Emergency Physician Perspectives on Central Venous Catheterization in the Emergency Department: A Survey‐based Study

Abstract

Objectives: The objective was to assess clinician experience, training, and attitudes toward central venous catheterization (CVC) in adult emergency department (ED) patients in a health system promoting increased utilization of CVC for severely septic ED patients. Methods:The authors surveyed all emergency physicians (EPs) within a 21-hospital integrated health care delivery system that had recently instituted a modified Rivers protocol for providing early goaldirected therapy (EGDT) to patients with severe sepsis or septic shock, including CVC if indicated. This initiative was accompanied by a structured, but optional, systemwide hands-on training for EPs in realtime ultrasound-guided CVC (US CVC). EPs' responses to questions regarding self-reported experience with CVC in the ED are reported. Data included frequency of CVC (by type) and US CVC training opportunities: both during and after residency and informal ("on-the-job training involving actual ED patients under the oversight of someone more experienced than yourself") and formal ("off-the-job training not involving actual ED patients"). The survey also asked respondents to report their comfort levels with different types of CVC as well as their agreement with possible barriers (philosophical, timerelated, equipment-related, and complication-related) to CVC in the ED. Multivariable ordinal logistic regression was used to identify provider characteristics and responses associated with higher yearly CVC volumes. Results:The survey response rate among eligible participants was 365 of 465 (78%). Overall, 154 of 365 (42%) respondents reported performing 11 or more CVCs a year, while 46 of 365 (13%) reported doing two or fewer. Concerning CVC techniques, 271 of 358 (76%) of respondents reported being comfortable with the internal jugular approach with US guidance, compared to 200 of 345 (58%) with the subclavian approach without US. Training rates were reported as 1) in residency, formal 167 of 358 (47%) and informal 189 of 364 (52%); and 2) postresidency, formal 236 of 359 (66%) and informal 260 of 365 (71%). The most commonly self-reported barriers to CVC were procedural time (56%) and complication risk (61%). After multivariate adjustment, the following were significantly associated with greater selfreported CVC use (p < 0.01): 1) informal bedside CVC training after residency, 2) male sex, 3) disagreement with complication-related barrier questions, and 4) self-reported comfort with placing USguided internal jugular catheters. Conclusions:In this cross-sectional survey-based study, EPs reported varying experience with CVC in the ED and reported high comfort with the US CVC technique. Postresidency informal training experience, male sex, negative responses to complication-related barrier questions, and comfort with placing US-guided internal jugular catheters were associated with yearly CVC volume. These results suggest that higher rates of CVC in eligible patients might be achieved by informal training programs in From The Permanente

Safety of peripheral administration of vasopressor medications: A systematic review

“…With the caveat that the studies included in this review were not of a universally high quality, the relatively low incidence of reported complications associated with the delivery of vasopressor infusions via PiVC is reassuring for clinicians. The time taken to ensure the safe placement of a CVC can be a significant barrier to clinicians undertaking this procedure . Given that a delay in the administration of vasopressors has been associated with an increase in mortality in certain clinical scenarios, the findings of this review will provide clinicians confidence in commencing a vasopressor infusion via a peripheral catheter while the resources for the safe placement of a CVC can be mobilised.…”

“…The time taken to ensure the safe placement of a CVC can be a significant barrier to clinicians undertaking this procedure. 4 Given that a delay in the administration of vasopressors has been associated with an increase in mortality in certain clinical scenarios, 5,6 the findings of this review will provide clinicians confidence in commencing a vasopressor infusion via a peripheral catheter while the resources for the safe placement of a CVC can be mobilised. For those clinicians who undertake this mode of delivery of vasopressors, it should be stressed that the low rate of reported adverse events may be due to the mandated rigorous clinical monitoring and protocols for managing extravasation, and that these aspects of the intervention should be carefully considered at an institutional level.…”

“…Placement of a CVC is not without risk, including vascular injury, pneumothorax, and even death . Safely inserting a CVC in a critically ill patient can be time‐consuming, with a majority of emergency physicians surveyed recently reporting that the time required to safely place a CVC was the most significant barrier to placement in the ED . There is a growing recognition that earlier commencement of vasopressors may be associated with reduced mortality in certain patient cohorts and delays related to CVC insertion may hinder the administration of vasopressors …”

“…3 Safely inserting a CVC in a critically ill patient can be time-consuming, with a majority of emergency physicians surveyed recently reporting that the time required to safely place a CVC was the most significant barrier to placement in the ED. 4 There is a growing recognition that earlier commencement of vasopressors may be associated with reduced mortality in certain patient cohorts and delays related to CVC insertion may hinder the administration of vasopressors. 5,6 Due to these concerns, there has been growing use of vasopressors via peripheral intravenous catheters (PiVCs), rather than a CVC, when vasopressors are required in a timecritical fashion.…”

Diagnostic Accuracy of Central Venous Catheter Confirmation by Bedside Ultrasound Versus Chest Radiography in Critically Ill Patients: A Systematic Review and Meta-Analysis

“…Operator ultrasound experience in the included studies ranged from experts to operators with only limited training in bedside ultrasound. Clinician access to and experience with ultrasound is highly variable in actual practice (52, 53). Although some evidence suggests that prior experience with bedside ultrasound-guided CVC placement can affect both the safety (9) of the procedure and the diagnostic accuracy (54) of the ultrasound interpretation, our subgroup analysis did not show a clinically significant difference in the sensitivity of ultrasound to detect catheter malposition.…”