Predictors of unattempted central venous catheterization in septic patients eligible for early goal-directed therapy

Evaluating the Role of Point-of-Care Ultrasound in Central Venous Pressure Monitoring for Critically Ill Patients. A Comprehensive Systematic Review and Meta-analysis

Central venous pressure (CVP) is a critical parameter for assessing volume status in critically ill patients, traditionally measured through invasive central venous catheterization. While effective, this method poses risks such as infection and procedural complications. Point-of-care ultrasound (POCUS) has emerged as a promising, non-invasive alternative, yet its accuracy in estimating CVP remains debated. From inception to December 2024, PubMed, Embase, MEDLINE, Web of Science, and Google Scholar databases were extensively searched. The search strategy used to identify relevant studies from these databases involved combining keywords such as "Point-of-care ultrasound," "central venous pressure," and "critically ill" with Boolean expression "AND" and "OR." Two independent reviewers then screened all potential studies and included those reporting the accuracy of POCUS in predicting CVP and those reporting the correlation between POCUS-measured indices and invasively-measured CVP in critically ill patients. Additionally, two independent reviewers extracted the relevant data from the included studies. Statistical analyses were conducted using MedCalc and Meta-Disc software, and quality appraisal was assessed using the QUADAS-2 tool. The review included studies evaluating POCUS-derived indices from the inferior vena cava (IVC) and internal jugular vein (IJV). Overall, strong correlations were observed between POCUS measurements and CVP, with IVC parameters showing the strongest associations. IJV measurements also demonstrated moderate reliability, particularly in scenarios where IVC assessments were impractical. Sensitivity and specificity analyses indicated that POCUS-derived indices could predict CVP with variable accuracy. These findings support the use of POCUS as a practical, non-invasive tool for estimating CVP in critically ill patients. IVC measurements appear to provide the most reliable correlations, while IJV assessments serve as a useful alternative. Despite its potential, variability in study methodologies and patient factors highlights the need for further research to refine POCUS-based CVP estimation and improve clinical application.

Emergency physician perspectives on central venous catheterization in the emergency department: a survey-based study

OBJECTIVES

The objective was to assess clinician experience, training, and attitudes toward central venous catheterization (CVC) in adult emergency department (ED) patients in a health system promoting increased utilization of CVC for severely septic ED patients.

METHODS

The authors surveyed all emergency physicians (EPs) within a 21-hospital integrated health care delivery system that had recently instituted a modified Rivers protocol for providing early goal-directed therapy (EGDT) to patients with severe sepsis or septic shock, including CVC if indicated. This initiative was accompanied by a structured, but optional, systemwide hands-on training for EPs in real-time ultrasound-guided CVC (US CVC). EPs' responses to questions regarding self-reported experience with CVC in the ED are reported. Data included frequency of CVC (by type) and US CVC training opportunities: both during and after residency and informal ("on-the-job training involving actual ED patients under the oversight of someone more experienced than yourself") and formal ("off-the-job training not involving actual ED patients"). The survey also asked respondents to report their comfort levels with different types of CVC as well as their agreement with possible barriers (philosophical, time-related, equipment-related, and complication-related) to CVC in the ED. Multivariable ordinal logistic regression was used to identify provider characteristics and responses associated with higher yearly CVC volumes.

RESULTS

The survey response rate among eligible participants was 365 of 465 (78%). Overall, 154 of 365 (42%) respondents reported performing 11 or more CVCs a year, while 46 of 365 (13%) reported doing two or fewer. Concerning CVC techniques, 271 of 358 (76%) of respondents reported being comfortable with the internal jugular approach with US guidance, compared to 200 of 345 (58%) with the subclavian approach without US. Training rates were reported as 1) in residency, formal 167 of 358 (47%) and informal 189 of 364 (52%); and 2) postresidency, formal 236 of 359 (66%) and informal 260 of 365 (71%). The most commonly self-reported barriers to CVC were procedural time (56%) and complication risk (61%). After multivariate adjustment, the following were significantly associated with greater self-reported CVC use (p < 0.01): 1) informal bedside CVC training after residency, 2) male sex, 3) disagreement with complication-related barrier questions, and 4) self-reported comfort with placing US-guided internal jugular catheters.

CONCLUSIONS

In this cross-sectional survey-based study, EPs reported varying experience with CVC in the ED and reported high comfort with the US CVC technique. Postresidency informal training experience, male sex, negative responses to complication-related barrier questions, and comfort with placing US-guided internal jugular catheters were associated with yearly CVC volume. These results suggest that higher rates of CVC in eligible patients might be achieved by informal training programs in US and/or by disseminating existing evidence about the low risk of complications associated with the procedure.