Abstract
IntroductionUltrasound-guided (UG) technique is the recommended procedure for central venous catheterization (CVC). However, as ultrasound may not be available in emergency situations, guidelines also propose that physicians remain skilled in landmark (LM) placement. We conducted this prospective observational study to determine the learning curve of the LM technique in residents only learning the UG technique.MethodsDuring the first three months of their rotation in our ICU, residents inexperienced in CVC used only the real-time UG technique. During the following three months, residents were allowed to place CVC by means of the LM technique when authorized by the attending physician.ResultsA total of 172 procedures (84 UG and 88 LM) were performed by the inexperienced residents during the study. The success rate was lower (72% versus 84%; P = 0.05) and the complication rate was higher (22% versus 10%; P = 0.04) for LM compared to UG procedures. Comparison between the five last UG procedures and the first five LM procedures performed demonstrated that the transition between the two techniques was associated with a marked decrease of the success rate (65% versus 93%; P = 0.01) and an increase of the complication rate (33% versus 8%; P = 0.01). After 10 LM procedures, residents achieved a success rate and a complication rate of 81% and 6%, respectively.ConclusionsResidents who only learn the UG technique will not be immediately able to perform the LM technique, but require specific training based on at least 10 LM procedures. The question of whether or not the LM technique should still be taught when an ultrasound device is not available must therefore be addressed.
Highlights
Ultrasound-guided (UG) technique is the recommended procedure for central venous catheterization (CVC)
Society of Echocardiography, the Society of Cardiovascular Anesthesiologists, the National Institute for Clinical Excellence and the American Society of Anesthesiologists all recognize that, in certain circumstances, such as emergency situations, the use of ultrasound may be impossible and that operators must maintain their skills by placing central catheters according to the landmark (LM) technique for these specific situations [1,2,3]
No significant difference in simplified acute physiologic score 2 (SAPS2), body mass index (BMI), heart rate, blood pressure, prothrombin time, activated partial thromboplastin time, platelet count and proportion of CVC/ dialysis catheters was observed between the 2 groups
Summary
Ultrasound-guided (UG) technique is the recommended procedure for central venous catheterization (CVC). As ultrasound may not be available in emergency situations, guidelines propose that physicians remain skilled in landmark (LM) placement We conducted this prospective observational study to determine the learning curve of the LM technique in residents only learning the UG technique. Some authors have suggested that the anatomical knowledge gained by using the ultrasound technique improves the operators’ skills when they need to use the LM technique in an emergency [6] This opinion is based exclusively on personal experience and not on any clinical data. It could be harmful for physicians who have only learned the UG technique to consider themselves sufficiently skilled to attempt an LM procedure in an emergency situation. The objective of this study was to determine the learning curve of the LM technique in residents who have only been trained in the UG technique
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