Ultrasound guidance for central venous catheterisation. A Colombian national survey

Ultrasound guidance for central venous catheterisation. A Colombian national survey Abstract Quality problem or issue Ultrasound (US) is a widely propagated medical technology. Anaesthesiologists increase procedural safety by using US techniques, but training and availability are essential for its usage. Although its utility for central venous catheterisation (CVC) is well established, only a paucity of evidence is available regarding its use in low- and middle-income countries. This study is a nationwide survey of Colombian anaesthesiologists designed to explore the current use of US guidance for CVC. Initial assessment and implementation Web-based survey at National level. Anaesthesiologists registered in the Colombian Society of Anaesthesiology and Resuscitation database. Choice of solution Demographic variables (age and gender), anaesthesia expertise, years of anaesthesiology practice, US availability, use of US during CVC, reasons for not using US and training experience were collected. Evaluation Of 351 respondents (12.3% response rate), 45% reported using US sometimes and always for CVC (95% CI 39%–50%) (n = 157). Most anaesthesiologists obtained training in US through external courses (50.4%) or from colleagues (22.8%). Of the total respondents, 62.7% (n = 220) have US equipment available at all time and this factor was independently associated with the use of US for CVC (adjusted odds ratio [OR] = 38.6, P < 0.001). Lessons learned US guidance is not a common technique used for CVC by Colombian anaesthesiologists; an important barrier for its use is lack of equipment. ultrasound, central venous catheterisation, patient safety Quality problem or issue Introduction of ultrasound (US) in the medical practice has shown several benefits in the safety of numerous procedures [1]. US-guided insertion of central venous catheter has become a highly recommended or even mandatory technique, according to several guidelines and protocols of venous catheterisation [1]. In 1984, Legler et al. [2] used the Doppler technique (ultrasonic Doppler, doppler study or evaluation) to guide jugular venous catheterisations. Two years later, Yonei et al. [3], used 2D-US to insert central venous catheters. Since then, this technique has improved in terms of precision, safety and availability for healthcare workers. CVC is a common procedure performed by anaesthesiologists and many physicians in the emergency department and intensive care units [1]. US has proven to be a good complementary strategy for CVC because of a great number of benefits, like increased success rates [1, 4], reduced number of attempts and shorter time required to perform the procedure compared with a landmark technique [4, 5] and lessened complications (e.g. malposition, lung or vascular injuries, pneumothorax and thrombosis) [5–7]. Because of these advantages, several medical organisations and government agencies advocate the use of this technique and encourage its propagation across all healthcare centres [8–12]. Despite these recommendations, many limitations and barriers still exist for US to become a universal technique for CVC and other anaesthesia-related procedures. Some of the major barriers are the access to a device and the requirement of advanced training and experience [13]. US-guided insertion of central venous catheters is considered a common practice in developed countries; however, there is a lack of information about the patterns of using this technique in low-income countries. We sought to describe and analyse the current use of US guidance for insertion of central venous catheters by Colombian anaesthesiologists. Initial assessment and implementation Approach The Institutional Review Board and the Research Ethics Committee from the Colombian Society of Anaesthesiology and Resuscitation (SCARE, for the term in Spanish) approved this study. Inclusion of participants in this study required electronic acceptance, but the written consent was waived by the committee because of the low risk represented by this study and the strict confidentiality and anonymity strategies for data management. Sampling and recruitment This study involved anaesthesiologists and fellows in anaesthesia registered in the SCARE database. Inclusion criteria included being registered in the database and accepting to answer an electronic web-based survey sent via email. There were no exclusion criteria. Two people with prior training from the authors of the protocol at the Universidad del Cauca in Colombia conducted the questionnaire and collected the data without knowledge of the study objectives to avoid observer-expectancy bias. Choice of solution The survey contained 15 questions (Supplementary material). The variables were grouped by the following sections: demographic variables (age, gender and current academic degree) and clinical variables (anaesthesia expertise, years of anaesthesiology practice, US availability, use of US, reasons for not using US, training experience and complications). To assess the use of US guidance for the insertion of central venous catheters, we used a passive question to reduce the risk of bias (Do you use US guidance for insertion of central venous catheter?) and the answer options for that question were ‘Always’, ‘Sometimes’, ‘Rarely’ and ‘Never’. For purposes of statistical analysis, we categorised this variable in ‘Use of ultrasound’ that included the options Always/Sometimes and ‘Do not use ultrasound’ included Rarely/Never. The first option was used as the main outcome under study. Specialised personnel from the SCARE designed the interface of the electronic web-based survey. The format and answer options were carefully revised and all authors discussed the questions before delivering such via email to the study population. Data analysis The time interval between delivering the survey and closing the option for input was 2 months. First, an initial exploratory analysis of the respondents was performed by describing the quantitative variables in averages with their respective standard deviations (SD) or median with interquartile ranges (IQR) according to the normal data distribution. Qualitative variables were expressed with absolute values as frequencies or proportions, with their respective 95% confidence interval (95% CI). Thereafter, a univariate analysis was performed, comparing the variables in order to use (grouping the options ‘Always’ and ‘Sometimes’) or not use (grouping the options ‘Rarely’ and ‘Never’) US for CVC. Comparison of qualitative variables was performed by using chi-squared test (χ2) and Student’s t-test. We conducted a logistic regression for the multivariate analysis by using a model that includes age, gender and professional degree. We calculated the linear trend for the relation of age versus percentage of US users. We considered a P-value <0.05 as statistically significant. The data was analysed in the R statistical software [14]. Evaluation Participants From July to September 2016, 351 responses were collected, which resulted in a response rate of 12.3% (351/2850). The respondents were predominantly general anaesthesiologists 76% (n = 266), followed by other fellowships, such as cardiovascular anaesthesia 9% (n = 30), intensive care 6% (n = 20), neuro-anaesthesia 3% (n = 10), paediatric anaesthesia 2% (n = 7), obstetric anaesthesia 1% (n = 4) and other subspecialisations 4% (n = 14). The mean age of the respondents was 44 years (SD = 9.9 years) and the male:female ratio was 3.2:1. Use of US guidance during CVC insertion The proportion of respondents who reported using US sometimes and always for guidance during CVC was 45% (95% CI 39–50%) (n = 157). Table 1 shows the characteristics of the US-guided CVC by Colombian anaesthesiologists. Table 1 Characteristics of the US-guided technique for CVC by Colombian anaesthesiologists (n = 157) Characteristic n (%) Time of US guidance  Since the beginning of the procedure 153 (97)  When there are difficulties of insertion 4 (3) Technique used  Real-time US-guided insertion 156 (99)  Anatomic assessment without guidance 1 (1) Needle approach  In plane 76 (48)  Out of plane 81 (52) Characteristic n (%) Time of US guidance  Since the beginning of the procedure 153 (97)  When there are difficulties of insertion 4 (3) Technique used  Real-time US-guided insertion 