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E-letters: Electronic letters published:
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Unintended consequencies of NICE Guidelines
- Andrew Higgs, Vicky Price (12 December 2007)
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Training and Availability of US
- Balamurugan Ramalingam (11 December 2007)
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Use of ultrasound for Central venous line placement-A different perspective
- Ravish jeeji (8 December 2007)
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Effect of the implementation of NICE guidelines for ultrasound guidance on the complication rates as
- Basil Almahdi, [James Carrannante], [Alan McGlennan] (3 December 2007)
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NICE guidelines for cental venous catheter placement, are some people resistant to change?
- Arun Krishnamurthy, Jeff Phillips (3 December 2007)
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Andrew Higgs, Consultant in Anaesthesia & Intensive Care Medicine , Vicky Price
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Dear Sir We read with interest the article by Dr Wigmore and colleagues reporting their audit of central venous catheter (CVC) insertions performed before and after publication of the National Institute for Clinical Excellence’s (NICE) guidelines recommending ultrasound (US)- guided insertion.1 We, also, fully support the NICE recommendation that 2- dimensional US imaging guidance is the preferred method of internal jugular (IJ) cannulations.2 However, whilst we agree with Wigmore et al’s conclusion that US guidance significantly reduces complication rates (they defined a complication as arterial puncture, pneumothorax, haematoma), we feel that it is salient to point-out that their definition only encompasses the (most feared) immediate mechanical complications. There are other, less acute, complications. Not least amongst these is catheter related sepsis. This is also a serious complication of CVC insertion and can be lethal. It appears to us that the NICE document may have had an unintended consequence with regard to catheter related sepsis: it highlights how much safer internal jugular line insertion has become since the introduction of widely available vascular access US probes. Consequently, practitioners are performing more IJ catheterisations and accordingly far fewer subclavian CVC insertions. It is our experience that this is especially true for doctors-in-training. This is a logical and predictable response to a highly commendable document and will certainly reduce immediate complication rates. Nevertheless, many studies demonstrate that the incidence of catheter related sepsis is significantly reduced when the subclavian approach is used compared to IJ access.3 Preserving sterility for any length of time at the site of IJ cannulation is inherently difficult – it is hard to dress and is readily soiled by oral secretions when compared to the infraclavicular fossa, which is relatively flat, reliably dressed and more remote from oral secretions. That most anaesthetists have their own individual methods of dressing IJ catheters attests to the fact that none are wholly satisfactory. Further, as specialists in anaesthesia, acute internal medicine and intensive care, we feel strongly that practitioners in these fields should become and remain both competent and confident in all 3 principle means of central venous cannulation –internal jugular, subclavian and femoral routes. NICE endorses this view: “the choice of access route depends on multiple factors including the reason for CVC insertion, anticipated duration of access and intact venous sites available” - but doesn’t allude to the site-specific infection risks of CVC insertion. Anecdotally, it appears to us that doctors-in-training are performing many fewer subclavian insertions than was the case even in the recent past, and are noticeably less confident performing this procedure. With the current state of the art, fewer subclavian insertions will mean more catheter related infections and this should be borne in mind when a CVC will remain in situ for several days. V Price A Higgs North Cheshire NHS Trust. 1. Wigmore TJ, Smythe JF, Hacking MB, Raobaikady R, MacCallum NS. Effect of the implementation of NICE guidelines for ultrasound guidance on the complication rates associated with central venous catheter placement in patients presenting for routine surgery in a tertiary referral centre. Br J Anaesth 2007; 99: 662-5. 2. National Institute for Clinical Excellence. Guidance on the use of ultrasound locating devices for placing central venous catheters. Technology Appraisal Guidance No 49, September 2002. Available from http://www.nice.org.uk. 3. Lorente L, Henry C, Martin MM, Jumenez A, Mora M. Central venous catheter-related infection in a prospective and observational study of 2595 catheters. Crit Care 2005; 9: R-631-5. Conflict of Interest:None declared |
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Balamurugan Ramalingam, Specialty Registrar QEQM Hospital, Kent
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Dear Editor, I read with interest, the article on 'the effect of implementation of NICE guidelines for central venous catheter placement'. Introduction of the guideline is one of the move towards the patient centered care by aiming to reduce the risk to patients. But, many questions need to be answered regarding the implementation of the guideline into practice. Firstly, not every hospital is able to provide adequate training in the use of ultrasound, specially in the district general hospitals. Both the trainers and the trainees need to be trained adequately. Many experienced consultants and SAS doctors are highly skilled in the landmark technique. For them to adopt a new technique, adequate training is essential. Another important issue is the availability of the equipment in places where it is required. Not every hospital has equipped both the intensive care and theatres with ultrasound machine. However, one cannot disagree that the use of ultrasound for central venous catheter placement has the potential to improve safety. Studies like this, especially multi centric study will be useful to emphasize the importance of use of ultrasound. Conflict of Interest:None declared |
