Journal of Pediatric Surgery 50 (2015) 11621167

Contents lists available at ScienceDirect

Journal of Pediatric Surgery

journal homepage: www.elsevier.com/locate/jpedsurg

Use of real-time ultrasound during central venous catheter placement:

Results of an APSA survey
Melvin S. Dassinger a,, Elizabeth J. Renaud b, Adam Goldin c, Eunice Y. Huang d, Robert T. Russell e,
Christian J. Streck f, Xinyu Tang g, Martin L. Blakely h
a
Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR
b
Albany Medical Center, Albany, NY
c
Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
d
University of Tennessee Health Sciences Center, Memphis, TN
e
Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, AL
f
Medical University of South Carolina, Charleston, SC
g
Biostatistics Program, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
h
Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Nashville, TN

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: The purpose of this study was to document the attitudes and practice patterns of pediatric surgeons re-
Received 20 January 2015 garding use of RTUS with CVC placement.
Received in revised form 23 February 2015 Methods: An analytic survey composed of 20 questions was sent via APSA headquarters to all practicing members.
Accepted 6 March 2015 Answers were summarized as frequency and percentage. Distributions of answers were compared using the chi-
square tests. P-values 0.05 were considered statistically signicant.
Key words:
Results: 361 of 1072 members chose to participate for a response rate of 34%. Most placed CVCs into the subcla-
Ultrasound
Venous
vian veins (SCV) of patients without coagulopathy, with the left SCV chosen approximately four times more often
Catheter than the right. Conversely, RTUS use at the internal jugular vein (IJV) was signicantly greater than that for the
Real-time SCV (p b 0.001). Coagulopathy, multiple previous catheters, and morbid obesity were identied as patient char-
Survey acteristics that would encourage RTUS use. The most commonly cited potential barriers to RTUS use were lack of
formal ultrasound training and the belief that ultrasound is not necessary.
Conclusions: Variability exists among pediatric surgeons regarding use of RTUS during CVC placement. Additional
studies are needed to document actual frequency of use, how RTUS is implemented, and its efcacy of preventing
adverse events in children.
2015 Elsevier Inc. All rights reserved.

Pediatric surgeons are frequently asked to place central venous cath-
eters (CVCs) into children. Common indications for placement include
reasons ranging from chemotherapy to the need for long term parenter-
al nutrition. Percutaneous placement of CVCs involves one of two tech-
niques: the traditional landmark approach or an ultrasound-guided
approach. The former utilizes knowledge of anatomic landmarks to lo-
cate and access the central vein without imaging assistance. The
ultrasound-guided approach uses imaging and has evolved over time.
Historically, static images were used to place an external mark on the
skin for guidance in access; more recently, dynamic, two-dimensional,
real-time ultrasound (RTUS) has gained favor [1,2].
The use of RTUS for central venous catheter placement was noted in
the Agency for Healthcare Quality and Research (AHRQ) 2001 report,
Making Health Care Safer, to be one of the safety practices with the stron-
gest evidence [3]. The follow-up report, released in 2013, again advocat-
ed for this practice; the authors concluded that use of real-time
Corresponding author at: Arkansas Children's Hospital, 1 Children's Way, Slot 837, Lit-
tle Rock AR.
E-mail address: dassingermelvins@uams.edu (M.S. Dassinger).
ultrasound in the placement of central venous catheters was one of
only ten practices deemed strongly encouraged for adoption [4].
This recommendation was based on the strength of evidence and its
ease of implementation. Literature cited in the most recent report in-
cluded studies in both adult and pediatric patients, including two sur-
veys of adult practitioners [5,6]. However, to date, no surveys have
been published which document the attitudes and practice patterns of
pediatric surgeons regarding routine use of RTUS with CVC placement.
1. Methods
After institutional review board (IRB) approval (#203266), an ana-
lytic survey was created and administered via Survey Monkey, a Web-
based survey development company. The survey was vetted through
the American Pediatric Surgery Association (APSA) Outcomes and Evi-
dence Based Practice Committee prior to distribution. An email was
sent on October 3, 2014 from APSA headquarters to 1072 members in-
viting voluntary survey participation. A reminder email was sent on
October 24th and the survey closed on October 31, 2014. The survey

