PURPOSE: Intrathoracic central line catheterization complication rates vary widely by setting. Factors implicated in high rates of complications include practitioner volume, clinical experience, location of catheter, and use of ultrasound marking before or continuously during placement. Results of a center employing continuous ultrasound in a procedure center and benchmarks are reported.
METHODS: We retrospectively reviewed a consecutive series of 1257 non-tunneled catheters at Cedars Sinai from October, 1990 to December, 2007. The lines were placed by members of a Procedure Center. Experience of the operators varied from less than one year to greater than ten years. Pneumothorax was diagnosed by either chest radiography or by fluoroscopy. For benchmarks, Ovid-Medline was searched for “pneumothorax” and “central venous catheter.” Included references were also reviewed.
RESULTS: Local Results–We identified one confirmed pneumothorax (0.1%), which was clinically insignificant (size ∼5%). The low rate of pneumothorax occurred at all levels of experience and in pediatric and adult cases. However, the sole verified pneumothorax occurred in the presence of a trainee. Published Benchmarks–With radiologic guidance, pneumothorax rates of < 0.1% have been reported. In the literature, with ultrasound marking, pneumothorax occurs in 2.4%. With continuous ultrasound, rates as low as 0% have been reported among physicians with at least five years of experience. In the pediatric population, 1% rates have been reported with ultrasound. Several reports provided benchmarks in academic centers without ultrasound from 1.7 to 4.5%.
CONCLUSION: We report low practice variation in the placement of non-tunneled, intrathoracic central venous catheters with continuous ultrasound. Continuous ultrasound was associated with the virtual elimination of pneumothorax in the hands of proceduralists with varying experience.
CLINICAL IMPLICATIONS: Given the wide variation of published reports on ultrasound-guided central line placement and these findings, we recommend further study of ultrasound training to mitigate the impact of volume or experience on complication rates.
DISCLOSURE: Dani Hackner, No Financial Disclosure Information; No Product/Research Disclosure Information