243: Emergency Physician Attitudes Regarding Ultrasound-Guided Central Venous Cannulation

243: Emergency Physician Attitudes Regarding Ultrasound-Guided Central Venous Cannulation

ICEM 2008 Scientific Abstract Program patient-based examination, reveals that 64-slice MDCT has enough sensitivity to be considered as an alternative ...

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ICEM 2008 Scientific Abstract Program patient-based examination, reveals that 64-slice MDCT has enough sensitivity to be considered as an alternative to conventional coronary angiography for the detection of coronary artery disease. This imaging technique should be considered as a screening tool for the evaluation of emergency department chest pain patients.

shift” was identified by 71% of respondents as a barrier to their use of ultrasound for central venous access and of those providing comments; “lack of machine availability” was the most common obstacle cited. Conclusion: Although emergency physicians recognize the merits of ultrasoundguided central venous access, a majority feel it is too time consuming and inconvenient. Improving access to ultrasound machines may encourage emergency physicians to use ultrasound as their standard of care when attempting central venous cannulation.

244

An Analysis of Emergency Department Bedside Ultrasound in the Diagnosis of Cholelithiasis

Larson JL, Fox JC, Scruggs W, Barajas G/University of California, Irvine, CA

243

Emergency Physician Attitudes Regarding Ultrasound-Guided Central Venous Cannulation

Fluman KR, Theodoro DL, Adhikari S/Washington University, St Louis, MO; University of Nebraska Medical Center, Omaha, NE

Study Objectives: Ultrasound-guided central venous cannulation benefits both the practicing physician and the patient. Despite its known advantages, many physicians continue to resist ultrasound assistance. The purpose of our study was to assess physician attitudes regarding the safety and convenience of ultrasound-guided central venous cannulation and evaluate their experience with the technique. Methods: The Web site www.surveymonkey.com was used to distribute a voluntary, online survey to a total of 81 physicians in August of 2007. The survey consisted of 17 multiple-choice questions related to ultrasound-guided central venous access. Non-responders were also sent up to 3 email reminders over a period of 6 weeks. Thirty-five attending-level emergency physicians and 46 emergency medicine residents (PGY 1-4) were invited to participate in the survey. All practice at an urban, academic, level 1 trauma center with over 85,000 adult emergency department visits per year and 2 ultrasound machines available at all times for emergency physician use. Results: The overall response rate was 94%, which included responses from 30 attending-level physicians and all 46 residents. Sixty-five percent of physicians polled reported experience inserting more than 30 central venous catheters during their career. Eighty percent of respondents stated that they were initially trained using the traditional landmark technique for central venous cannulation. Only 32% of physicians reported using ultrasound to place central venous catheters more than 60% of the time. Over half of respondents (53%) acknowledged that they were aware of controlled trials demonstrating the benefits of ultrasound-guided central venous access. Eighty-eight percent of physicians agreed that ultrasound-guided central venous access is safer than the traditional landmark method, with 79% of respondents agreeing that ultrasound guidance reduces complications and placement failure rates associated with central venous access. A majority of physicians (93%) felt that ultrasound guidance is especially useful in patients considered to be difficult line placements. Twenty-five percent felt it was faster and 29% thought it was more convenient than the traditional landmark technique. “Not enough time during a busy

Volume , .  : April 

Study Objective: The objective of this research project was to determine if emergency department (ED) physicians could use bedside ultrasound (BUS) to accurately diagnose cholelithiasis. BUS does not expose patients to the radiation that a computed tomography (CT) scan does, and is a quicker and less expensive alternative to radiological imaging, the most common imaging modality for the diagnosis of cholelithiasis. Methods: This study retrospectively reviewed 37 consecutive months of ED gallbladder BUS scans at a Level I trauma center. Both attending and resident physicians in the ED who performed these scans had previous experience ranging from 50-1000 supervised scans of various types. As part of the standard of patient care, the Emergency Department Ultrasound Process Improvement Committee (EDUPIC) reviews all BUS scans. The results of the BUS scans were compared to those of the EDUPIC and those of radiology; the results of the EDUPIC were then compared to those of radiology as well. Results: Of the 1690 ED gallbladder BUS scans that met the study’s inclusion criteria, 575 (34%) also received radiological imaging. When compared to the EDUPIC, the ED physicians were 88% sensitive (95% Confidence Interval [CI], 85-90) and 97% specific (95% CI, 95-98). When compared to radiology, sensitivity was 88% (95% CI, 84-91) and specificity was 87% (95% CI, 82-91). The EDUPIC interpretation was 90% sensitive (95% CI, 87-93) and 90% specific (95% CI, 85-93) when compared to radiology. Conclusions: The results from this research study indicate that ED physicians are both sensitive and specific in the diagnosis of cholelithiasis with BUS. Additionally, patients can benefit from a quicker diagnosis, as well as a less expensive alternative when compared to radiological imaging. One important limitation to this study was the inability to determine the experience of the ED physician who performed the BUS scan.

245

Predictors of Central Venous Cannulation Complications in the Emergency Department

Theodoro DL, Bausano BJ, Lewis L, Evanoff B, Kollef M/Washington University, St Louis, MO

Study Objectives: Emergency physicians insert greater numbers of central venous catheters due to new resuscitation guidelines and higher patient volume. Some physicians believe ultrasound technology assists in line placement while others find it cumbersome and cite no difference in complication rates of the procedure under experienced operators. The purpose of our study was to identify predictors of central line insertion complications in an urban emergency department. Methods: We assembled a prospective observational cohort undergoing central venous cannulation, cannulation outcomes, and complications. Complications were defined as hematoma, arterial cannulation, pneumothorax, and unsuccessful placement. Physicians performing the procedure recorded anatomical site of cannulation, ultrasound assistance, and complications. They indicated whether the patient required cannulation for physiologic reasons, or inability to obtain peripheral access. We calculated body mass index and dichotomized into “obese” and “nonobese” categories. We used logistic regression to model whether patient BMI category, ultrasound assistance, indication, or anatomic location predicted complications. Results: Emergency physicians placed 243 central lines in a 5-month period. Forty-one percent were placed in the internal jugular, 29 % in the subclavian vein, and 35% in the femoral vein. Physicians encountered a complication in 23 % of cases. The median BMI in this cohort was 26.1. Relative to the subclavian approach, ultrasound guided internal jugular cannulations (OR .31, 95% CI .14-.70) and nonultrasound-guided femoral cannulations (OR .33, 95% CI .14-.77) were less likely to result in complications. Predictors of complications included inability to cannulate

Annals of Emergency Medicine 545