http://dx.doi.org/10.1016/j.jpedsurg.2015.03.003
0022-3468/ 2015 Elsevier Inc. All rights reserved.
 M.S. Dassinger et al. / Journal of Pediatric Surgery 50 (2015) 11621167 1163

consisted of 20 questions. Participants had the option to answer either Table 2

all the questions or some of the questions on the survey. Anatomic site preference.

Scenario %
1.1. Statistical analysis Nontunneled CVC, no coagulopathy (n = 349)
Right internal jugular 31
All data were analyzed using the statistical software R v3.1.0 Right subclavian 13
(R Foundation for Statistical Computing, Vienna, Austria). The answers Left internal jugular 1
Left subclavian 55
to each survey question were summarized as frequency and percentage.
Femoral 1
The distributions of answers were compared among different groups Tunneled CVC, no coagulopathy (n = 340)
using the chi-square tests. P-values 0.05 were considered statistically Right internal jugular 31
signicant. Right subclavian 14
Left internal jugular 2
Left subclavian 53
2. Results Tunneled CVC, coagulopathy (n = 315)
Right internal jugular 49
2.1. Demographics Right subclavian 8
Left internal jugular 4
Left subclavian 40
Of the 1072 members who received the survey, 361 chose to partic-
CVC for hemodialysis (n = 349)
ipate for a response rate of 34%. 91% of respondents had a university ap- Right internal jugular 81
pointment or afliation and 61% worked at a free-standing children's Right subclavian 4
hospital. 54% of respondents placed CVCs with general surgery residents Left internal jugular 2
in N 50% of cases, while 17% placed CVCs with pediatric surgery fellows Left subclavian 13

in the majority of cases (see Table 1). Sum N100% owing to rounding.
Ultrasound performed by the surgeon was rarely implemented (01
times per week) in other aspects, e.g. FAST, of 78% of the respondents'
practices. Additionally, only 24% had attended an ultrasound course thrombocytopenic patient. When placing hemodialysis catheters, 17%
within the past 15 years. Only 8% of participating pediatric surgeons of respondents chose the subclavian veins.
had ever received written or verbal feedback from hospital administra-
tion regarding use of RTUS for CVC placement. 2.3. Attitudes regarding ultrasound use

2.2. Anatomic site preference
Surgeons' anatomic site preferences are depicted in Table 2. Most
pediatric surgeons indicated their preference to place both tunneled
and nontunneled CVCs into the subclavian veins (SCV) of patients with-
out coagulopathy or thrombocytopenia (68 and 69%, respectively). The
left subclavian vein was chosen approximately four times more often
than the right subclavian vein and the infraclavicular subclavian was
preferred by 98% of participants. The percentage that preferred the sub-
clavian veins decreased to 48% when the scenario depicted a
The most commonly cited potential barriers to RTUS use becoming
standard of care were lack of formal ultrasound training and the belief
that ultrasound is not necessary. Additionally, 49% of respondents felt
that either RTUS did not reduce complications or were unsure if its
use reduced complications when used during CVC placement. Coagu-
lopathy, multiple previous catheters, and morbid obesity were identi-
ed by 39%, 55%, and 50% of respondents, respectively, as patient
characteristics that would encourage RTUS use.
2.4. Ultrasound usage by anatomic site