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Ravish jeeji, Specilaist Registrar anaesthesia Manchester Royal infirmary
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Editor- It was interesting to read the audit by Wingmore et al–Effect of the implementation of NICE guidelines for ultrasound guidance on the complication rates associated with central venous catheter placement in patients presenting for routine surgery in a tertiary referral centre. The result was similar to that published earlier, but the interesting finding was the difference in complication rates between consultants and specialist registrars. As the title of the audit says, this is the effect of NICE guidelines. What will be its effect as time goes on? Even though Meta analysis showed that there was reduction in complication rate26 with the use of US (Ultrasound) for CVC (central venous catheter) placement, there are other studies showing that the use of ultrasound did not result in improvement in procedure related complications1or there were increased incidents of complications4.As authors pointed out, the evidence in favour of US came from a variety of clinical groups with little evidence from studies involving anaesthetists. To gain competency in any technique one needs good training, and to maintain it there is a need to perform this procedure on a regular basis. This is true for both landmark and US techniques. Anaesthetists as a group have the opportunity to perform & teach landmark technique in theatres (ideal circumstance to teach & learn CVC placement).They get chances to perform it on regular basis to maintain this skill. The complication rates among groups who perform any technique repeatedly will be less than those who perform it less frequently. Grebenik et al4 reported that the incidence of complications was more in US group and Martin MJ et al 1found that there was no difference with the use of US. Experience of these groups in landmark technique or relative inexperience with US when compared with landmark technique explains these results. Similarly relative inexperience with landmark technique may be the reason for the higher complication rate reported by other groups using landmark technique. The difference in complication rate reported by Wigmore et al 5 between Consultants and Specialist Registrars may be explained by difference in level of competency of these groups in landmark technique. The take up of US for CVC is low among anaesthetists as showed by a survey conducted among members of cardiovascular anaesthesiologists3.This survey also found that the physicians in academics ,veterans in administrative settings and critical care physicians are more likely to use US. This may be because these groups either don’t have the opportunity to perform landmark technique often enough to maintain the skill or had not gained enough experience during their initial training in the procedure. The degree of training & opportunities to maintain the skill gives one the confidence to carry out a procedure or look for alternative techniques. This also has an effect on the complication rates. Introduction of NICE guidelines has affected the training in central line placement of anaesthetic trainees. Trainers were trying to learn US guided technique themselves resulting in the poor quality of training in both techniques. The present training in US technique for anaesthetists is well below the standard set by Royal college of Radiologists as pointed out by Wigmore et al and also below the standards of training that the modern day anaesthetist receives in other techniques they perform. One cannot assume that an anaesthetist who uses ultrasound less often than a radiologist can learn the technique with a day’s training and become competent enough to teach the trainees. The days of ‘see one-do one-teach one’ are long gone. The training model for Registrars suggested by Wingmore et al is an attractive one, but it may be difficult to achieve. The skill of the trainers also has a big influence in the degree of competence achieved by trainees. An ideal situation would be to teach the trainees landmark technique in the early stage of training and US technique as an advanced skill like fiberoptic intubation is for airway management. By doing so, the trainers will be able to maintain their competency in landmark technique. Land mark technique is not difficult to master as internal jugular vein is not a deep structure and looking at JVP is one of the earliest clinical skills taught in medicine. When positioned for placement of central line one will be able to see or feel internal jugular vein in majority of the patients. Martin MJ et al1 has reported that complication rates among residents was related to the degree of supervision. With the present standards of training in Anaesthesia we can safely teach landmark technique to the new generation anaesthetists. If the NICE guideline is strictly adhered to, in the near future doctors will lose the skill & confidence to perform central line placement. In any modern NHS hospital we can’t assume that US will be available at all times for the placement of central lines. Other departments seek the help of anaesthetists for central line placements when they are faced with difficulties such as unavailability of US or failure in spite of using US. Therefore it is important that anaesthetists should achieve a high level of competency in both landmark & US guided techniques. 1)Martin MJ, Husain FA, Piesman M, Mullenix PS, Steele SR, Andersen CA, Giacoppe GN. Curr Surg. 2004 Jan-Feb;61(1):71-4 2)Randolph, Adrienne G. Cook, Deborah J.Gonzales, Calle A. Pribble, Charles G. MD Critical Care Medicine. 24(12):2053-2058, Dec 1996 3)Peter L. Bailey, Laurent G. Glance, Michael P. Eaton, Bob Parshall, and Scott McIntosh A Survey of the Use of Ultrasound During Central Venous Catheterization Anesth. Analg. 2007 104: 491-497 4) C. R. Grebenik, A. Boyce, M. E. Sinclair, R. D. Evans, D. G. Mason and B. Martin1 British Journal of Anaesthesia, 2004, Vol. 92, No. 6 827- 830 5) T. J. Wigmore, J. F. Smythe, M. B. Hacking, R. Raobaikady, and N. S. MacCallum Br. J. Anaesth., November 2007; 99: 662 – 665 Conflict of Interest:None declared |