156 (99)  Anatomic assessment without guidance 1 (1) Needle approach  In plane 76 (48)  Out of plane 81 (52) Abbreviations: US, ultrasound; CVC, central venous catheterisation. Table 1 Characteristics of the US-guided technique for CVC by Colombian anaesthesiologists (n = 157) Characteristic n (%) Time of US guidance  Since the beginning of the procedure 153 (97)  When there are difficulties of insertion 4 (3) Technique used  Real-time US-guided insertion 156 (99)  Anatomic assessment without guidance 1 (1) Needle approach  In plane 76 (48)  Out of plane 81 (52) Characteristic n (%) Time of US guidance  Since the beginning of the procedure 153 (97)  When there are difficulties of insertion 4 (3) Technique used  Real-time US-guided insertion 156 (99)  Anatomic assessment without guidance 1 (1) Needle approach  In plane 76 (48)  Out of plane 81 (52) Abbreviations: US, ultrasound; CVC, central venous catheterisation. The participants with US equipment available ‘all the time’ in their workplaces were 62.7% (n = 220). The main reason given for not using or only having limited use of US guidance for CVC was the lack of US equipment in 50% of cases (n = 174) while a minority admitted that the use of US exceeds their clinical abilities 5% (n = 18). The training on this technique was variable, 50.4% (n = 177) of the respondents have had external courses, 22.8% (n = 80) have acquired experience from colleagues, 29.3% (n = 103) from empirical experience and 16% (n = 56) have never received training on this technique. Determinants of the use of US guidance Univariate analysis showed that age (<40 years) and availability of US were related with the use of US for CVC. Figure 1 illustrates the linear trend of the use of US depending on age (P < 0.001). After adjusting for covariates (gender and professional degree) availability of US was an independent factor associated with use of the technique. Table 2 shows details of the univariate and multivariate analyses. Figure 1 View largeDownload slide Relationship between age and proportion of US use during CVC (n = 351). Figure 1 View largeDownload slide Relationship between age and proportion of US use during CVC (n = 351). Table 2 Univariate and multivariate analyses for the relation between covariates and the use of US guidance during CVC (n = 351) Variable Univariate analysis Multivariate analysis OR P-value Adjusted OR (95% CI) P-value Age (years)  ≥61 Ref. Ref.  56–60 0.83 0.77 0.61 [0.11–3.30] 0.57  51–55 0.88 0.84 0.33 [0.06–1.62] 0.17  46–50 2.34 0.14 2.50 [0.51–12.1] 0.26  41–45 2.00 0.23 1.72 [0.35–8.32] 0.50  36–40 3.48 0.03 2.78 [0.58–13.2] 0.20  31–35 2.71 0.07 2.77 [0.58–13.1] 0.20  ≤30 4.74 0.05 3.11 [0.38–25.3] 0.29 Gender  Male Ref. Ref.  Female 2.14 0.01 1.29 [0.55–3.05] 0.55 Type of anaesthesia practice  General Ref. Ref.  Cardiovascular 2.64 0.06 2.78 [0.79–9.77] 0.11  Intensive care 1.20 0.68 1.99 [0.56–7.02] 0.28  Neuro-anaesthesia 2.10 0.35 1.45 [0.14–15.2] 0.75  Other 1.60 0.29 0.76 [0.16–3.49] 0.73 Technology availability  Not available Ref. Ref.  Available 27.4 <0.001 38.6 [18.5–80.3] <0.001 Variable Univariate analysis Multivariate analysis OR P-value Adjusted OR (95% CI) P-value Age (years)  ≥61 Ref. Ref.  56–60 0.83 0.77 0.61 [0.11–3.30] 0.57  51–55 0.88 0.84 0.33 [0.06–1.62] 0.17  46–50 2.34 0.14 2.50 [0.51–12.1] 0.26  41–45 2.00 0.23 1.72 [0.35–8.32] 0.50  36–40 3.48 0.03 2.78 [0.58–13.2] 0.20  31–35 2.71 0.07 2.77 [0.58–13.1] 0.20  ≤30 4.74 0.05 3.11 [0.38–25.3] 0.29 Gender  Male Ref. Ref.  Female 2.14 0.01 1.29 [0.55–3.05] 0.55 Type of anaesthesia practice  General Ref. Ref.  Cardiovascular 2.64 0.06 2.78 [0.79–9.77] 0.11  Intensive care 1.20 0.68 1.99 [0.56–7.02] 0.28  Neuro-anaesthesia 2.10 0.35 1.45 [0.14–15.2] 0.75  Other 1.60 0.29 0.76 [0.16–3.49] 0.73 Technology availability  Not available Ref. Ref.  Available 27.4 <0.001 38.6 [18.5–80.3] <0.001 R2 = 0.57. Table 2 Univariate and multivariate analyses for the relation between covariates and the use of US guidance during CVC (n = 351) Variable Univariate analysis Multivariate analysis OR P-value Adjusted OR (95% CI) P-value Age (years)  ≥61 Ref. Ref.  56–60 0.83 0.77 0.61 [0.11–3.30] 0.57  51–55 0.88 0.84 0.33 [0.06–1.62] 0.17  46–50 2.34 0.14 2.50 [0.51–12.1] 0.26  41–45 2.00 0.23 1.72 [0.35–8.32] 0.50  36–40 3.48 0.03 2.78 [0.58–13.2] 0.20  31–35 2.71 0.07 2.77 [0.58–13.1] 0.20  ≤30 4.74 0.05 3.11 [0.38–25.3] 0.29 Gender  Male Ref. Ref.  Female 2.14 0.01 1.29 [0.55–3.05] 0.55 Type of anaesthesia practice  General Ref. Ref.  Cardiovascular 2.64 0.06 2.78 [0.79–9.77] 0.11  Intensive care 1.20 0.68 1.99 [0.56–7.02] 0.28  Neuro-anaesthesia 2.10 0.35 1.45 [0.14–15.2] 0.75  Other 1.60 0.29 0.76 [0.16–3.49] 0.73 Technology availability  Not available Ref. Ref.  Available 27.4 <0.001 38.6 [18.5–80.3] <0.001 Variable Univariate analysis Multivariate analysis OR P-value Adjusted OR (95% CI) P-value Age (years)  ≥61 Ref. Ref.  56–60 0.83 0.77 0.61 [0.11–3.30] 0.57  51–55 0.88 0.84 0.33 [0.06–1.62] 0.17  46–50 2.34 0.14 2.50 [0.51–12.1] 0.26  41–45 2.00 0.23 1.72 [0.35–8.32] 0.50  36–40 3.48 0.03 2.78 [0.58–13.2] 0.20  31–35 2.71 0.07 2.77 [0.58–13.1] 0.20  ≤30 4.74 0.05 3.11 [0.38–25.3] 0.29 Gender  Male Ref. Ref.  Female 2.14 0.01 1.29 [0.55–3.05] 0.55 Type of anaesthesia practice  General Ref. Ref.  Cardiovascular 2.64 0.06 2.78 [0.79–9.77] 0.11  Intensive care 1.20 0.68 1.99 [0.56–7.02] 0.28  Neuro-anaesthesia 2.10 0.35 1.45 [0.14–15.2] 0.75  Other 1.60 0.29 0.76 [0.16–3.49] 0.73 Technology availability  Not available Ref. Ref.  Available 27.4 <0.001 38.6 [18.5–80.3] <0.001 R2 = 0.57. Lessons learned This study describes the current patterns of using US for CVC among Colombian anaesthesiologists. Our results demonstrated that US guidance is not a common practice for CVC and it appears that availability of this technology is an important limitation to its use. The prevalence of US guidance for CVC by Colombian anaesthesiologists was 45%. The range of proportions reported in the literature varies between 15% and 96% [13, 15–20], depending on the population, year of the survey [16], country and other settings. Table 3 describes studies that have assessed the use of US for CVC. Note a high qualitative heterogeneity among studies clearly reflected in the different rates of US use. Our results show that Colombian anaesthesiologists, compared with other scenarios from high-income countries, underuse US. Table 3 Similar survey studies about use of US guidance during CVC insertion in other scenarios around the world Study Country Participants Percentage of US-guided CVC Comments Adhikari et al. [16] USA Emergency medicine residents 53%, 96% Increasing of ultrasound use from 2007 to 2013 Bailey et al. [13] USA Members of the Society of Cardiovascular Anaesthesiologists 15% (223/1494) Availability of US equipment was associated with use of US (OR = 18.9, P < 0.001) Bosman et al. [15] UK Paediatric anaesthesiologists 68% (133/196) Girard et al. [17] USA Surgery, anaesthesia, emergency medicine, internal medicine and family medicine house staff 15% (19/137) A total of 19 anaesthesiologists were surveyed, of which only five use US with a frequency of 21–60%. Lindgren et al. [18] Sweden Anaesthesiology and intensive care departments 53% (26/49) Schummer et al. [19] Germany Anaesthesia departments 40% (188/468) 12.7% routinely and 60% when faced difficulties Soni et al. [20] USA Intensivist and Hospitalist 82.5% (647/784) US guidance varied by site from 80% for internal jugular vein to 31% in subclavian vein Tovey et al. [21] UK Paediatric anaesthesiologists 49% (104/212) Study Country Participants Percentage of US-guided CVC Comments Adhikari et al. [16] USA Emergency medicine residents 53%, 96% Increasing of ultrasound use from 2007 to 2013 Bailey et al. [13] USA Members of the Society of Cardiovascular Anaesthesiologists 15% (223/1494) Availability of US equipment was associated with use of US (OR = 18.9, P < 0.001) Bosman et al. [15] UK Paediatric anaesthesiologists 68% (133/196) Girard et al. [17] USA Surgery, anaesthesia, emergency medicine, internal medicine and family medicine house staff 15% (19/137) A total of 19 anaesthesiologists were surveyed, of which only five use US with a frequency of 21–60%. Lindgren et al. [18] Sweden Anaesthesiology and intensive care departments 53% (26/49) Schummer et al. [19] Germany Anaesthesia departments 40% (188/468) 12.7% routinely and 