The clinical notion that the additional equipment and manipulation associated with the ultrasound method might have increased the rate of catheter-related infection was not confirmed by the data. The number of infections in the total study population was significantly related to the number of needle passes, the researchers said.

For example, a possible explanation for a significantly higher incidence of coagulase-negative Staphylococci in the landmark group may be related to the increased access time and the number of average attempts documented in the landmark group versus the ultrasound group.


Although venous thrombosis was detected in slightly more ultrasound patients than landmark patients, ultrasound imaging is an important tool in identifying cases of preexisting thrombus formation and anatomic variations in the jugular vein location, the investigators pointed out.

The major impediment to the widespread implementation of the ultrasound-guided cannulation is the purchase cost of the ultrasound machine. However, past studies have provided sufficient economic arguments supporting the notion that ultrasound-guided central venous cannulation is cost effective, the investigators said.

Finally, the researchers wrote that the ultrasound method is technically demanding, requiring a well-trained operator and adequate experience in performing it. The benefits of this method, they said, may not accrue until after an initial learning period for operators already used to the landmark technique.

However, Dr. Karakitsos summed up, saying, "We believe that ultrasound imaging is a readily available technology and may be employed by inexperienced operators to facilitate the placement of a central vein catheter and by experienced operators to improve the safety of the procedure."

In a commentary in the same Critical Care issue, Andrew Bodenham, M.D., of Leeds General Infirmary in England wrote that skeptics of the ultrasound technology should urgently appraise their practice.

Dr. Bodenham noted that he is regularly invited as an expert witness in Britain to comment on fatal and nonfatal complications of central venous access. In the past, he said, it was possible to defend clinicians not using ultrasound on the basis that it was not yet routine or of proven benefit, but he thinks this position will become increasingly untenable in the future.

Other considerations like patient discomfort with multiple needle passes are also significant. You should ask yourself, he wrote, if faced by the prospect of central venous access, often under local anesthesia alone, what would you prefer? A landmark technique with the risks cited by Dr. Karakitsos following multiple needle passes, or the near 100% success rate with minimal passes and a near zero procedural complication rate with the use of ultrasound.

"The low overall cost of ultrasound devices compared with many other interventions now means that you and your patient can no longer afford complacency in this area," he concluded.

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