Ultrasound-guidance can reduce adverse events during femoral central venous cannulation.

BACKGROUND: Ultrasound-guidance for internal jugular central venous cannulation (CVC) has become the recommended best practice and has been shown to improve placement success and reduce complications. There is a dearth of studies that evaluate emergency point-of-care ultrasound guidance of femoral CVC. OBJECTIVE: Our aim was to determine if point-of-care ultrasound guidance for femoral CVC decreases adverse events and increases the likelihood of successful placement when compared with the landmark technique. METHODS: We conducted an Institutional Review Board-approved, prospective, observational study of consecutive patients who required CVC. Physicians who performed CVC completed a standardized, web-based data sheet for a national CVC registry. We evaluated single-institution data regarding CVC site, ultrasound usage, CVC indication, and mechanical complications (e.g., pneumothorax, arterial puncture, failed access, catheter misdirection, and hematoma). The study period was between January 2006 and June 2010. Analysis using Pearson's χ(2) and Agresti-Coull binomial confidence intervals was performed; significance was defined as p < 0.05. RESULTS: We evaluated data for 143 patients who had femoral CVC in our institution. Sixty CVCs (42%) were performed under ultrasound guidance, 83 (58%) via landmark technique (p = 0.0159); 3.3% of femoral central venous lines placed by ultrasound guidance had recorded adverse events compared with 9.6% for the landmark technique (p = 0.145). There was no statistically significant difference in complications between ultrasound-guidance and landmark techniques. Our data showed a trend toward decreased rates of arterial puncture and reduced cannulation attempts resulting in improved placement success. CONCLUSIONS: Our experience shows that ultrasound guidance for femoral CVC might decrease complications and improve placement success, although we cannot recommend this approach without additional data. We recommend a larger study to further evaluate this technique.

Defining an Ultrasound-guided Regional Anesthesia Curriculum for Emergency Medicine.

OBJECTIVES: Ultrasound-guided regional anesthesia (UGRA) can be a powerful tool in the treatment of painful conditions commonly encountered in emergency medicine (EM) practice. UGRA can benefit patients while avoiding the risks of procedural sedation and opioid-based systemic analgesia. Despite these advantages, many EM trainees do not receive focused education in UGRA and there is no published curriculum specifically for EM physicians. The objective of this study was to identify the components of a UGRA curriculum for EM physicians. METHODS: A list of potential curriculum elements was developed through an extensive literature review. An expert panel was convened that included 13 ultrasound faculty members from 12 institutions and from a variety of practice environments and diverse geographical regions. The panel voted on curriculum elements through two rounds of a modified Delphi process. RESULTS: The panelists voted on 178 total elements, 110 background knowledge elements, and 68 individual UGRA techniques. A high level of agreement was achieved for 65 background knowledge elements from the categories: benefits to providers and patients, indications, contraindications, risks, ultrasound skills, procedural skills, sterile technique, local anesthetics, and educational resources. Ten UGRA techniques achieved consensus: interscalene brachial plexus, supraclavicular brachial plexus, radial nerve, median nerve, ulnar nerve, serratus anterior plane, fascia iliaca, femoral nerve, popliteal sciatic nerve, and posterior tibial nerve blocks. CONCLUSIONS: The defined curriculum represents ultrasound expert opinion on a curriculum for training practicing EM physicians. This curriculum can be used to guide the development and implementation of more robust UGRA education for both residents and independent providers.