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LETTER TO THE EDITOR

Central Landmark for Central Venous Catheterization

Department of Anesthesiology, University of Rochester, Rochester, New York, Peter_Bailey{at}URMC.Rochester.edu

In Response:

We would like to thank Drs. Ye, Zhu, and Liu for their comments (1). On the basis of the literature and our practice, we do recommend ultrasound (screening technique and/or real-time use) for all central venous catheterizations (CVC). However, our study neither determined nor concluded that ultrasound should be mandated for CVC (2). The para-carotid approach has the same limitations that all landmark "feel" or "blind" techniques have; they cannot discern variations in the size of the internal jugular vein or its relationship to the carotid artery. We also do not feel that a success rate of "over 93%" is necessarily sufficient. In most settings the desired outcome is 100% success with minimal or no complications and little to no delay. Waiting for failure of any approach to occur before using ultrasound seems illogical, as there is no risk associated with ultrasound. We believe that waiting to use ultrasound until difficulties have been encountered is likely to diminish its benefits. Interestingly, Dr. Ye et al. state that they find the literature ample to justify the use of ultrasound in children. The evidence supporting the use of ultrasound for CVC in adults is stronger than in pediatrics (3–12). Finally, recommending that clinicians who routinely obtain CVC via the right internal jugular vein should use the subclavian route in emergencies is an untested hypothesis. Clinicians are probably most successful in emergent situations, using the techniques they do most often.

REFERENCES

1. Ye L, Zhu T, Liu J. Central landmark for central venous catheterization. Anesth Analg 2007;104:216.[Free Full Text]
2. Bailey PL, Whitaker EE, Palmer LS, Glance LG. The accuracy of the central landmark used for central venous catheterization of the internal jugular vein. Anesth Analg 2006;102:1327–32.[Abstract/Free Full Text]
3. Troianos CA, Jobes DR, Ellison N. Ultrasound-guided cannulation of the internal jugular vein. A prospective, randomized study. Anesth Analg 1991;72:823–6.[Free Full Text]
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8. Rothschild JM. Making health care safer: a critical analysis of patient safety practices. Evidence report/technology assessment. no. 43. Rockville, MD: Agency for Healthcare Research and Quality, 2001:245–53.
9. Shojania KG, Duncan BW, McDonald KM, et al. Making health care safer: a critical analysis of patient safety practices. Evid Rep Technol Assess (Summ) 2001;i-x, 1–668.
10. Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 2003;327:361–4.[Abstract/Free Full Text]
11. Feller-Kopman D. Ultrasound-guided central venous catheter placement: the new standard of care? Crit Care Med 2005;33:1875–7.[Web of Science][Medline]
12. Calvert N, Hind D, McWilliams RG, et al. The effectiveness and cost-effectiveness of ultrasound locating devices for central venous access. The National Institute for Clinical Excellence, 2002:1–98.

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