In this respect, maybe children are just small adults (with smaller, harder-to-cannulate veins). Ultrasound has definitively been shown to facilitate central line placement in adults, and single-center and operating room studies also support its use in children (NEJM JW Emerg Med Nov 2014 and Acad Emerg Med 2014; 21:981). However, oddly, ultrasound is still not always used for central line placement in pediatric intensive care units (PICUs). These authors conducted a prospective, observational study of central line placement at 26 PICUs in Spain; at each PICU, clinical providers selected the insertion technique. The researchers used propensity matching in their analysis to account for potential confounding. Of 500 central line placements in 354 patients aged 0 to 18 years, providers chose to use ultrasound guidance for 323 procedures and the landmark technique only for 177 procedures. Ten PICUs routinely used ultrasound (≥80% of cases) and 5 routinely used landmarks. After propensity matching, ultrasound guidance was associated with significantly higher first-attempt success (47% vs. 30%) and lower complication rate (12% vs. 23%). Complications significantly increased, and ultimate success decreased, when three or more attempts were required at a single site. |
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Ultrasound guidance has been the standard of care for central line placement in adults for almost a decade. While it is valuable to have data from children rather than generalizing from adult studies, it is surprising that some PICUs in this study used ultrasound guidance for <20% of cases. Nonetheless, there is plenty of evidence that ultrasound guidance is helpful in children and no evidence of a downside.