Trauma Surgery Division, Department of Surgery, University of Campinas, Campinas - SP, 13083-970, BrazilBrazil
Resident of Surgery, Department of Surgery, University of Campinas, Campinas, SP, BrazilBrazil
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Obtaining central venous access is a fundamental clinical skill for managing patients in a wide variety of clinical situations. The role of routine portable Ultrasound (US) in the placement of Central Venous Catheters (CVCs) has been debated and some important evidence-based guidelines supporting the liberal use of ultrasound for this specific procedure have been published.
Letter to the Editor Current Specialist Awareness on Ultrasound * *Corresponding author Use for Central Venous Catheterization Bruno M. Pereira, MD, MHSc, PhD, FACS, FCCM Associate Professor Trauma Surgery & Surgical Critical Care 1* 2 University of Campinas Bruno M. Pereira, MD, MHSc, PhD, FACS, FCCM ; Alcir E. Dorigatti, MD Campinas - SP, 13083-970, Brazil E-mail: bpererira@unicamp.br 1Trauma Surgery Division, Department of Surgery, University of Campinas, Campinas - SP, 13083-970, Brazil Volume 2 : Issue 1 2 Resident of Surgery, Department of Surgery, University of Campinas, Campinas, SP, Brazil Article Ref. #: 1000EMOJ2119 Article History Obtaining central venous access is a fundamental clinical skill for managing patients th Received: March 14th, 2016 in a wide variety of clinical situations. The role of routine portable Ultrasound (US) in the th Accepted: April 19th, 2016 placement of Central Venous Catheters (CVCs) has been debated and some important evi- th Published: April 19th, 2016 dence-based guidelines supporting the liberal use of ultrasound for this specific procedure have 1-3 been published.1-3 The use of ultrasound to help on central venous catheterization has shown to improve success rates with reduced complications, however the ultrasound has not been Citation adopted worldwide for this specific end. Also, specialists’ response to new publications on this Pereira BM, Dorigatti AE. Current spe- subject is unknown. It is our feeling that, although many manuscripts have already proven that cialist awareness on ultrasound use for central venous catheterization. the US is safe and effective, its use is not routinely observed in a daily practice. Emerg Med Open J. 2016; 2(1): 1-4.
doi: 10.17140/EMOJ-2-119 With this observation made, a question to validate this affirmative has blossomed and these authors decided to post it on a scientific social network, so we could be able to investigate current opinion and awareness from worldwide physicians from different specialties on ultra- sound use for central venous catheterization. Throughout a specific scientific social network (researchgate.net) composed by 9 million members up-to-date from different professional areas including medicine, the question: “Is ultrasound an essential tool for placing central venous lines?” was raised. One of the website tools is a section where members perform questions and get answers on specific subject from different worldwide scientists. After 500 days online, answers were no longer accepted and the question placed offline for analysis. The follow- ing variables were analyzed: number of answers, number of countries answering the question, number of institutions involved on the query, quality of responders (based on published articles/ citations and impact factors), specialties and opinions.
Two-hundred and twenty-four answers were registered. Three answers were excluded: two from registered nurses and one from a veterinarian. In total, 221 physician’s answers were analyzed. Thirty-six countries and 114 different institutions participated answering the pro- posed question as represented in Table 1. All responders were analyzed regarding their aca- demic activity. A mean of 21.5 articles published (average of 28.39 impact factor) were related to responders (SD±37.4) with 85.5(SD±427.62) average of citations.
Regarding all specialties 61.66% were anesthesiologists, 10% ER physicians, 7.5% surgeons, 5.83% critical care specialists, 5% pediatricians, 3% GI specialists and the remaining neonatologists, cardiologists, hematologists, radiologists, orthopedics and general practitioners summed 4.98% all together.
Copyright In regards to the specific question “Is ultrasound an essential tool for placing central ©2016 Pereira BM. This is an open venous lines?” an average of 54% of responders answered yes (46% otherwise). Among the access article distributed under the Creative Commons Attribution 4.0 top five specialties that more participated on this research, ER physicians and pediatricians International License (CC BY 4.0), are those that most likely believe that the ultrasound is an essential tool for placing CVCs which permits unrestricted use, (50%), followed by surgeons (44.4%), critical care specialists (42.85%) and anesthesiologists distribution, and reproduction in (41.89%).
