Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Real-time ultrasonography-guided femoral vein catheterization was faster than the landmark-guided technique

ACP J Club. 1997 Jul-Aug;127:15. doi:10.7326/ACPJC-1997-127-1-015


Source Citation

Hilty WM, Hudson PA, Levitt MA, Hall JB. Real-time ultrasound-guided femoral vein catheterization during cardiopulmonary resuscitation. Ann Emerg Med. 1997 Mar;29:331-7.


Abstract

Objective

To compare femoral vein catheterization using real-time ultrasonography with the conventional landmark technique in patients requiring intravenous access during cardiopulmonary resuscitation.

Design

Randomized controlled trial.

Setting

An emergency department of a U.S. urban teaching hospital.

Patients

20 patients (mean age 64 y, 65% men) who presented with cardiopulmonary arrest at the emergency department.

Intervention

Each patient received bilateral femoral venous lines using a standard Seldinger technique inserted by 1 investigator using each method. Order (landmark vs ultrasonography) and side (left vs right) were randomized. One line was inserted by the landmark-oriented technique using a pulse that was generated during cardiopulmonary resuscitation (if present) or a point estimated to be midway between the anterior superior iliac crest and the symphysis pubis. The other technique used real-time ultrasonography guidance to locate the dark hypoechoic vein and artery. The probe was centered over the medial vessel (femoral vein), and the finder needle was inserted under the middle of the probe with the free hand. All placements were confirmed by ultrasonography. Follow-up was complete.

Main outcome measures

Rate of successful placement of the catheter. Secondary outcomes were time to flash of blood, time to catheterization, number of attempts, and number of arterial catheterizations. Failure was defined as > 15 unsuccessful needle passes, arterial catheterization, or subcutaneous tissue catheterization.

Main results

The rate of success was 90% for the ultrasonography-guided technique and 65% for the landmark-guided technique (P = 0.058). Measured from the time of readiness to insert the needle, the ultrasonography-guided technique compared with the landmark-guided technique had a shorter time to flash of blood (31 vs 34 s, P < 0.001) and to catheterization (121 vs 124 s, P < 0.001), fewer mean number of attempts (2.3 vs 5.5, P = 0.006), and fewer arterial catheterizations (0% vs 20%, P = 0.025).

Conclusion

The real-time ultrasonography-guided technique for femoral vein catheterization was faster and resulted in fewer inadvertent arterial catheterizations than the conventional landmark technique in patients requiring intravenous access for cardiopulmonary resuscitation in the emergency department.

Source of funding: No external funding.

For article reprint: Dr. W.M. Hilty, Highland General Hospital, Department of Emergency Medicine, 1411 East 31st Street Oakland, CA 94602, USA. FAX 510-437-8322. E-mail hilty@itsa.ucsfi.edu.


Commentary

Several clinical investigations have examined the usefulness of ultrasonography-guided central venous catheterization. Hilty and colleagues have extended this application to femoral vein catheterization in the setting of cardiopulmonary resuscitation. In comparing ultrasonography guidance with the conventional landmark method, they showed a similar rate of successful cannulation. The time to completion of catheterization was shorter in the ultrasonography-guided group. However, although it was statistically significant, this time difference averaged only 3 seconds and therefore was of no clinical advantage. Further, the temporal comparison did not consider any time taken to set up the instrument at the bedside. Nevertheless, little or no added time seems to be necessary to use this guidance technique if the ultrasonography instrument and transducer are readily available.

When a normal femoral arterial pulse is palpable, the standard landmark method relies on directing the cannulation needle just medial to the pulsation, thus avoiding the artery but penetrating the adjacent vein. As has been previously reported, the authors observed that groin pulsations during application of cardiopulmonary resuscitation arise not from the femoral arteries but rather from the femoral veins. Thus, when attempts to catheterize the femoral vein during cardiopulmonary resuscitation are guided only by cardiac massage-generated pulsations, the cannulation needle is sometimes inserted directly into the pulsation in contradistinction to the usual technique. Although this method is logical, further clinical investigation should be done to validate the finding of fewer arterial catheterizations with ultrasonography-guided application.

This study does not support a clear advantage for the use of ultrasonography guidance, other than the fact that ultrasonography allows fewer unintentional arterial catheterizations. However, this particular complication has special relevance in the setting of cardiopulmonary resuscitation, first because arterial catheterization is not easily recognized during cardiac arrest, and second because of the known potential hazards associated with arterial infusion of certain drugs, such as those used during cardiac resuscitation.

James A. Kruse, MD
Wayne State UniversityDetroit, Michigan, USA

James A. Kruse, MD
Wayne State University
Detroit, Michigan, USA