60% when faced difficulties Soni et al. [20] USA Intensivist and Hospitalist 82.5% (647/784) US guidance varied by site from 80% for internal jugular vein to 31% in subclavian vein Tovey et al. [21] UK Paediatric anaesthesiologists 49% (104/212) Table 3 Similar survey studies about use of US guidance during CVC insertion in other scenarios around the world Study Country Participants Percentage of US-guided CVC Comments Adhikari et al. [16] USA Emergency medicine residents 53%, 96% Increasing of ultrasound use from 2007 to 2013 Bailey et al. [13] USA Members of the Society of Cardiovascular Anaesthesiologists 15% (223/1494) Availability of US equipment was associated with use of US (OR = 18.9, P < 0.001) Bosman et al. [15] UK Paediatric anaesthesiologists 68% (133/196) Girard et al. [17] USA Surgery, anaesthesia, emergency medicine, internal medicine and family medicine house staff 15% (19/137) A total of 19 anaesthesiologists were surveyed, of which only five use US with a frequency of 21–60%. Lindgren et al. [18] Sweden Anaesthesiology and intensive care departments 53% (26/49) Schummer et al. [19] Germany Anaesthesia departments 40% (188/468) 12.7% routinely and 60% when faced difficulties Soni et al. [20] USA Intensivist and Hospitalist 82.5% (647/784) US guidance varied by site from 80% for internal jugular vein to 31% in subclavian vein Tovey et al. [21] UK Paediatric anaesthesiologists 49% (104/212) Study Country Participants Percentage of US-guided CVC Comments Adhikari et al. [16] USA Emergency medicine residents 53%, 96% Increasing of ultrasound use from 2007 to 2013 Bailey et al. [13] USA Members of the Society of Cardiovascular Anaesthesiologists 15% (223/1494) Availability of US equipment was associated with use of US (OR = 18.9, P < 0.001) Bosman et al. [15] UK Paediatric anaesthesiologists 68% (133/196) Girard et al. [17] USA Surgery, anaesthesia, emergency medicine, internal medicine and family medicine house staff 15% (19/137) A total of 19 anaesthesiologists were surveyed, of which only five use US with a frequency of 21–60%. Lindgren et al. [18] Sweden Anaesthesiology and intensive care departments 53% (26/49) Schummer et al. [19] Germany Anaesthesia departments 40% (188/468) 12.7% routinely and 60% when faced difficulties Soni et al. [20] USA Intensivist and Hospitalist 82.5% (647/784) US guidance varied by site from 80% for internal jugular vein to 31% in subclavian vein Tovey et al. [21] UK Paediatric anaesthesiologists 49% (104/212) To our best knowledge, sufficient evidence is unavailable about US use for CVC in developing countries. Despite the potential of US-based imaging to improve the diagnosis of many medical conditions and to guide individual patient management, we know little about current practices in low- and middle-income countries, such as the extent of use of portable US devices, major indications for the use of US techniques and impact on patient outcome. A recent systematic review did not find any study on the use of US during CVC [22]. Most current applications focus on obstetrical and abdominal complaints, with a lack of high-quality evidence from developing countries [22]. In terms of procedural US in the developing world, most evidence relates to peripheral venous access, ultrasound-guided thoracentesis or paracentesis and regional anaesthesia [23]. A well-documented association exists between availability of US equipment and use of this technique for CVC [11, 20]. Our survey reports conflictive results in terms of using US in operating rooms. Although 62% of the participants report having US equipment inside the operating room, they also report the absence of equipment as a reason for not using it. Many hospitals in Colombia only have a single portable US device for use in many services and wards. Therefore, knowing that the equipment is available at the hospital does not guarantee its use all the time; this could explain the difference between availability and actual usage during CVC. Access to US has increased significantly in resource-limited settings, including the developing world. A survey on perceived barriers in the use of US in low- and middle-income settings identified lack of training as a primary barrier to regular use of US in their practice, followed by lack of equipment. Equipment requirements, including maintenance and cost of machines, are also important factors [24]. Our results show availability of equipment as an independent factor for using the technique among respondents, but this potential association should be taken with caution due to the very high uncertainty with the broad CI of the estimation. The World Bank currently identifies Colombia as a middle-income country, but it is still in the process of developing a modern healthcare and academic system. Most anaesthesiology residency programs in Colombia have begun to incorporate US into their education, training, and clinical practice to improve the quality and safety of healthcare. However, even in some of Colombia’s most advanced urban university-based hospitals, limited resources are still a reality. In addition, there is a lack of evidence related with the current use of procedural US. Henwood et al. [25] conducted a nationwide survey of Colombian emergency medicine residents designed to explore the state of US use and examine barriers for its expansion. The most frequently indicated barriers to ultrasound use were lack of instructors, equipment and time. We consider this finding could also be valid for anaesthesiologists and other specialisations. Patient safety is a priority in this revolutionary era of technology [26, 27]; catheterisations have inherent risks of mechanical, infectious and haemodynamic complications [16]. Mechanical complications (e.g. arterial puncture, failure rates of insertion, haemothorax and pneumothorax) are common and independently increased by the number of attempts [28]. A recent Cochrane systematic review compared US guidance versus a landmark technique for CVC and concluded that US guidance is significantly associated with lower number of attempts needed for successful catheterisation, increased chances of success at the first attempt, and reduced possibilities of haematoma formation. However, this technique did not show a significant reduction in mechanical complications, such as arterial punctures or time for successful catheterisation [6]. The infectious risk of US equipment is a controversial concern of this technique. This concern is based on a recent outbreak in which sterile gel acted as a vehicle for the spread of infection to patients. This led to a product safety alert by the United States Food and Drug Administration [29]. However, a recent prospective observational study rejected this hypothetical association [30]. In this study, age seems to be related to not using US guidance during CVC. We found a non-adjusted linear trend depending on the age of the anaesthesiologist, which disappeared after multivariate analysis. Regarding this finding, there is growing evidence on the effect of age on practitioners’ performance. Aging is associated with decreased processing speed, limiting ability to complete complex tasks, increased difficulty for information processing, reduced hearing and visual acuity, and decreased manual dexterity and visuospatial ability [31–34]. US guidance requires motor and visuospatial skills that aging practitioners may have not acquired or have lost. In addition, young anaesthesiologists could have greater exposure to US training during their residency programmes. On the other hand, older practitioners may feel they have developed enough experience allowing them to perform the insertion without the US technique. Study limitations This study had important limitations, including a small sample size. We used the database of all anaesthesiologists registered in SCARE (~2850) although many of them are not active practitioners. The response rate can be considered acceptable, compared with other similar online-based surveys. Additionally, the respondents using US guidance could be more motivated to complete the questionnaire in which case the frequency of use of US for CVC in this study would be overestimated. Another limitation is the study design in which the accuracy and self-reporting information from participants was assumed correct because direct observations were not conducted. All the questions included