ULTRASOUND GUIDED CENTRAL VENOUS CANNULATION BY ANESTHESIA TRAINEE: NEED OF THE HOUR DURING COVID PANDEMIC

Covid pandemic has created deciency of doctors needed to administer skilled procedures in ICUs and operating rooms. Post graduate trainees need to acquire skills fast and perform it safely on patients. Ultrasound (USG)-guided central venous cannulation (CVC) is one such. The study aimed at nding the feasibility of training USG-guided CVC cannulation to anesthesia trainee as opposed to landmark method in terms of ease, speed and safety. Patients needing CVC were divided into 2 groups of 50 each, where Group 1 was subjected to Landmark method and Group 2 to USG-guided method. Continuous variables were compared using unpaired t test and categorical variables using either the Chi square test. Access time (in seconds) was signicantly less in the USG group (258.78 ± 11.17) as opposed to Landmark technique (301.60 ± 14.03) (p 0.03). Accidental carotid artery puncture was seen in 9 patients in Landmark group as opposed to none in the USG group. No patient in any group developed pneumothorax. USG-guided technique is superior and safer than the traditional landmark technique in hands of anaesthesia trainee in terms of a shorter access time, and less incidence of arterial puncture which is desirable in COVID patients to shorten the exposure time. USG-guided method needs an assistant to focus the probe. Nonetheless, this training should be imparted to the trainee to ll the gap created by skilled doctors falling sick during COVID pandemic.

Avoiding harm: central venous access in Kartagener syndrome and other vascular anomalies

Placement of internal jugular catheters is more likely to be complicated if a left-sided approach is used, assuming normal anatomy. Kartagener syndrome is the sine qua non of sidedness confusion and results in cognitive challenges that increase the risk of adverse patient outcomes. The altered anatomy can cause profound disorientation from our usual processes. In normal circumstances the right-sided approach is used for placement of internal jugular catheters, but in Kartagener syndrome the left-sided approach should be preferred. Surgical volume and use of ultrasound guided techniques are positively correlated with better outcomes. Clinical experience may be a detriment to performance. Knowledge of these issues will help clinicians maintain vigilance and avoid error. Keywords: Kartagener syndrome, central venous access, superior vena cava, landmark technique, internal jugular vein catheterization cognitive bias

A Review of Various Techniques of Central Venous Catheter Insertion

Central venous catheterization is a standard procedure used in the resuscitation of critically ill patients. There are different routes of CVP insertion which are:- subclavian vein, internal jugular vein, axillary vein and femoral vein. Each route has its own set of complications like artery puncture, pneumothorax, nerve injury, infections. Initially catheters were inserted by the landmark technique using guidewire through the needle commonly called seldinger technique. The landmark technique is found to be associated with a higher range of mechanical complications. The use of USG however has proved to improve the success rate and decrease the complications. Keywords: Central venous catheterization, resuscitation, internal jugular vein.

THE SUCCESS OF ULTRASOUND GUIDED INSERTION OF CENTRAL VENOUS CATHETER VERSUS LANDMARK TECHNIQUE

Objective: Central venous catheterization is an important skill for doctors working in the departments ofmedicine, surgery, critical care, anesthesiology, and emergency. The Agency for Healthcare Research and Quality, USA named ultrasound guidance of central venous catheter placement as one of 11 most underutilized practices that can enhance patient safety with greatest strength of evidence to provide clear opportunities for safety improvement. In this study, we compare the success of ultrasound-guided insertion of central venous catheter versus landmark technique. Study Design: Randomized controlled clinical trial. Place and Duration of Study: Pak Emirates Military Hospital, Rawalpindi, from Jul to Dec 2016.Methodology: One hundred twenty patients admitted in its wards and undergone CVC were included. Patientswere divided into group A & group B containing 60 patients each. In ‘group A’ CVC was done with ultrasoundassistance while in ‘group B’ CVC was done with landmark technique. The primary study outcome was No. ofattempts at which CVC was done. Results: In this study, 120 patients were enrolled. There was no difference in demographic data comparison.Success rate was found to be 28 (46.67%) in-group A while 16 (26.67%) in-group B with the p-value of 0.042 which is significant. Conclusion: We concluded that CVC with ultrasound guidance is more successful than landmark technique.

Safety of Subclavian Venous Catheterization Using Anatomical Landmark Technique Versus Ultrasound-Guided Internal Jugular Central Venous Method Inserted in The Neuro-Intensive Care Unit

Background:Central venous (CV) catheterization is one of the important interventions used for various purposes. Accordingly, this study aimed to compare the complication rates of internal jugular vein (IJV) assisted by ultrasound with those of subclavian vein (SCV) catheterization using the anatomical landmark technique.Methods:Prospective, nonrandomized, single center study. Data from patients undergoing central venous catheterization either via IJV or SCV were recorded. The overall complication rate as well as number of attempts and catheter misplacement were analyzed comparing both methodsResults:Data from 398 (IJV: 206; SCV:192) patients were analyzed. The rate of pneumothorax did not demonstrate a significant difference between the IJV (0.5 %) and SCV (2.1 %) groups, p = 0.2. The success rate on the first attempt was similar in both groups (64%; p = 1.0). More catheter misplacements were observed in the SCV group (4.7%) than in the IJV group (3%), p = 0.4.Conclusions:Our results demonstrated that the complication rates of anatomical landmark guided SCV is very low and comparable to US guided IJV method.

Central Venous Catheter Insertion: A Scoring System for Evaluation of Both the Procedure and the Operator (CVCI Score/Gaber Score)

Introduction. Currently, there is no method to assess the performance while inserting a central venous catheter. We suggest a new scoring system for evaluation of both the technique as well as the operator, and then we applied it for the comparison between the landmark and ultrasound techniques to assess its validity. Methods. Four hundred patients were divided into two equal groups: group (A): internal jugular vein (IJV) and group (B): subclavian vein (SV). The landmark technique and the ultrasound guidance were used equally (100 patients for each) in both groups. Results. In group (A), 20% of patients in the landmark group achieved score 4, while 82% of patients in the ultrasound group achieved the same score. This suggests that the ultrasound technique for catheterization of IJV decreased overall complications and improved the success rate. In group (B), there were 70% of patients in the landmark group who achieved score 5, while 49% of patients in the ultrasound group achieved the same score which proposes that the landmark technique might be deceptively better than the ultrasound technique for catheterization of SV. This could be because the time required for catheterization of SV by the ultrasound technique was longer than that in the landmark technique. Overall complications of 15% with the landmark technique vs. 2% with ultrasound guidance in this group of patients are not only statistically significant but also increase morbidity and mortality with a highly invasive procedure. Complications and their incidences are by far more significant than seconds of time. Our results suggest that the ultrasound technique could decrease the incidence of overall complications, but it is time-consuming in group (B). These results support the validity of our new scoring system. Conclusion. We suggest a new scoring system for CVC insertion that can be used for evaluation of both the technique and the operator. It can evaluate the performance of junior staff and follow their progress. It can be applied in the medical and critical care practice as well as the quality management privileges and protocols.