Ultrasound Guidance Should Not Be Standard of Care

Frank J. Overdyk, MSEE, MD

To the Editor

The “opinion” of Webster and Blitt in a recent APSF Newsletter mandating routine use of ultrasound (US) in guiding central venous access (CVA) was very disturbing.1 Recently, a drug with an excellent safety profile and many years of effective use was “black boxed” by the FDA. The FDA’s case was supported by weak data and a flawed argument that has since been easily rebuked in our literature.2 Now I am told that the thousands of central access procedures my colleagues and I perform yearly without significant complications (a check of the Medical University of South Carolina Anesthesia QA Database [2001] revealed the following: 2,036 central axis placements, 3 adverse events, and 0 adverse outcomes) should be performed exclusively under US guidance? What is next? All general anesthesia cases require BIS? All endotracheal tube placements should be confirmed fiberoptically?

The Institute of Medicine report is being used to indiscriminately mandate the use of technology or protocols to increase “safety.” Fortunately, the Agency for Healthcare Research and Quality report did not jump on this bandwagon and recommended that experienced anesthesiologists continue obtaining CVA without US guidance. Closer examination of Blitt and Webster’s bibliography in support of their “strong disagreement” with this position show it is only of limited relevance, and in instances contradicts their position. Two references involve access in chronic hemodialysis patients, which are more likely to involve difficult CVA than our typical population. Other references suggest that landmark-based cannulation is successful 95% of the time, and that the internal jugular may lie behind or even medial to the carotid artery, but this occurs less than 6% of the time. So the need for US guiding on every CVA procedure is not supported for routine cases. To assume US guided placement will lead to fewer lawsuits is absurd as most litigation occurs in the absence of a deviation from the standard of care.3 Furthermore, most of the complications of CVA are inadvertent arterial puncture or cannulation, neither of which have serious sequela and the latter of which can be avoided by transducing the access. Serious complications are rare and involve retained guide wires or torn vessels, neither of which will be reduced by US guidance. Webster and Blitt backpedal halfway through their opinion suggesting practitioners “have a look” with US, and not use it for “complete guidance,” whatever that means. Certainly US guided CVA has merit, particularly in children and in patient populations with known difficult access. But recommending routine use on the basis of legal scare mongering or without scientific evidence should not occur in the newsletter of the APSF, the respected authority on patient safety, even as an opinion.

Frank J. Overdyk, MSEE, MD
Charleston, SC

References

  1. Webster T, Blitt C. Portable ultrasound facilitates central vascular access: a case for routine use. APSF Newsletter 2002; 17(3):35.
  2. White P. Droperidol: a cost-effective antiemetic for over thirty years. Anesth Analg 2002; 95:789-790.
  3. Laing B, Cullen D. The legal system and patient safety: charting a divergent course. Anesthesiology 1999; 91:609-11.

 

To the Editor

We disagree with the opinion article “Portable ultrasound facilitates central vascular access: a case for routine use.”1 Thousands of central vascular access devices (CVAD) are safely placed in patients daily without the use of ultrasound. To state that “portable ultrasound should be routinely used in all elective vascular access procedures even when performed by experienced anesthesiologists” is to call for the use of such devices as a standard of care.

One might as well contend that all intubations should be conducted using fiberoptic bronchoscopes to confirm endotracheal tube placement. To state that ultrasound be done on all patients routinely is unfortunate and will only result in more litigation.

Robert F. LaPorta, PhD, MD
David B. Berger, MD
Glen Cove, NY

Reference

  1. Webster TA, Blitt CD. Portable ultrasound facilities central vascular access: a case for routine use. APSF Newsletter 2002;17:35.