in our survey were closed ended, which might have introduced response bias. Finally, the questions used in the questionnaire did not distinguish the use of US for internal jugular, subclavian, or femoral vein catheterisation. Conclusion Use of US for CVC is not a common practice among Colombian anaesthesiologists. Limited availability of this technology in healthcare centres hinders the use of this technique. Only half of the respondents have taken an external course to learn about US Management, the rest admitted to acquiring experience by themselves or from colleagues. More education and strict compliance of protocols on this technology would be helpful for safer CVC. Further, US guidance can be used in many other procedural applications, like regional anaesthesia, basic echocardiography, vascular assessment, pleural drainage, pulmonary US, and others, ensuring safety and quality of care. References 1 Reusz G , Csomos A . The role of ultrasound guidance for vascular access . Curr Opin Anaesthesiol 2015 ; 28 : 710 – 6 . Google Scholar PubMed 2 Legler D , Nugent M . Doppler localization of the internal jugular vein facilitates central venous cannulation . Anesthesiology 1984 ; 60 : 481 – 2 . Google Scholar Crossref Search ADS PubMed 3 Yonei A , Nonoue T , Sari A . Real-time ultrasonic guidance for percutaneous puncture of the internal jugular vein . Anesthesiology 1986 ; 64 : 830 – 1 . Google Scholar Crossref Search ADS PubMed 4 Lalu MM , Fayad A , Ahmed O et al. . Ultrasound-guided subclavian vein catheterisation: a systematic review and meta- analysis . Crit Care Med 2015 ; 43 : 1498 – 507 . Google Scholar Crossref Search ADS PubMed 5 White L , Halpin A , Turner M et al. . Ultrasound-guided radial artery cannulation in adult and paediatric populations: a systematic review and meta-analysis . Br J Anaesth 2016 ; 116 : 610 – 7 . Google Scholar Crossref Search ADS PubMed 6 Brass P , Hellmich M , Kolodziej L et al. . Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterisation . Cochrane Database Syst Rev 2015 ; 1 : CD006962 . Google Scholar PubMed 7 Kumada K , Murakami N , Okada H et al. . Rare central venous catheter malposition—an ultrasound-guided approach would be helpful: a case report . J Med Case Rep 2016 ; 10 : 248 . Google Scholar Crossref Search ADS PubMed 8 Troianos CA , Hartman GS , Glas KE et al. . Special articles: guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists . Anesth Analg 2012 ; 114 : 46 – 72 . Google Scholar Crossref Search ADS PubMed 9 NICE . Guidance on the use of ultrasound locating devices for placing central venous catheters. Technology appraisal guidance. 2002 ; 49. 10 O’Grady NP , Alexander M , Dellinger EP et al. . Guidelines for the prevention of intravascular catheter-related infections . Clin Infect Dis 2002 ; 35 : 1281 – 307 . Google Scholar Crossref Search ADS 11 Shekelle PG , Wachter RM , Pronovost PJ et al. . Making health care safer II: an updated critical analysis of the evidence for patient safety practices . Evid Rep Technol Assess (Full Rep) 2013 ; 211 : 1 – 945 . 12 Frykholm P , Pikwer A , Hammarskjold F et al. . Clinical guidelines on central venous catheterisation. Swedish Society of Anaesthesiology and Intensive Care Medicine . Acta Anaesthesiol Scand 2014 ; 58 : 508 – 24 . Google Scholar Crossref Search ADS PubMed 13 Bailey PL , Glance LG , Eaton MP et al. . A survey of the use of ultrasound during central venous catheterisation . Anesth Analg 2007 ; 104 : 491 – 7 . Google Scholar Crossref Search ADS PubMed 14 R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. 2013. ISBN 3-900051-07-0; 2014 . 15 Bosman M , Kavanagh RJ . Two dimensional ultrasound guidance in central venous catheter placement; a postal survey of the practice and opinions of consultant pediatric anesthetists in the United Kingdom . Paediatr Anaesth 2006 ; 16 : 530 – 7 . Google Scholar Crossref Search ADS PubMed 16 Adhikari S , Theodoro D , Raio C et al. . Central venous catheterisation: are we using ultrasound guidance? J Ultrasound Med 2015 ; 34 : 2065 – 70 . Google Scholar Crossref Search ADS PubMed 17 Girard TD , Schectman JM . Ultrasound guidance during central venous catheterisation: a survey of use by house staff physicians . J Crit Care 2005 ; 20 : 224 – 9 . Google Scholar Crossref Search ADS PubMed 18 Lindgren S , Pikwer A , Ricksten SE et al. . Survey of central venous catheterisation practice in Sweden . Acta Anaesthesiol Scand 2013 ; 57 : 1237 – 44 . Google Scholar Crossref Search ADS PubMed 19 Schummer W , Sakka SG , Huttemann E et al. . Ultrasound guidance for placement control of central venous catheterisation. Survey of 802 anesthesia departments for 2007 in Germany . Anaesthesist 2009 ; 58 : 677 – 85 . Google Scholar Crossref Search ADS PubMed 20 Soni NJ , Reyes LF , Keyt H et al. . Use of ultrasound guidance for central venous catheterisation: a national survey of intensivists and hospitalists . J Critl Care 2016 ; 36 : 277 – 83 . Google Scholar Crossref Search ADS 21 Tovey G , Stokes M . A survey of the use of 2D ultrasound guidance for insertion of central venous catheters by UK consultant paediatric anaesthetists . Eur J Anaesthesiol 2007 ; 24 : 71 – 5 . Google Scholar Crossref Search ADS PubMed 22 Becker DM , Tafoya CA , Becker SL et al. . The use of portable ultrasound devices in low- and middle-income countries: a systematic review of the literature . Trop Med Int Health 2016 ; 21 : 294 – 311 . Google Scholar Crossref Search ADS PubMed 23 Sippel S , Muruganandan K , Levine A et al. . Review article: use of ultrasound in the developing world . Int J Emerg Med 2011 ; 4 : 72 . Google Scholar Crossref Search ADS PubMed 24 Shah S , Bellows BA , Adedipe AA et al. . Perceived barriers in the use of ultrasound in developing countries . Crit Ultrasound J 2015 ; 7 : 28 . Google Scholar Crossref Search ADS PubMed 25 Henwood PC , Beversluis D , Genthon AA et al. . Characterizing the limited use of point-of-care ultrasound in Colombian emergency medicine residencies . Int J Emerg Med 2014 ; 7 : 7 . Google Scholar Crossref Search ADS PubMed 26 Werner HC , Vieira RL , Rempell RG et al. . An educational intervention to improve ultrasound competency in ultrasound-guided central venous access . Pediatr Emerg Care 2016 ; 32 : 1 – 5 . Google Scholar Crossref Search ADS PubMed 27 Cho YJ , Han SS , Lee SC . Guidewire malposition during central venous catheterisation despite the use of ultrasound guidance . Korean J Anesthesiol 2013 ; 64 : 469 – 71 . Google Scholar Crossref Search ADS PubMed 28 Calvache JA , Rodríguez MV , Trochez A et al. . Incidence of mechanical complications of central venous catheterisation using landmark technique: do not try more than 3 times . J Intensive Care Med 2016 ; 31 : 397 – 402 . Google Scholar Crossref Search ADS PubMed 29 Chittick P , Russo V , Sims M et al. . An outbreak of Pseudomonas aeruginosa respiratory tract infections associated with intrinsically contaminated ultrasound transmission gel . Infect Control Hosp Epidemiol 2013 ; 34 : 850 – 3 . Google Scholar Crossref Search ADS PubMed 30 Cartier V , Haenny A , Inan C et al. . No association between ultrasound-guided insertion of central venous catheters and bloodstream infection: a prospective observational study . J Hosp Infect 2014 ; 87 : 103 – 8 . Google Scholar Crossref Search ADS PubMed 31 Choudhry NK , Fletcher RH , Soumerai SB . Systematic review: the relationship between clinical experience and quality of health care . Ann Intern Med 2005 ; 142 : 260 – 73 . Google Scholar Crossref Search ADS PubMed 32 Eva KW . Stemming the tide: cognitive aging theories and their implications for continuing education in the health professions . J Contin Educ Health Prof 2003 ; 23 : 133 – 40 . Google Scholar Crossref Search ADS PubMed 33 Eva KW . The aging physician: changes in cognitive processing and their impact on medical practice . Acad Med 2002 ; 77 : S1 – 6 . Google Scholar Crossref Search ADS PubMed 34 Dellinger EP , Pellegrini CA , Gallagher TH . The aging physician and the medical profession: a review . JAMA Surg 2017 ; 152 : 967 – 71 . Google Scholar Crossref Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal for Quality in Health Care Oxford University Press

Loading next page...
 
/lp/ou_press/ultrasound-guidance-for-central-venous-catheterisation-a-colombian-0QqnvhtE0V
Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
ISSN
1353-4505
eISSN
1464-3677
D.O.I.
