via the SV developed pneumothorax while no one in Group SA had the complication (P = 0.57).
The use of ultrasound guidance improves the success rate of CVC insertion via the IJV by inexperienced trainees. However, in the SV approach the efficacy of ultrasound guidance is not proven, and the incidence of pneumothorax increased in our study.