Risk Factors for Acute Adverse Events During Ultrasound-guided Central Venous Cannulation in the Emergency Department

Ultrasound (US) greatly facilitates cannulation of the internal jugular vein. Despite the ability to visualize the needle and anatomy, adverse events still occur. We hypothesized that the technique has limitations among certain patients and clinical scenarios. Objective: The purpose of our study was to identify characteristics of adverse events surrounding US-guided central venous cannulation (CVC). Methods: We assembled a prospective observational cohort of emergency department (ED) patients undergoing consecutive CVC under US. The primary outcome of interest was a composite of acute mechanical adverse events including hematoma, arterial cannulation, pneumothorax, and unsuccessful placement. Physicians performing the CVC recorded anatomical site, reason for insertion, and acute complications. We followed the catheters until they were removed based on radiographic evidence hospital nursing records. ED charts and pharmacy records contributed variables of interest. A self reported online survey provided physician experience information. Logistic regression was used to calculate the odds of an adverse outcome. Results: Physicians attempted 289 CVC on 282 patients. An adverse outcome occurred in 57 attempts (19.7%, 95%CI 15.5–24.7) the most common being 31 unsuccessful placements (11%, 95% CI 7.7–14.8). Patients with a history of end stage renal disease (OR 3.54, 95%CI 1.59–7.89) and central lines placed by operators with intermediate experience (OR 2.26, 95% CI 1.19–4.32) were most likely to encounter adverse events. Previously cited predictors such as BMI, coagulopathy, and pulmonary hyperinflation were not significant in our final model. Conclusions: Acute adverse events occurred in approximately 20% of US guided central line attempts. We identified both patient (history of end stage renal disease) and physician (intermediate experience level) factors that are associated with acute adverse events.