10.1093/intqhc/mzy066
Publisher site
See Article on Publisher Site

Abstract

Abstract Quality problem or issue Ultrasound (US) is a widely propagated medical technology. Anaesthesiologists increase procedural safety by using US techniques, but training and availability are essential for its usage. Although its utility for central venous catheterisation (CVC) is well established, only a paucity of evidence is available regarding its use in low- and middle-income countries. This study is a nationwide survey of Colombian anaesthesiologists designed to explore the current use of US guidance for CVC. Initial assessment and implementation Web-based survey at National level. Anaesthesiologists registered in the Colombian Society of Anaesthesiology and Resuscitation database. Choice of solution Demographic variables (age and gender), anaesthesia expertise, years of anaesthesiology practice, US availability, use of US during CVC, reasons for not using US and training experience were collected. Evaluation Of 351 respondents (12.3% response rate), 45% reported using US sometimes and always for CVC (95% CI 39%–50%) (n = 157). Most anaesthesiologists obtained training in US through external courses (50.4%) or from colleagues (22.8%). Of the total respondents, 62.7% (n = 220) have US equipment available at all time and this factor was independently associated with the use of US for CVC (adjusted odds ratio [OR] = 38.6, P < 0.001). Lessons learned US guidance is not a common technique used for CVC by Colombian anaesthesiologists; an important barrier for its use is lack of equipment. ultrasound, central venous catheterisation, patient safety Quality problem or issue Introduction of ultrasound (US) in the medical practice has shown several benefits in the safety of numerous procedures [1]. US-guided insertion of central venous catheter has become a highly recommended or even mandatory technique, according to several guidelines and protocols of venous catheterisation [1]. In 1984, Legler et al. [2] used the Doppler technique (ultrasonic Doppler, doppler study or evaluation) to guide jugular venous catheterisations. Two years later, Yonei et al. [3], used 2D-US to insert central venous catheters. Since then, this technique has improved in terms of precision, safety and availability for healthcare workers. CVC is a common procedure performed by anaesthesiologists and many physicians in the emergency department and intensive care units [1]. US has proven to be a good complementary strategy for CVC because of a great number of benefits, like increased success rates [1, 4], reduced number of attempts and shorter time required to perform the procedure compared with a landmark technique [4, 5] and lessened complications (e.g. malposition, lung or vascular injuries, pneumothorax and thrombosis) [5–7]. Because of these advantages, several medical organisations and government agencies advocate the use of this technique and encourage its propagation across all healthcare centres [8–12]. Despite these recommendations, many limitations and barriers still exist for US to become a universal technique for CVC and other anaesthesia-related procedures. Some of the major barriers are the access to a device and the requirement of advanced training and experience [13]. US-guided insertion of central venous catheters is considered a common practice in developed countries; however, there is a lack of information about the patterns of using this technique in low-income countries. We sought to describe and analyse the current use of US guidance for insertion of central venous catheters by Colombian anaesthesiologists. Initial assessment and implementation Approach The Institutional Review Board and the Research Ethics Committee from the Colombian Society of Anaesthesiology and Resuscitation (SCARE, for the term in Spanish) approved this study. Inclusion of participants in this study required electronic acceptance, but the written consent was waived by the committee because of the low risk represented by this study and the strict confidentiality and anonymity strategies for data management. Sampling and recruitment This study involved anaesthesiologists and fellows in anaesthesia registered in the SCARE database. Inclusion criteria included being registered in the database and accepting to answer an electronic web-based survey sent via email. There were no exclusion criteria. Two people with prior training from the authors of the protocol at the Universidad del Cauca in Colombia conducted the questionnaire and collected the data without knowledge of the study objectives to avoid observer-expectancy bias. Choice of solution The survey contained 15 questions (Supplementary material). The variables were grouped by the following sections: demographic variables (age, gender and current academic degree) and clinical variables (anaesthesia expertise, years of anaesthesiology practice, US availability, use of US, reasons for not using US, training experience and complications). To assess the use of US guidance for the insertion of central venous catheters, we used a passive question to reduce the risk of bias (Do you use US guidance for insertion of central venous catheter?) and the answer options for that question were ‘Always’, ‘Sometimes’, ‘Rarely’ and ‘Never’. For purposes of statistical analysis, we categorised this variable in ‘Use of ultrasound’ that included the options Always/Sometimes and ‘Do not use ultrasound’ included Rarely/Never. The first option was used as the main outcome under study. Specialised personnel from the SCARE designed the interface of the electronic web-based survey. The format and answer options were carefully revised and all authors discussed the questions before delivering such via email to the study population. Data analysis The time interval between delivering the survey and closing the option for input was 2 months. First, an initial exploratory analysis of the respondents was performed by describing the quantitative variables in averages with their respective standard deviations (SD) or median with interquartile ranges (IQR) according to the normal data distribution. Qualitative variables were expressed with absolute values as frequencies or proportions, with their respective 95% confidence interval (95% CI). Thereafter, a univariate analysis was performed, comparing the variables in order to use (grouping the options ‘Always’ and ‘Sometimes’) or not use (grouping the options ‘Rarely’ and ‘Never’) US for CVC. Comparison of qualitative variables was performed by using chi-squared test (χ2) and Student’s t-test. We conducted a logistic regression for the multivariate analysis by using a model that includes age, gender and professional degree. We calculated the linear trend for the relation of age versus percentage of US users. We considered a P-value <0.05 as statistically significant. The data was analysed in the R statistical software [14]. Evaluation Participants From July to September 2016, 351 responses were collected, which resulted in a response rate of 12.3% (351/2850). The respondents were predominantly general anaesthesiologists 76% (n = 266), followed by other fellowships, such as cardiovascular anaesthesia 9% (n = 30), intensive care 6% (n = 20), neuro-anaesthesia 3% (n = 10), paediatric anaesthesia 2% (n = 7), obstetric anaesthesia 1% (n = 4) and other subspecialisations 4% (n = 14). The mean age of the respondents was 44 years (SD = 9.9 years) and the male:female ratio was 3.2:1. Use of US guidance during CVC insertion The proportion of respondents who reported using US sometimes and always for guidance during CVC was 45% (95% CI 39–50%) (n = 157). Table 1 shows the characteristics of the US-guided CVC by Colombian anaesthesiologists. Table 1 Characteristics of the US-guided technique for CVC by Colombian anaesthesiologists (n = 157) Characteristic n (%) Time of US guidance  Since the beginning of the procedure 153 (97)  When there are difficulties of insertion 4 (3) Technique used  Real-time US-guided insertion 156 (99)  Anatomic assessment without guidance 1 (1) Needle approach  In plane 76 (48)  Out of plane 81 (52) Characteristic n (%) Time of US guidance  Since the beginning of the procedure 153 (97)  When there are difficulties of insertion 4 (3) Technique used  Real-time US-guided insertion 156 (99)  Anatomic assessment without guidance 