RTUS use for cannulation of the internal jugular vein (IJV) is signi-
Table 1
cantly greater than that for both the SCV and femoral vein sites
Demographics.
(p b 0.001); 64% of participants always used RTUS for IJV compared to
% 3% for the SCV and 33% for the femoral vein. Conversely, 66% of respon-
University afliation or appointment (n = 359) dents never used RTUS for the SCV compared to 8% for the IJV and 12%
Yes 91 for the femoral vein (Fig. 1).
No 9 RTUS usage for placement of CVCs into the IJV was associated with a
Practice Setting (n = 353)
Free-standing children's hospital 61
more recent completion of pediatric surgery fellowship training (p =
Pediatric hospital within adult hospital 36 0.02). Additionally, those who always used RTUS at the IJV site were
General adult hospital 3 more likely to preferentially choose the IJV in all scenarios compared
Number of CVCs placed with last 12 months (n = 356) to those who never used RTUS (p b 0.001). Further, they were more
025 28
likely to believe that RTUS usage is already the standard of care
2650 37
5175 23 (p b 0.001) and that its use reduces complications (p b 0.001). Those re-
76100 9 spondents that never used RTUS at the IJV site were less likely to be af-
N100 3 liated with a university (p = .04) and were more likely to never use
Estimate of percentage of CVCs placed with general surgery resident RTUS at other anatomic sites (p b 0.001). Setting of practice, number
(n = 353)
025 28
of CVCs placed within the last 12 months, and resident or fellow in-
2650 18 volvement were not associated with a signicant difference in RTUS
5175 20 usage at the IJV site.
76100 34 Those who always used RTUS regardless of anatomic site (n = 82)
Estimate of percentage of CVCs placed with pediatric surgery fellow
preferentially chose the right IJV for CVC placement. Respondents who
(n = 350)
025 66 never used ultrasound for CVC placement (n = 24) were more likely
2650 17 to choose the left SCV except for hemodialysis access; in this scenario,
5175 9 the RIJ was chosen by 74%, with the remaining 26% choosing a SCV.
76100 9 Those who never used RTUS regardless of site identied all options pre-
Sum is N100% owing to rounding. sented as barriers to RTUS use: lack of access to an ultrasound machine;
1164 M.S. Dassinger et al. / Journal of Pediatric Surgery 50 (2015) 11621167

lack of formal training; belief that ultrasound cannot adequately delin-

eate venous anatomy; time and efciency constraints; and belief that ul-
trasound is unnecessary (Fig. 2).

3. Discussion

There is a growing body of evidence supporting the use of RTUS for

Fig. 1. Percentage of time RTUS used during CVC placement based on anatomic site.
CVC placement [79]. In response, many professional organizations
and governmental agencies, including the American College of Sur-
geons, have put forth position statements supporting this practice
[3,10,11]. Since that time, several surveys have documented the practice
patterns of other specialists that place CVCs including anesthesiologists
and emergency room physicians [5,6,12,13]. However, this survey is the
rst to document the practice patterns and attitudes of a group of sur-
geons, specically pediatric surgeons, regarding use of RTUS during
CVC placement.
Our survey indicates that pediatric surgeons preferentially chose the
SCV for placement of CVCs in most instances. This preference of the SCV
site represents a fundamental difference between the practices of sur-
geons and that of other specialties and likely stems from differences in
training; while other specialties' trainees are initially taught IJV cannu-
lation, surgical residents have traditionally been taught to place CVCs
into the subclavian vein, almost exclusively using landmark techniques.
Increasing comfort level with this method acquired through years of ex-
perience, along with difcult visualization of the SCV owing to the over-
lying clavicle, likely contributes to the low rate of RTUS use at this site.
These factors may help explain the choice of 17% respondents to prefer-
entially place a hemodialysis catheter into the SCV, a practice which
runs counter to the published recommendations of IJV placement [14].
Pediatric surgeons are more likely to use RTUS when placing CVCs
into the IJV compared to other anatomic sites. However, the percentage
of participants who indicated that they always used US at the IJV was
only 66% despite the preponderance of the literature supporting its
use [7,8,15]. This rate of usage is likely multifactorial. First, the rate pre-
sumably represents a reluctance to change ingrained, comfortable prac-
tices as it is similar to that reported in surveys of other specialties
[5,6,12,13]. In addition, pediatric surgeons may be skeptical of the pub-
lished literature supporting RTUS use in children. The majority of the
data which comprised the AHRQ reports involved adult patients, poten-
tially making it less generalizable to the pediatric population [79].
Complicating matters further are the results of studies performed in in-
fants and children. While some randomized trials demonstrated a de-
creased complication rate when RTUS was used, these studies are

