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

Abstract

IntroductionUltrasound-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.MethodsDuring 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.ResultsA 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.ConclusionsResidents 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 Guidance and Other Determinants of Successful Peripheral Artery Catheterization in Critically Ill Children*

“…In contrast to previous studies, we found no evidence that the adoption of ultrasound guidance by trainees is associated with reduced proficiency in landmark-based methods(18). This may be because the two methods share a common requisite skill set, and becoming proficient in the landmark-based approach flows naturally from first learning ultrasound-based techniques.…”

“…Finally, we looked for evidence supporting the hypothesis that the adoption of ultrasound by trainees comes at the expense of proficiency in landmark based methods(18). Evaluating only palpation-guided procedures, we found no significant differences in outcomes between trainees who exclusively utilized the palpation method (n= 23 trainees, n = 65 procedures, 16.7 ± 9.6 minutes) compared to trainees who were capable of utilizing either ultrasound or palpation (n = 22 trainees, n = 61 procedures, 16.4 ± 7.8 minutes, p = 0.915) (Supplemental Figure 3).…”

Residents' Procedural Experience Does Not Ensure Competence: A Research Synthesis

“…For instance, 1 study demonstrated that after an educational intervention, residents inserting CVCs had increased their success rate to approximately 90% after 10 ultrasound-guided catheter insertions (compared with approximately 80% after 1 to 3 insertions), and the rate of complications was (and persisted at) approximately 8% after only 4 catheter insertions (compared with approximately 13% after 1 to 3 insertions). 25 Another study of CVC insertion suggested that up to 50 procedures were needed to reduce complications from subclavian line insertions, 3 while a study of colonoscopy showed that up to 80 procedures were necessary for improved patient care. 7 Bariatric surgery yearly volumes of over 150 were also associated with better performance and lower complications compared with lower-volume practitioners.…”

Credentialing of Hospitalists in Ultrasound‐Guided Bedside Procedures: A Position Statement of the Society of Hospital Medicine

“…Assessors should be expert providers who regularly perform the ultrasound-guided procedure in a similar practice environment. 9,[89][90][91][92][93][94] For example, providers who are not hospitalists but who are experts in an ultrasound-guided procedure and commonly perform it on the hospital wards would be acceptable assessors. However, a radiologist who only performs that procedure in a fully-staffed interventional radiology suite with fluoroscopy or computed tomography guidance would not be an acceptable assessor.…”