1 (1) Needle approach  In plane 76 (48)  Out of plane 81 (52) Abbreviations: US, ultrasound; CVC, central venous catheterisation. Table 1 Characteristics of the US-guided technique for CVC by Colombian anaesthesiologists (n = 157) Characteristic n (%) Time of US guidance  Since the beginning of the procedure 153 (97)  When there are difficulties of insertion 4 (3) Technique used  Real-time US-guided insertion 156 (99)  Anatomic assessment without guidance 1 (1) Needle approach  In plane 76 (48)  Out of plane 81 (52) Characteristic n (%) Time of US guidance  Since the beginning of the procedure 153 (97)  When there are difficulties of insertion 4 (3) Technique used  Real-time US-guided insertion 156 (99)  Anatomic assessment without guidance 1 (1) Needle approach  In plane 76 (48)  Out of plane 81 (52) Abbreviations: US, ultrasound; CVC, central venous catheterisation. The participants with US equipment available ‘all the time’ in their workplaces were 62.7% (n = 220). The main reason given for not using or only having limited use of US guidance for CVC was the lack of US equipment in 50% of cases (n = 174) while a minority admitted that the use of US exceeds their clinical abilities 5% (n = 18). The training on this technique was variable, 50.4% (n = 177) of the respondents have had external courses, 22.8% (n = 80) have acquired experience from colleagues, 29.3% (n = 103) from empirical experience and 16% (n = 56) have never received training on this technique. Determinants of the use of US guidance Univariate analysis showed that age (<40 years) and availability of US were related with the use of US for CVC. Figure 1 illustrates the linear trend of the use of US depending on age (P < 0.001). After adjusting for covariates (gender and professional degree) availability of US was an independent factor associated with use of the technique. Table 2 shows details of the univariate and multivariate analyses. Figure 1 View largeDownload slide Relationship between age and proportion of US use during CVC (n = 351). Figure 1 View largeDownload slide Relationship between age and proportion of US use during CVC (n = 351). Table 2 Univariate and multivariate analyses for the relation between covariates and the use of US guidance during CVC (n = 351) Variable Univariate analysis Multivariate analysis OR P-value Adjusted OR (95% CI) P-value Age (years)  ≥61 Ref. Ref.  56–60 0.83 0.77 0.61 [0.11–3.30] 0.57  51–55 0.88 0.84 0.33 [0.06–1.62] 0.17  46–50 2.34 0.14 2.50 [0.51–12.1] 0.26  41–45 2.00 0.23 1.72 [0.35–8.32] 0.50  36–40 3.48 0.03 2.78 [0.58–13.2] 0.20  31–35 2.71 0.07 2.77 [0.58–13.1] 0.20  ≤30 4.74 0.05 3.11 [0.38–25.3] 0.29 Gender  Male Ref. Ref.  Female 2.14 0.01 1.29 [0.55–3.05] 0.55 Type of anaesthesia practice  General Ref. Ref.  Cardiovascular 2.64 0.06 2.78 [0.79–9.77] 0.11  Intensive care 1.20 0.68 1.99 [0.56–7.02] 0.28  Neuro-anaesthesia 2.10 0.35 1.45 [0.14–15.2] 0.75  Other 1.60 0.29 0.76 [0.16–3.49] 0.73 Technology availability  Not available Ref. Ref.  Available 27.4 <0.001 38.6 [18.5–80.3] <0.001 Variable Univariate analysis Multivariate analysis OR P-value Adjusted OR (95% CI) P-value Age (years)  ≥61 Ref. Ref.  56–60 0.83 0.77 0.61 [0.11–3.30] 0.57  51–55 0.88 0.84 0.33 [0.06–1.62] 0.17  46–50 2.34 0.14 2.50 [0.51–12.1] 0.26  41–45 2.00 0.23 1.72 [0.35–8.32] 0.50  36–40 3.48 0.03 2.78 [0.58–13.2] 0.20  31–35 2.71 0.07 2.77 [0.58–13.1] 0.20  ≤30 4.74 0.05 3.11 [0.38–25.3] 0.29 Gender  Male Ref. Ref.  Female 2.14 0.01 1.29 [0.55–3.05] 0.55 Type of anaesthesia practice  General Ref. Ref.  Cardiovascular 2.64 0.06 2.78 [0.79–9.77] 0.11  Intensive care 1.20 0.68 1.99 [0.56–7.02] 0.28  Neuro-anaesthesia 2.10 0.35 1.45 [0.14–15.2] 0.75  Other 1.60 0.29 0.76 [0.16–3.49] 0.73 Technology availability  Not available Ref. Ref.  Available 27.4 <0.001 38.6 [18.5–80.3] <0.001 R2 = 0.57. Table 2 Univariate and multivariate analyses for the relation between covariates and the use of US guidance during CVC (n = 351) Variable Univariate analysis Multivariate analysis OR P-value Adjusted OR (95% CI) P-value Age (years)  ≥61 Ref. Ref.  56–60 0.83 0.77 0.61 [0.11–3.30] 0.57  51–55 0.88 0.84 0.33 [0.06–1.62] 0.17  46–50 2.34 0.14 2.50 [0.51–12.1] 0.26  41–45 2.00 0.23 1.72 [0.35–8.32] 0.50  36–40 3.48 0.03 2.78 [0.58–13.2] 0.20  31–35 2.71 0.07 2.77 [0.58–13.1] 0.20  ≤30 4.74 0.05 3.11 [0.38–25.3] 0.29 Gender  Male Ref. Ref.  Female 2.14 0.01 1.29 [0.55–3.05] 0.55 Type of anaesthesia practice  General Ref. Ref.  Cardiovascular 2.64 0.06 2.78 [0.79–9.77] 0.11  Intensive care 1.20 0.68 1.99 [0.56–7.02] 0.28  Neuro-anaesthesia 2.10 0.35 1.45 [0.14–15.2] 0.75  Other 1.60 0.29 0.76 [0.16–3.49] 0.73 Technology availability  Not available Ref. Ref.  Available 27.4 <0.001 38.6 [18.5–80.3] <0.001 Variable Univariate analysis Multivariate analysis OR P-value Adjusted OR (95% CI) P-value Age (years)  ≥61 Ref. Ref.  56–60 0.83 0.77 0.61 [0.11–3.30] 0.57  51–55 0.88 0.84 0.33 [0.06–1.62] 0.17  46–50 2.34 0.14 2.50 [0.51–12.1] 0.26  41–45 2.00 0.23 1.72 [0.35–8.32] 0.50  36–40 3.48 0.03 2.78 [0.58–13.2] 0.20  31–35 2.71 0.07 2.77 [0.58–13.1] 0.20  ≤30 4.74 0.05 3.11 [0.38–25.3] 0.29 Gender  Male Ref. Ref.  Female 2.14 0.01 1.29 [0.55–3.05] 0.55 Type of anaesthesia practice  General Ref. Ref.  Cardiovascular 2.64 0.06 2.78 [0.79–9.77] 0.11  Intensive care 1.20 0.68 1.99 [0.56–7.02] 0.28  Neuro-anaesthesia 2.10 0.35 1.45 [0.14–15.2] 0.75  Other 1.60 0.29 0.76 [0.16–3.49] 0.73 Technology availability  Not available Ref. Ref.  Available 27.4 <0.001 38.6 [18.5–80.3] <0.001 R2 = 0.57. Lessons learned This study describes the current patterns of using US for CVC among Colombian anaesthesiologists. Our results demonstrated that US guidance is not a common practice for CVC and it appears that availability of this technology is an important limitation to its use. The prevalence of US guidance for CVC by Colombian anaesthesiologists was 45%. The range of proportions reported in the literature varies between 15% and 96% [13, 15–20], depending on the population, year of the survey [16], country and other settings. Table 3 describes studies that have assessed the use of US for CVC. Note a high qualitative heterogeneity among studies clearly reflected in the different rates of US use. Our results show that Colombian anaesthesiologists, compared with other scenarios from high-income countries, underuse US. Table 3 Similar survey studies about use of US guidance during CVC insertion in other scenarios around the world Study Country Participants Percentage of US-guided CVC Comments Adhikari et al. [16] USA Emergency medicine residents 53%, 96% Increasing of ultrasound use from 2007 to 2013 Bailey et al. [13] USA Members of the Society of Cardiovascular Anaesthesiologists 15% (223/1494) Availability of US equipment was associated with use of US (OR = 18.9, P < 0.001) Bosman et al. [15] UK Paediatric anaesthesiologists 68% (133/196) Girard et al. [17] USA Surgery, anaesthesia, emergency medicine, internal medicine and family medicine house staff 15% (19/137) A total of 19 anaesthesiologists were surveyed, of which only five use US with a frequency of 21–60%. Lindgren et al. [18] Sweden Anaesthesiology and intensive care departments 53% (26/49) Schummer et al. [19] Germany Anaesthesia departments 40% (188/468) 12.7% routinely and 60% when faced difficulties Soni et al. [20] USA Intensivist and Hospitalist 82.5% (647/784) US guidance varied by site from 80% for internal jugular vein to 31% in subclavian vein Tovey et al. [21] UK Paediatric anaesthesiologists 49% (104/212) Study Country Participants Percentage of US-guided CVC Comments Adhikari et al. [16] USA Emergency medicine residents 53%, 96% Increasing of ultrasound use from 2007 to 2013 Bailey et al. [13] USA Members of the Society of Cardiovascular Anaesthesiologists 15% (223/1494) Availability of US equipment was associated with use of US (OR = 18.9, P < 0.001) Bosman et al. [15] UK Paediatric anaesthesiologists 68% (133/196) Girard et al. [17] USA Surgery, anaesthesia, emergency medicine, internal medicine and family medicine house staff 15% (19/137) A total of 19 anaesthesiologists were surveyed, of which only five use US with a frequency of 21–60%. Lindgren et al. [18] Sweden Anaesthesiology and intensive care departments 53% (26/49) Schummer et al. [19] Germany Anaesthesia departments 40% (188/468) 12.7% routinely and 60% when