Fig. 2. Barriers identied to RTUS during CVC placement comparing those respondents who always use RTUS to those who never use RTUS.
 M.S. Dassinger et al. / Journal of Pediatric Surgery 50 (2015) 11621167 1165

limited by small sample size, single institution nature, and practitioner Appendix A
unfamiliarity with the landmark technique [16,17]. A more recent
study documented fewer cannulation attempts when using RTUS but Use of ultrasound (US) during central venous catheter (CVC) place-
no change in rates of serious complication [18]. Moreover, other studies ment has been the subject of multiple recent studies, including at least
have reported lower complication rates using the traditional landmark two surveys documenting use of this modality by adult practitioners.
approach [19,20]. All of these factors likely contribute to the belief To date, however, no surveys have been published documenting atti-
expressed by 38% of respondents that RTUS is unnecessary. tudes and practice patterns of pediatric surgeons regarding use of
Another barrier to RTUS use during CVC placement that our survey real-time US with CVC placement.
identied was lack of formal training; 45% of respondents indicated
1. Do you have an appointment or afliation with a university?
this as an impediment, making it the most commonly selected option.
a. Yes
An emphasis on education is a potential solution to this problem. Only
24% of our participants had attended a formal US course. This number b. No
compares unfavorably to results of another survey in which 60% of 2. What is the setting where you perform the majority of your
responding emergency physicians had received specic training in US- operations?
guided vascular access. Furthermore, in this same study, 80% of respon- a. Free-standing children's hospital
dents had used at least one educational resource, with the top two being b. Pediatric hospital within a general adult hospital
ultrasound courses and texts [13]. However, contemporary general sur- c. General adult hospital
gery residents may overcome the lack of formal training by ever- d. Other
increasing exposure to RTUS use in other specialties such as trauma, 3. What year did you complete your pediatric fellowship training?
breast, and vascular surgery. This exposure may explain the increasing
a. Enter year ______
use of RTUS at the IJV by those participants that had recently nished
4. Have you attended an ultrasound training course, which included
pediatric surgery fellowship. However, their predecessors did not have
specic instruction in its use during central venous catheter (CVC)
this same exposure. Increased availability of both didactic and hands-
placement, within the past 15 years?
on training sessions offered at venues such as national meetings
a. Yes
would likely be benecial.
b. No
Practice change would involve not only the individual practitioners
but also hospital administration. This support would likely involve 5. Please estimate the number of percutaneous CVCs, either tunneled
both oversight and investment. Only 8% of survey participants indicated or non-tunneled, you placed in the operating room within the last
that they had been approached by a hospital administrator such as a 12 months.
safety ofcer regarding use of RTUS. This low number is interesting a. 025
since complications that arise from CVC placement are increasingly b. 2650
being viewed by agencies such as the Centers for Medicare and Medic- c. 5175
aid Services as preventable error [21]. Furthermore, if RTUS is to become d. 76100
standard of care, institutions would likely need to purchase more e. N100
equipment as 25% of respondents indicated that an ultrasound machine 6. Please estimate the percentage of cases performed by you within
is not routinely available. While an initial investment would need to be the last 12 months involving CVC placement in the operating
made, the machine could likely be shared across several specialties. Fur- room in which a general surgery resident was involved.
thermore, ultrasound has been demonstrated to be cost-effective when a. 025%
used during CVC placement [22]. b. 2650%
There are several limitations to our study. First, the response rate c. 5175%
was 34%. However, this number is similar to the response rate of d. 76100%
other studies [5,23]. Second, we have very little information about 7. Please estimate the percentage of cases performed by you within
nonresponders, potentially leading to bias. Another possible source the last 12 months involving CVC placement in the operating
of bias lies in our respondents' demographics: 91% identied them- room in which a pediatric surgery fellow was involved.
selves as being afliated with a university, skewing answers toward a. 025%
opinions and practices of academic surgeons. Additionally, the num- b. 2650%
ber of respondents who either always used RTUS or never used RTUS c. 575%
was small, making meaningful comparisons between the two groups d. 76100%
difcult. Furthermore, our survey does not attempt to discriminate 8. A 12 year old is in the operating room for repair of a traumatic
how ultrasound was used, but simply how often it is used; future femur fracture and anesthesia has requested placement of a non-
studies are needed to investigate exactly how ultrasound is imple- tunneled CVC. Her cervical spine has been cleared and collar re-
mented. Finally, there were internal inconsistencies in responses; moved. Her platelet count and INR are within normal limits. What
some participants that indicated that RTUS was always used for is your preferred site for percutaneous temporary central venous
CVC placement also indicated less than 100% use at anatomic sites catheter (CVC) placement?
other than the IJV. a. Right Internal Jugular
In summary, this survey is the rst of its kind to document atti- b. Right Subclavian
tudes and perceived practice patterns of pediatric surgeons regard- c. Left Internal Jugular
ing the use of RTUS during CVC placement. Several barriers to this d. Left Subclavian
modality's use were identied including surgeons' fundamental be- e. Innominate
lief that RTUS is unnecessary and its use may not reduce complica- f. Femoral
tions. These perspectives of actively practicing pediatric surgeons, g. Other
when juxtaposed against the recommendations from governmental 9. A 9 year old with rhabdomyosarcoma is in need of a tunneled CVC
agencies, illustrate a knowledge gap that exists in the current data for chemotherapy. She has never had central venous access placed
regarding safety outcomes in the pediatric population. Additional previously. Her platelet count and INR are within normal limits.
studies comparing CVC placement by pediatric surgeons with and What is your preferred site for percutaneous long term central ve-
without ultrasound guidance are needed. nous catheter (CVC) placement?
1166 M.S. Dassinger et al. / Journal of Pediatric Surgery 50 (2015) 11621167

