March/April Common Sense

Page 67



Does Ultrasound Guidance During Insertion of Central Venous Catheters Increase Risk of Infection?: A Review of Recommendations and What You Can Do to Reduce this Risk Stephanie Sorensen, DO PGY 3, Daniel Puebla, MD PGY 2, and Mark A Newberry, DO FAAEM

oint-of-care ultrasound continues to evolve into a favorite tool in the emergency physician’s arsenal, especially when it comes to procedural guidance. There is an abundance of evidence supporting its use to prevent mechanical complications (e.g. inadvertent arterial puncture, hematoma formation) and increase chance of success at the first attempt during central venous catheter (CVC) placement.1 However, a recent post hoc analysis published by Buetti et al calls attention to a lesser-studied complication—catheter-related infections. Surprisingly, use of ultrasound was associated with higher rates of catheter-related bloodstream infections (CRBSIs), major catheter-related infections (MCRIs), and catheter colonization for both jugular and femoral sites compared to anatomic landmarks.2 In this discussion, we will take a closer look at this publication and offer some evidence-based recommendations for how to mitigate this risk in your department. To begin, we will summarize the highlights of this recent publication. Data from three randomized controlled trials (RCTs) taking place in French intensive care units were used to evaluate the effect of specific prevention measures (e.g. type of dressing, skin cleaning solution, site selected) on the risk of intravascular catheter complications.3-5 During a post-hoc analysis, these data were additionally used to determine if there was an association with CRBSIs, MCRIs, and catheter colonization for ultrasound guidance versus use of anatomical landmarks alone. Ultrasound guidance was utilized at the non-random discretion of treating intensivists. For jugular and femoral CVCs, the use of ultrasound guidance was associated with: • Increased CRBSI with a hazard ratio (HR) of 2.21 (CI 1.17-4.16, P = 0.014) • Increased MCRI with a HR of 1.55 (CI 1.01-2.38, P = 0.045) • Increased catheter colonization after removal if in-situ for seven days or less (P = 0.0045) The authors offer explanations as to why these results may have been obtained. They note that all of the RCTs in the review were performed during a time when ultrasound guidance was not a standard practice among all intensivists. Additionally, there was no randomization to ultrasound versus anatomical landmarks alone, and there was no information reported about the hygiene of the ultrasound equipment. Taking

into consideration this publication wasn’t designed to generate these outcomes and while there are many potential confounds, we continue to conclude that special care should be paid to the hygiene of ultrasound equipment in an effort to curtail risk of infection. Hospitals should take caution to ensure that all departments follow appropriate machine hygiene protocols. Many sources discuss guidelines for infection prevention in ultrasonography.6,7,12,24 We will use these guidelines to offer tips for reducing risk of microorganism introduction during ultrasound-guided CVC placement and provide the evidence as to why these recommendations matter.

Wash hands before and after the procedure. In the wake of the growing infectious and monetary burden of health care associated infections, simple basics such as hand hygiene become crucial. In most health care institutions, hand hygiene is only performed in up to 40% of indicated situations. Furthermore, the hands of

In the wake of the growing infectious and monetary burden of health care associated infections, simple basics such as hand hygiene become crucial.”




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