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Country Institution Country Institution Argentina Hospital Durand Iran Tehran University of Medical Sciences Australia University of Sydney Shahid Beheshti University of Medical Sciences University of New South Wales Japan Japan Community Health Care Organization St John of God Healthcare Jordan King Hussein Medical Center Royal Flying Doctor Services Morocco Université Ibn Tofail Brazil University of Campinas Nigeria University of Ibadan Canada University of Ottawa Netherlands Academisch Medisch Centrum Universiteit van Amsterdam SickKids - Toronto University of Groningen China Jinhua Municipal Central Hospital Radboud University Nijmegen Chinese University of Hong Kong Pakistan Hamdard University Peru Hospital Regional Docente de Trujillo Croacia University Clinical Hospital Center Klinički bolnički centar Rijeka Poland Children’s Memorial Health Institute Varazdin General Hospital Portugal Coimbra University Hospital Center University Hospital Centre Zagreb Qatar Hamad Medical Corporation Czech Republic Charles University of Prague Romania Universitatea de Medicina si Farmacie Grigore T. P.
Denmark Aarhus University Hospital Institutul Clinic Fundeni Egypt Zagazig University Saudi Arabia Prince Sultan Military Medical City France Hôpital Universitaire Necker King Faisal Specialist Hospital and Research Center Centre Hospitalier de Saint-Quentin Singapure National University Health System Clinique Du Parc Saint Lazar Hospital Universitário La Paz Clinique Saint Augustin Spain Onkologikoa Institut de Radiologie de Neuchâtel Hospital Universitario Miguel Servet Clinique Hospitalier de Fontainebleau Hospital Universitari i Politècnic la Fe Elisabeth-Krankenhaus University of Valencia Germany University of Cologne Sweeden Linköping University Herz- und Diabeteszentrum Nordrhein-Westfalen Gulhane Military Medical Academy Turkey General Hospital Preveza Haseki Training and Research Hospital Greece General University Hospital of Larissa Necmettin Erbakan Üniversitesi Hygeia Hospital Anadolu Medical Center Hungary Kaposi Mór Oktató Kórház Cleveland Clinic Abu Dhabi United Arab Emirates India All India Institute of Medical Sciences Rishkesh Tawan Hospital Madras Institute of Orthopaedics and Traumatology NMC Healthcare LLC Sanjay Gandhi Post Graduate Institute of Medical Specialized Medical Care Hospital Sciences United States of Washington University in St. Louis Institute of Medical Sciences America University of Miami Miller School of Medicine Postgraduate Institute of Medical Education and Medical College of Wisconsin Research Tampa General Hospital Sanjay Gandhi Post Graduate Institute of Medical Sciences University of California Global Hospital University of Texas Health Science Center Columbia Asia Hospital - Mysore Vail Valley Medical Center Reliance Industries Limited Greater Baltimores Medical Center B. J. Medical College Mayo Foundation for Medical Education and Research Kingsway Healthcare University of Nebraska Medical Center AIIMS Bhopal All India Institute of Medical Sciences Hartford Hospital Institute of Liver and Biliary Sciences University of South Carolina Pondicherry Institute of Medical Sciences Loyola University Medical Center Lady Hardinge Medical College University of Pittsburgh Italy CTO Torino (Italy) Trauma Center United Kingdom University of Manchester Hospital of Imola Southern Health and Social Care Trust Azienda Ospedaliera Santa Maria della Misericordia NHS Lanarkshire Azienda Ospedaliero-Universitaria Pisana National Health Service Azienda USL Valle d’Aosta Central Manchester University Hospitals NHS Foundation Ospedale San Pietro Fatebenefratelli Zayed Military Hospital Azienda Ospedaliera Papa Giovanni XXIII Imperial College Healthcare NHS Azienda Ospedaliero Universitaria Careggi Walsall Healthcare NHS Trust AORN Ospedali dei Colli Belfast Health and Social Care Trust University Hospital of Parma University of Dundee Israel Hillel Yaffe Medical Center
Ten responder opinions were relevant to mention, as follows: publishing, then we were probably dealing with a very special high-level group of specialists. This is the reason why we also 1) Ultrasound is the gold standard for the placement of CVCs - searched on responders’ publications, impact factor of publica- 56.34%; tions and citations. To the end of this very first section of the study we realized that we were dealing with a strong group of 2) US device for CVC placement should be preferred if US is specialists involved with many publications of good power. An available - 53.17%; average of 21.5 manuscripts were related to each responder with 3) Physicians should be trained in both anatomic landmark an impact factor average of 28.39 confirming that our group of technique (AL) and US technique (US) - 46.82%; responders are all involved in academics and indeed are experts 4) Residents must be taught into both techniques AL and US on the subject. Fifty-four percent of specialists believe that the -44.44%; ultrasound is an essential tool for placing central venous lines. Fifty percent of emergency physicians and pediatricians were 5) US use should be mandatory - 42.85%; skeptical in affirm that the ultrasound is essential for the proce- 6) US technique is difficult to use on subclavian vein - 11.9%; dure in question. Not too far from this number were surgeons, 7) Physicians should be free to use whatever technique he/she intensivists and anesthesiologists, dividing the population of thinks is better for their patients - 11.11%; specialists on the opinion that ultrasound is or is not an essential tool for obtaining central lines. The point that these two authors 8) Physicians should learn first anatomic landmark technique were not able to clarify is why specialists are divided on the use before start handling the US for this matter - 10.31%; of ultrasound for this purpose, even though literature enforces 9) The US learning curve is long - 4.76%; safety and efficacy with fewer complications with the use of this modern point-of-care device?
