Residents learning ultrasound-guided catheterization are not sufficiently skilled to use landmarks.

INTRODUCTION: Ultrasound-guided (UG) technique is the recommended procedure for central venous catheterization (CVC). However, as ultrasound may not be available in emergency situations, guidelines also propose that physicians remain skilled in landmark (LM) placement. We conducted this prospective observational study to determine the learning curve of the LM technique in residents only learning the UG technique. METHODS: During the first three months of their rotation in our ICU, residents inexperienced in CVC used only the real-time UG technique. During the following three months, residents were allowed to place CVC by means of the LM technique when authorized by the attending physician. RESULTS: A total of 172 procedures (84 UG and 88 LM) were performed by the inexperienced residents during the study. The success rate was lower (72% versus 84%; P = 0.05) and the complication rate was higher (22% versus 10%; P = 0.04) for LM compared to UG procedures. Comparison between the five last UG procedures and the first five LM procedures performed demonstrated that the transition between the two techniques was associated with a marked decrease of the success rate (65% versus 93%; P = 0.01) and an increase of the complication rate (33% versus 8%; P = 0.01). After 10 LM procedures, residents achieved a success rate and a complication rate of 81% and 6%, respectively. CONCLUSIONS: Residents who only learn the UG technique will not be immediately able to perform the LM technique, but require specific training based on at least 10 LM procedures. The question of whether or not the LM technique should still be taught when an ultrasound device is not available must therefore be addressed.

Ultrasound-guided central venous cannulation is superior to quick-look ultrasound and landmark methods among inexperienced operators: a prospective randomized study.

OBJECTIVE: Quick-look ultrasound with a skin mark (UM) has been frequently used for central vein cannulation. The aim of this study is to compare this method with landmark (LM) and ultrasound-guided (UG) cannulation of jugular and femoral veins by inexperienced operators. DESIGN: Prospective randomized single-center study. SETTING: A medical intensive care unit (ICU) of a university medical center. PATIENTS: Patients requiring jugular or femoral central cannula placement. INTERVENTION: Each inexperienced resident randomly inserted a central venous line using the UM, LM or UG technique. MEASUREMENTS AND FINDINGS: The primary outcome was the success rate, and secondary outcomes were the placement time, number of attempts, mechanical complication rate, and catheter colonization rate. A total of 118 patients were randomly assigned to the three groups. The mean age of patients included in the study was 65 ± 15 years, and the mean Simplified Acute Physiology Score 2 (SAPS2) was 57 ± 20. The success rate was higher in the UG group than in the LM and UM groups (100, 74, and 73 %, respectively; p = 0.01). The total number of mechanical complications was higher in the LM and UM groups than in the UG group (24 and 36 versus 0 %, respectively; p = 0.01). The number of attempts and the access time were higher in the LM group than in the UG group, but not compared with the UM group. No difference in terms of catheter colonization was observed between the three groups. CONCLUSIONS: Ultrasound-guided cannulation of the internal jugular or femoral vein by inexperienced residents appears to be more reliable than the LM or UM methods and was associated with a lower mechanical complication rate among ICU patients.

Hypertension in the intensive care unit.

PURPOSE OF REVIEW: The severity of hypertensive crises is determined by the presence of target organ damage rather than the level of blood pressure. Hypertensive urgencies with no signs of organ dysfunction can therefore be distinguished from hypertensive emergencies in which the presence of severe end-organ damage requires prompt therapy. Hypertensive emergencies include acute aortic dissection, hypertensive encephalopathy, acute myocardial ischaemia, severe pulmonary oedema, eclampsia, and acute renal failure. RECENT DEVELOPMENTS: Malignant hypertension is a severe form of hypertensive emergency demanding special consideration because of the risks of permanent blindness and renal failure. Catecholamine excess and postoperative hypertension may also sometimes require urgent treatment. The management of patients with hypertensive emergencies must be ensured in an intensive care unit, and must include the parenteral administration of antihypertensive drugs and accurate blood pressure monitoring. SUMMARY: Except for acute aortic dissection, the recommended goals of treatment are a reduction of mean arterial pressure by no more than 20% during the first few hours, because an abrupt fall in blood pressure in patients with preexisting hypertension may induce severe ischaemic injury in major organs as a result of the chronic adaptation of autoregulation mechanisms. Hypertension in the context of acute stroke should be treated only rarely and cautiously because of the presence of impaired autoregulation.