|The College was invited to contribute to the provision of expert advice to inform this NICE Technology Appraisal. The College response was coordinated by Dr Peter Simpson and the expert advice was provided by Dr Andrew Bodenham and Dr Charlotte Gilhooly. The Guidance itself is entirely the work of NICE and the College has only had opportunity to comment at the draft stage. The College was well aware of the implications of a wholesale recommendation of the use of 2D ultrasound for the placement of central venous lines, recognising that there was a significant difference between anaesthetists, expert in their insertion in the intensive care and cardiac surgery situation, and inexperienced junior staff inserting feeding lines in less than ideal circumstances. Nevertheless, there are a growing number of clinicians who feel that, given appropriate equipment and training, the use of 2D ultrasound represents a major advance in the safety of central venous cannulation.
At the draft stage the College made strenuous representation that, although NICE considered that 2D ultrasound represented a significant advance, wholesale recommendation would produce major problems as follows:
1. Subsequent failure to use 2D ultrasound could have major medico-legal implications.
2. In certain situations such as ITU or cardiac theatres, serious delays in instigating monitoring and subsequent treatment could occur.
3. It is relatively impractical in the emergency situation.
4. It would result in deskilling with regard to use of the landmark technique.
5. A significant financial burden on Trusts, since a number of machines (4-6) would be required on each site and training would be necessary for all users.
As a result of this, the final document has been considerably modified to take account of these anxieties. Although the Guidance (1) implies that ultrasound guidance should be used whenever possible, it is important to read the document more fully. 1.1 emphasises the elective situation only and 1.2 just states that 2D should be considered in all situations.
It is also important to read 4.3.5 and 4.3.6 concerning the practicality and financial implications, which are detailed under 6. The financial implications for the NHS are enormous. Unless a Trust provides both the equipment and the training, clinicians have no alternative but to use the landmark technique. Furthermore, if ultrasound equipment is unavailable for whatever reason, it is clearly essential to maintain landmark skills. This is of particular importance for trainees, who move between hospitals with varying ultrasound provision, at regular intervals.
The College draws attention to 4.3.6, in which it is emphasised that we should continue to use and teach the landmark technique. Regrettably, this recommendation is not emphasised in the guidance, which has been a major source of clinicians' anxiety. We also note that in 4.3.3, the part played by the skill and experience of the operator is emphasised. This is confirmed under 7.6.
In summary, the College feels that the guidance is fair and sensible but considers that utilisation of the landmark method is still an acceptable alternative, whether or not 2D ultrasound is available. We would recommend that whenever a central venous catheter is inserted, a note is made of which method of localisation, i.e. 2D ultrasound or landmark technique, is used. This would have the added benefit of allowing future comparison of the two techniques.
Dr Peter Simpson
In view of the above developments, AnaesthesiaUK has developed a new educational section regarding Ultrasound and Anaesthesia. This section is sponsored by an educational grant from Sonosite.