a. Right Internal Jugular or lack of use of ultrasound with CVC placement in the
b. Right Subclavian operating room?
c. Left Internal Jugular a. Yes
d. Left Subclavian b. No
e. Innominate 18. If ultrasound use during CVC placement were to become standard
f. Femoral of care at your institution, what barriers to its use would you antic-
g. Other ipate (check all that apply)?
10. A 7 year old with leukemia is in need of a tunneled CVC for chemo- a. Lack of access to an ultrasound machine
therapy. He has never had central venous access placed previously. b. Lack of formal ultrasound training
His platelet count is 46,000. What is your preferred site for percuta- c. Belief that ultrasound cannot adequately delineate venous anatomy
neous long term central venous catheter (CVC) placement? d. Time and efciency constraints
a. Right Internal Jugular e. Belief that ultrasound is unnecessary
b. Right Subclavian f. Not applicable- it is already standard of care
c. Left Internal Jugular g. Other
d. Left Subclavian 19. Do you believe the use of ultrasound with CVC placement
e. Innominate reduces complications?
f. Femoral a. Yes
g. Other b. No
11. A 13 year old with longstanding renal insufciency is approaching c. Unsure
the need for hemodialysis. She is neither coagulopathic nor throm-
20. Approximately how many times per week do you perform ultra-
bocytopenic and has had no previously placed central access. What
sound in other aspects of your clinical practice, e.g. FAST?
is your preferred site for long-term, tunneled hemodialysis catheter
a. 01
placement?
b. 25
a. Right Internal Jugular
c. 67
b. Right Subclavian
d. 810
c. Left Internal Jugular
e. N10
d. Left Subclavian
e. Innominate
f. Femoral References
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