Ultrasound guidance for central venous catheter placement: results from the Central Line Emergency Access Registry Database.

BACKGROUND: Ultrasound guidance of central venous catheter (CVC) insertion improves success rates and reduces complications and is recommended by several professional and regulatory organizations. METHODS: This is a prospective observational study using data extracted from the Central Line Emergency Access Registry database, a multicenter online registry of CVC insertions from medical centers throughout the United States. We compared success rates with ultrasound and with the anatomic-landmark technique. RESULTS: A total of 1250 CVC placement attempts by emergency medicine residents during the study period were selected from the Central Line Emergency Access Registry database. Because a few attempts (n = 28) were made to place lines in either the left or right supraclavicular locations, data on these attempts were eliminated from the analysis. A total of 1222 CVC attempts from 5 institutions were analyzed. Successful placement on the first attempt occurred in 1161 (86%) cases and varied according to anatomic location. Ultrasound guidance was used in 478 (41%) of the initial attempts. The remainder of placements were presumably placed using the anatomic-landmark technique based on visible surface and palpatory subcutaneous structures. Overall successful placement rate did not vary according to the use of ultrasound guidance, nor did it vary at different anatomic sites. However, ultrasound was found to be significant for reducing the total number of punctures per attempt (P < .02, t = 2.30). CONCLUSIONS: Our study did not observe improved success with the use of ultrasound for CVC cannulation on the first attempt, but we did observe a reduced number of total punctures per attempt.

Outcomes after environmental hyperthermia.

OBJECTIVES: This study was conducted to describe the characteristics and outcomes of patients who presented to the emergency department (ED) with presumed environmental hyperthermia. METHODS: A retrospective chart review was performed in 2 institutions with patients who were seen in the ED and had a discharge diagnosis of hyperthermia, heat stroke, heat exhaustion, or heat cramps. Exclusion criteria were an alternative diagnosis potentially explaining the hyperthermia (pneumonia, etc). Research assistants, who were blinded to the purpose of the study, performed a systematic chart review after a structured training session. If necessary, a third reviewer acted as a tiebreaker. Data regarding patient demographics, comorbidities, vital signs, laboratory results, and short-term outcome were collected. Data were analyzed with Excel and STATA software. RESULTS: We enrolled 52 patients with a mean age of 42.6 years (range, 0.4-81 years) from August 1, 2003 to August 31, 2005. The mean high daily temperature was 103.6 degrees F (range, 88-118 degrees F). At presentation, the mean body temperature was 105.1 degrees F (range, 100.2-111.2 degrees F) and the Glasgow Coma Scale score was less than 14 in 36 (69.2%) patients. Laboratory results demonstrated that 21 (40.4%) patients had a creatinine level of more than 1.5 mg/dL, 35 (67.3%) patients had a creatine kinase (CK) of more than 200 U/L, 30 patients (57.7%) had a prothrombin time of more than 13 seconds, 29 (55.8%) patients had an aspartate aminotransferase (AST) of more than 45 U/L, and only 3 patients (5.7%) had a glucose of less than 60 mg/dL. Ethanol or illicit drugs were involved in 18 (34.6%) cases. The mean hospital stay was 4.7 days (range, 1-30 days), and there were 15 deaths (28.8%). A kappa score for interreviewer reliability was 0.69. Major limitations were the retrospective nature and lack of homogeneity in patient evaluation and test ordering. CONCLUSIONS: Hyperthermic patients with higher initial temperatures, hypotension, or low Glasgow Coma Scale score were more likely to die.