10)Physicians used to anatomic landmark technique have trou- ble to learn the US technique - 1.58%; Following this rationale, only 56% of responders ex- pressed that the use of ultrasound for determining a CVC is the This brief opinion report brings to light whether spe- standard-of-care. In the same way, only 53.7% affirm that ul- cialists are aware of the use of ultrasound on placing CVCs.
trasound should be preferred when available. In a time of evi- Many studies were published reinforcing the use of ultrasound dence-based medicine shouldn’t we expect a higher number of for this purpose proving to be safe and effective. Even though 3-5 physicians defending the use of ultrasound? Maybe, because there are a number of recent papers stressing the use of ultra- of ultrasound for determining CVC and ultrasound point-of-care sound as an essential tool in placing CVCs, this device is not is something relatively new in medicine, adoption for this new available at all institutions and it is not currently the standard of technique including its learning curve and training would be a care worldwide.
hassle for experienced physicians to shift from one technique to The question on how physicians from different spe- another. The answer is no. Based on this research only 1.58% ex- cialties worldwide are aware about using the ultrasound for this pressed in the discussion that learning another technique would specific purpose have aroused, creating an interesting field of be an issue. 10.31% of physicians expressed that should learn investigation on current opinion of specialists on this specific first anatomic landmark technique before start handling the US matter. One important need for these authors was to determine for this matter. In the other hand, around 90% of this selective whether or not the responders group are involved in academic group of responders do not agree that a physician should use activities. The meaning of this is that if the majority of respond- whatever technique he or she thinks is the best for their patients, ers are really involved in academic activities, doing research and suggesting that a protocol must be followed. In order to that, lar access. Intensive Care Med. 2012; 38(7): 1105-1117. doi: some training must happen in any stage of medical career but 10.1007/s00134-012-2597-x only 44.44% of these opinion leaders defended in the discussion that residents must be taught into both techniques. Many ques- 5. Latif RK, Bautista AF, Memon SB, et al. Teaching aseptic tions and debates are arising on literature regarding training for technique for central venous access under ultrasound guidance: central venous line access and learning both techniques during a randomized trial comparing didactic training alone to didac- residency looks reasonable, in contrast to specialists’ position tic plus simulation-based training. Anesth Analg. 2012; 114(3): on this research where 66% of responders did not expressed any 626-633. doi: 10.1213/ANE.0b013e3182405eb3 argument for residents training in both techniques. Our opinion is that both residents and physicians must be prepared for the use of ultrasound or not depending on the situation or where he is working. In a critical scenario the quick use of the ultrasound may be difficult due to patient’s severity and anatomic landmark should be stimulated. By the other hand, ultrasound should be the first option when available, in agreement with responders (58%) that stated that ultrasonography should not be mandatory.
A physician should have adequate proficiency in the landmark technique as in the ultrasound technique but the evidence favors for the ultrasound technique. The fact that a certain percentage of people agreed with the same opinion does not mean that the others disagree with them; therefore, this dataset could estimate the real opinion from responders but was not precise about it.
With this brief opinion report it is clear to us that in a time of evidence-based medicine there are still some controver- sies that need to be addressed regarding the use of ultrasound for placing CVCs, including a uniform opinion on training, proto- cols and finally broad use of a proven benefic device. The pros and cons on using or not the ultrasound for the subject herein discussed maybe never end; however, there are so strong evi- dences that support its use in order to avoid not only mechanical complications but infectious complications and thrombosis that the use of US seems in fact the best option.