Ultrasound-guided or landmark techniques for central venous catheter placement in critically ill children.

Abstract

To assess whether ultrasound guidance improves central venous catheter placement outcomes compared to the landmark technique in critically ill children. A prospective multicentre observational study was carried out in 26 paediatric intensive care units over 6months. Children 0-18years old who received a temporary central venous catheter, inserted using either ultrasound or landmark techniques, were eligible. The primary outcome was the first-attempt success rate. Secondary outcomes included overall placement success, number of puncture attempts, number of procedures requiring multiple punctures (>3 punctures), number of procedures requiring punctures at more than one vein site and immediate mechanical complications. To account for potential confounding factors, we used propensity scores. Our primary analysis was based on 1:1 propensity score matching. The association between cannulation technique and outcomes in the matched cohort was estimated using generalized estimating equations and mixed-effects models to account for patient-level and hospital-level confounders. Five hundred central venous catheter-placement procedures involving 354 patients were included. Ultrasound was used for 323 procedures, and the landmark technique was used for 177. Two hundred and sixty-six procedures were matched (133 in the ultrasound group and 133 in the landmark group). Ultrasound was associated with an increase in the first-attempt success rate [46.6 vs. 30%, odds ratio 2.09 (1.26-3.46); p<0.001], a reduced number of puncture attempts [2 (1-3) vs. 2 (1-4), B coefficient -0.51 (95% confidence interval -1.01 to -0.03), p=0.035], and fewer overall mechanical complications [12 vs. 22.5%, odds ratio 0.47 (95% confidence interval 0.24-0.91), p=0.025] in the matched cohort. The number of puncture attempts was the main factor associated with overall complications. Compared with the landmark technique, ultrasound guidance was associated with an increased first-attempt success rate, a reduced number of puncture attempts, and fewer complications during central venous catheter placement in critically ill children.