faced difficulties Soni et al. [20] USA Intensivist and Hospitalist 82.5% (647/784) US guidance varied by site from 80% for internal jugular vein to 31% in subclavian vein Tovey et al. [21] UK Paediatric anaesthesiologists 49% (104/212) Table 3 Similar survey studies about use of US guidance during CVC insertion in other scenarios around the world Study Country Participants Percentage of US-guided CVC Comments Adhikari et al. [16] USA Emergency medicine residents 53%, 96% Increasing of ultrasound use from 2007 to 2013 Bailey et al. [13] USA Members of the Society of Cardiovascular Anaesthesiologists 15% (223/1494) Availability of US equipment was associated with use of US (OR = 18.9, P < 0.001) Bosman et al. [15] UK Paediatric anaesthesiologists 68% (133/196) Girard et al. [17] USA Surgery, anaesthesia, emergency medicine, internal medicine and family medicine house staff 15% (19/137) A total of 19 anaesthesiologists were surveyed, of which only five use US with a frequency of 21–60%. Lindgren et al. [18] Sweden Anaesthesiology and intensive care departments 53% (26/49) Schummer et al. [19] Germany Anaesthesia departments 40% (188/468) 12.7% routinely and 60% when faced difficulties Soni et al. [20] USA Intensivist and Hospitalist 82.5% (647/784) US guidance varied by site from 80% for internal jugular vein to 31% in subclavian vein Tovey et al. [21] UK Paediatric anaesthesiologists 49% (104/212) Study Country Participants Percentage of US-guided CVC Comments Adhikari et al. [16] USA Emergency medicine residents 53%, 96% Increasing of ultrasound use from 2007 to 2013 Bailey et al. [13] USA Members of the Society of Cardiovascular Anaesthesiologists 15% (223/1494) Availability of US equipment was associated with use of US (OR = 18.9, P < 0.001) Bosman et al. [15] UK Paediatric anaesthesiologists 68% (133/196) Girard et al. [17] USA Surgery, anaesthesia, emergency medicine, internal medicine and family medicine house staff 15% (19/137) A total of 19 anaesthesiologists were surveyed, of which only five use US with a frequency of 21–60%. Lindgren et al. [18] Sweden Anaesthesiology and intensive care departments 53% (26/49) Schummer et al. [19] Germany Anaesthesia departments 40% (188/468) 12.7% routinely and 60% when faced difficulties Soni et al. [20] USA Intensivist and Hospitalist 82.5% (647/784) US guidance varied by site from 80% for internal jugular vein to 31% in subclavian vein Tovey et al. [21] UK Paediatric anaesthesiologists 49% (104/212) To our best knowledge, sufficient evidence is unavailable about US use for CVC in developing countries. Despite the potential of US-based imaging to improve the diagnosis of many medical conditions and to guide individual patient management, we know little about current practices in low- and middle-income countries, such as the extent of use of portable US devices, major indications for the use of US techniques and impact on patient outcome. A recent systematic review did not find any study on the use of US during CVC [22]. Most current applications focus on obstetrical and abdominal complaints, with a lack of high-quality evidence from developing countries [22]. In terms of procedural US in the developing world, most evidence relates to peripheral venous access, ultrasound-guided thoracentesis or paracentesis and regional anaesthesia [23]. A well-documented association exists between availability of US equipment and use of this technique for CVC [11, 20]. Our survey reports conflictive results in terms of using US in operating rooms. Although 62% of the participants report having US equipment inside the operating room, they also report the absence of equipment as a reason for not using it. Many hospitals in Colombia only have a single portable US device for use in many services and wards. Therefore, knowing that the equipment is available at the hospital does not guarantee its use all the time; this could explain the difference between availability and actual usage during CVC. Access to US has increased significantly in resource-limited settings, including the developing world. A survey on perceived barriers in the use of US in low- and middle-income settings identified lack of training as a primary barrier to regular use of US in their practice, followed by lack of equipment. Equipment requirements, including maintenance and cost of machines, are also important factors [24]. Our results show availability of equipment as an independent factor for using the technique among respondents, but this potential association should be taken with caution due to the very high uncertainty with the broad CI of the estimation. The World Bank currently identifies Colombia as a middle-income country, but it is still in the process of developing a modern healthcare and academic system. Most anaesthesiology residency programs in Colombia have begun to incorporate US into their education, training, and clinical practice to improve the quality and safety of healthcare. However, even in some of Colombia’s most advanced urban university-based hospitals, limited resources are still a reality. In addition, there is a lack of evidence related with the current use of procedural US. Henwood et al. [25] conducted a nationwide survey of Colombian emergency medicine residents designed to explore the state of US use and examine barriers for its expansion. The most frequently indicated barriers to ultrasound use were lack of instructors, equipment and time. We consider this finding could also be valid for anaesthesiologists and other specialisations. Patient safety is a priority in this revolutionary era of technology [26, 27]; catheterisations have inherent risks of mechanical, infectious and haemodynamic complications [16]. Mechanical complications (e.g. arterial puncture, failure rates of insertion, haemothorax and pneumothorax) are common and independently increased by the number of attempts [28]. A recent Cochrane systematic review compared US guidance versus a landmark technique for CVC and concluded that US guidance is significantly associated with lower number of attempts needed for successful catheterisation, increased chances of success at the first attempt, and reduced possibilities of haematoma formation. However, this technique did not show a significant reduction in mechanical complications, such as arterial punctures or time for successful catheterisation [6]. The infectious risk of US equipment is a controversial concern of this technique. This concern is based on a recent outbreak in which sterile gel acted as a vehicle for the spread of infection to patients. This led to a product safety alert by the United States Food and Drug Administration [29]. However, a recent prospective observational study rejected this hypothetical association [30]. In this study, age seems to be related to not using US guidance during CVC. We found a non-adjusted linear trend depending on the age of the anaesthesiologist, which disappeared after multivariate analysis. Regarding this finding, there is growing evidence on the effect of age on practitioners’ performance. Aging is associated with decreased processing speed, limiting ability to complete complex tasks, increased difficulty for information processing, reduced hearing and visual acuity, and decreased manual dexterity and visuospatial ability [31–34]. US guidance requires motor and visuospatial skills that aging practitioners may have not acquired or have lost. In addition, young anaesthesiologists could have greater exposure to US training during their residency programmes. On the other hand, older practitioners may feel they have developed enough experience allowing them to perform the insertion without the US technique. Study limitations This study had important limitations, including a small sample size. We used the database of all anaesthesiologists registered in SCARE (~2850) although many of them are not active practitioners. The response rate can be considered acceptable, compared with other similar online-based surveys. Additionally, the respondents using US guidance could be more motivated to complete the questionnaire in which case the frequency of use of US for CVC in this study would be overestimated. Another limitation is the study design in which the accuracy and self-reporting information from participants was assumed correct because direct observations were