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Basil Almahdi, Specialest Registrar in Anaesthesia , [James Carrannante], [Alan McGlennan]
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BJA CORRESPONDENCE Editor, We read with interest the paper by Dr Wigmore and colleagues1 regarding the effect of the implementation of NICE guidelines for ultrasound (US) guidance on complication rates associated with central venous catheter (CVC) placement. We wish to comment on their audit. We agree with the concept of US guidance for CVC placement. In a recent survey at the Royal Free Hospital anaesthetic department, US uptake after implementation of NICE guidelines is higher (75%) than that estimated in the Royal Marsden audit (59.5%). 37% of our Consultant anaesthetists have attended a SonositeTM or equivalent vascular access course. Our trainees see on average two US-guided CVC insertions and then do three supervised lines, before independent practice. Only 18% of our trainees have used training mannequins. We would like to raise a couple of issues. Firstly, the training suggested by Dr Wigmore and colleagues of watching five US-guided insertions and then being supervised in performing a further five, and then being deemed competent sounds ambitious. In addition their training model doesn’t necessarily reflect true competence. We have a large anaesthetic department at the Royal Free Hospital, with a greater number of pre-fellowship trainees than the Royal Marsden Hospital. In addition, we anaesthetise a large number of emergency as well as elective patients. We would find the Royal Marsden training model hard to apply. Similarly, we feel that the average District General Hospital would have difficulty following the training programme described. It would take too long for each trainee to be competent in US-guided CVC placement. The CVC insertion may have to be performed by a Consultant, possibly called out-of-hours, if the trainee has not achieved ‘competency’. We acknowledge that the Royal Marsden Hospital does also have a high number of cases, but we feel their model cannot be applied to all hospitals in the UK. In common with the RCA competency demand, we feel that we should not be using the Royal Marsden model. So what is the answer? We all have different learning curves, achieving competency in practical skills at different rates. Whilst one trainee may master the skill in one or two attempts, five attempts may not be enough for another. Although the Royal Marsden model of training US- guided CVC insertion is better than the old-fashioned SODOTO approach (See One, Do One, Teach One), wouldn’t it be better to carry out a DOPS (Directly Observed Procedure). We think an individualised approach combined with a realistic training recommendation is the way forward. There is a role for the use of mannequins for US-guided CVC insertion training. Finally, the paper’s authors did not define an ‘attempt’ at CVC insertion. We understand it to be the passage of a needle through tissue in one direction towards the vein. We think it is difficult to achieve 1.31 attempts with the landmark technique without the need to withdraw the needle and redirect it. B.Almahdi* J.Carrannante A.McGlennan London, UK *E-mail: bma1973@hotmail.com 1 Wigmore TJ et al. Effect of the implementation of NICE guidelines for ultrasound guidance on the complication rates associated with central venous catheter placement in pateitns presenting for routine surgery in a tertiary referral centre. Br J Anaesth 2007; 99: 662-5 Conflict of Interest:None declared |
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Arun Krishnamurthy, Doctor Consultant in Anaesthetics and Intensive Care at Princess Alexandra Hospital, Harlow, Jeff Phillips
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Editor- We read with interest the paper by Wigmore and colleagues and wish to share our experiences. In their discussion, they remark on the reluctance in some quarters to adopt the use of ultrasound for central venous catheter (CVC) placement. We know that guidelines are supposed to represent what is best practice, but it is apparent that merely issuing guidelines does not necessarily change a clinician’s practice. With this in mind we conducted a survey of our anaesthetic department, to see what impact the use of ultrasound locating devices for CVC placement had made. The results showed a difference in practice between trainees and that of consultants. 55% of consultants surveyed reported no change in technique with the introduction of the NICE guidance, whereas 77% of trainees surveyed reported a large increase in the use of ultrasound at the expense of the landmark method. 60% of consultants reported as having no training or poor training in CVC insertion whereas 66% of trainees stated that their training was good to very good. There are, perhaps, several reasons for this difference. Senior clinicians may feel that they are already have a longstanding expertise in the landmark technique, recall few complications and so have little desire to change their practice – particularly when compelled to do so by a body of non-anaesthetists. This level of expertise is not seen in trainees who are therefore more motivated to adopt a new practice especially when the added technology may be viewed as more of an attraction than a hindrance. We wonder whether or not the results might be different if our Royal College or Association of Anaesthetists had issued the guidance? Conflict of Interest:None declared |
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