not conducted. All the questions included in our survey were closed ended, which might have introduced response bias. Finally, the questions used in the questionnaire did not distinguish the use of US for internal jugular, subclavian, or femoral vein catheterisation. Conclusion Use of US for CVC is not a common practice among Colombian anaesthesiologists. Limited availability of this technology in healthcare centres hinders the use of this technique. Only half of the respondents have taken an external course to learn about US Management, the rest admitted to acquiring experience by themselves or from colleagues. More education and strict compliance of protocols on this technology would be helpful for safer CVC. Further, US guidance can be used in many other procedural applications, like regional anaesthesia, basic echocardiography, vascular assessment, pleural drainage, pulmonary US, and others, ensuring safety and quality of care. References 1 Reusz G , Csomos A . The role of ultrasound guidance for vascular access . Curr Opin Anaesthesiol 2015 ; 28 : 710 – 6 . Google Scholar PubMed 2 Legler D , Nugent M . Doppler localization of the internal jugular vein facilitates central venous cannulation . Anesthesiology 1984 ; 60 : 481 – 2 . Google Scholar Crossref Search ADS PubMed 3 Yonei A , Nonoue T , Sari A . Real-time ultrasonic guidance for percutaneous puncture of the internal jugular vein . Anesthesiology 1986 ; 64 : 830 – 1 . Google Scholar Crossref Search ADS PubMed 4 Lalu MM , Fayad A , Ahmed O et al. . Ultrasound-guided subclavian vein catheterisation: a systematic review and meta- analysis . Crit Care Med 2015 ; 43 : 1498 – 507 . Google Scholar Crossref Search ADS PubMed 5 White L , Halpin A , Turner M et al. . Ultrasound-guided radial artery cannulation in adult and paediatric populations: a systematic review and meta-analysis . Br J Anaesth 2016 ; 116 : 610 – 7 . Google Scholar Crossref Search ADS PubMed 6 Brass P , Hellmich M , Kolodziej L et al. . Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterisation . Cochrane Database Syst Rev 2015 ; 1 : CD006962 . Google Scholar PubMed 7 Kumada K , Murakami N , Okada H et al. . Rare central venous catheter malposition—an ultrasound-guided approach would be helpful: a case report . J Med Case Rep 2016 ; 10 : 248 . Google Scholar Crossref Search ADS PubMed 8 Troianos CA , Hartman GS , Glas KE et al. . Special articles: guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists . Anesth Analg 2012 ; 114 : 46 – 72 . Google Scholar Crossref Search ADS PubMed 9 NICE . Guidance on the use of ultrasound locating devices for placing central venous catheters. Technology appraisal guidance. 2002 ; 49. 10 O’Grady NP , Alexander M , Dellinger EP et al. . Guidelines for the prevention of intravascular catheter-related infections . Clin Infect Dis 2002 ; 35 : 1281 – 307 . Google Scholar Crossref Search ADS 11 Shekelle PG , Wachter RM , Pronovost PJ et al. . Making health care safer II: an updated critical analysis of the evidence for patient safety practices . Evid Rep Technol Assess (Full Rep) 2013 ; 211 : 1 – 945 . 12 Frykholm P , Pikwer A , Hammarskjold F et al. . Clinical guidelines on central venous catheterisation. Swedish Society of Anaesthesiology and Intensive Care Medicine . Acta Anaesthesiol Scand 2014 ; 58 : 508 – 24 . Google Scholar Crossref Search ADS PubMed 13 Bailey PL , Glance LG , Eaton MP et al. . A survey of the use of ultrasound during central venous catheterisation . Anesth Analg 2007 ; 104 : 491 – 7 . Google Scholar Crossref Search ADS PubMed 14 R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. 2013. ISBN 3-900051-07-0; 2014 . 15 Bosman M , Kavanagh RJ . Two dimensional ultrasound guidance in central venous catheter placement; a postal survey of the practice and opinions of consultant pediatric anesthetists in the United Kingdom . Paediatr Anaesth 2006 ; 16 : 530 – 7 . Google Scholar Crossref Search ADS PubMed 16 Adhikari S , Theodoro D , Raio C et al. . Central venous catheterisation: are we using ultrasound guidance? J Ultrasound Med 2015 ; 34 : 2065 – 70 . Google Scholar Crossref Search ADS PubMed 17 Girard TD , Schectman JM . Ultrasound guidance during central venous catheterisation: a survey of use by house staff physicians . J Crit Care 2005 ; 20 : 224 – 9 . Google Scholar Crossref Search ADS PubMed 18 Lindgren S , Pikwer A , Ricksten SE et al. . Survey of central venous catheterisation practice in Sweden . Acta Anaesthesiol Scand 2013 ; 57 : 1237 – 44 . Google Scholar Crossref Search ADS PubMed 19 Schummer W , Sakka SG , Huttemann E et al. . Ultrasound guidance for placement control of central venous catheterisation. Survey of 802 anesthesia departments for 2007 in Germany . Anaesthesist 2009 ; 58 : 677 – 85 . Google Scholar Crossref Search ADS PubMed 20 Soni NJ , Reyes LF , Keyt H et al. . Use of ultrasound guidance for central venous catheterisation: a national survey of intensivists and hospitalists . J Critl Care 2016 ; 36 : 277 – 83 . Google Scholar Crossref Search ADS 21 Tovey G , Stokes M . A survey of the use of 2D ultrasound guidance for insertion of central venous catheters by UK consultant paediatric anaesthetists . Eur J Anaesthesiol 2007 ; 24 : 71 – 5 . Google Scholar Crossref Search ADS PubMed 22 Becker DM , Tafoya CA , Becker SL et al. . The use of portable ultrasound devices in low- and middle-income countries: a systematic review of the literature . Trop Med Int Health 2016 ; 21 : 294 – 311 . Google Scholar Crossref Search ADS PubMed 23 Sippel S , Muruganandan K , Levine A et al. . Review article: use of ultrasound in the developing world . Int J Emerg Med 2011 ; 4 : 72 . Google Scholar Crossref Search ADS PubMed 24 Shah S , Bellows BA , Adedipe AA et al. . Perceived barriers in the use of ultrasound in developing countries . Crit Ultrasound J 2015 ; 7 : 28 . Google Scholar Crossref Search ADS PubMed 25 Henwood PC , Beversluis D , Genthon AA et al. . Characterizing the limited use of point-of-care ultrasound in Colombian emergency medicine residencies . Int J Emerg Med 2014 ; 7 : 7 . Google Scholar Crossref Search ADS PubMed 26 Werner HC , Vieira RL , Rempell RG et al. . An educational intervention to improve ultrasound competency in ultrasound-guided central venous access . Pediatr Emerg Care 2016 ; 32 : 1 – 5 . Google Scholar Crossref Search ADS PubMed 27 Cho YJ , Han SS , Lee SC . Guidewire malposition during central venous catheterisation despite the use of ultrasound guidance . Korean J Anesthesiol 2013 ; 64 : 469 – 71 . Google Scholar Crossref Search ADS PubMed 28 Calvache JA , Rodríguez MV , Trochez A et al. . Incidence of mechanical complications of central venous catheterisation using landmark technique: do not try more than 3 times . J Intensive Care Med 2016 ; 31 : 397 – 402 . Google Scholar Crossref Search ADS PubMed 29 Chittick P , Russo V , Sims M et al. . An outbreak of Pseudomonas aeruginosa respiratory tract infections associated with intrinsically contaminated ultrasound transmission gel . Infect Control Hosp Epidemiol 2013 ; 34 : 850 – 3 . Google Scholar Crossref Search ADS PubMed 30 Cartier V , Haenny A , Inan C et al. . No association between ultrasound-guided insertion of central venous catheters and bloodstream infection: a prospective observational study . J Hosp Infect 2014 ; 87 : 103 – 8 . Google Scholar Crossref Search ADS PubMed 31 Choudhry NK , Fletcher RH , Soumerai SB . Systematic review: the relationship between clinical experience and quality of health care . Ann Intern Med 2005 ; 142 : 260 – 73 . Google Scholar Crossref Search ADS PubMed 32 Eva KW . Stemming the tide: cognitive aging theories and their implications for continuing education in the health professions . J Contin Educ Health Prof 2003 ; 23 : 133 – 40 . Google Scholar Crossref Search ADS PubMed 33 Eva KW . The aging physician: changes in cognitive processing and their impact on medical practice . Acad Med 2002 ; 77 : S1 – 6 . Google Scholar Crossref Search ADS PubMed 34 Dellinger EP , Pellegrini CA , Gallagher TH . The aging physician and the medical profession: a review . JAMA Surg 2017 ; 152 : 967 – 71 . Google Scholar Crossref Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Journal

International Journal for Quality in Health CareOxford University Press

Published: Oct 1, 2018

References

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off