A landmark paper?

A blog by Dr James Day () for OXICM

I found this open access article doing the rounds on twitter. It was something that I had thought about too through my training:

Residents learning ultrasound-guided catheterization are not sufficiently skilled to use landmarks. Maizel J, Guyomarc H L, Henon P, Modeliar SS, de Cagny B, Choukroun G, Slama M. Crit Care. 2014 Feb 23;18(1):R36. [Epub ahead of print]

Pubmed link Open access link


Current guidelines date back from 2002, issued by NICE. These have been reviewed, with no changes, in 2005 and 2010. Their guidance advises:

“Two-dimensional (2-D) imaging ultrasound guidance is recommended as the preferred method for insertion of central venous catheters (CVC’s) into the internal jugular vein (IJV) in adults and children in elective situations.”

“The use of two-dimensional (2-D) imaging ultrasound guidance should be considered in most clinical circumstances where CVC insertion is necessary either electively or in an emergency situation” 

The Committee also considered that although 2-D ultrasound imaging guidance in CVC placement may eventually become the routine method for placing CVC’s, the landmark method would remain important in some circumstances, such as emergency situations, when ultrasound equipment and/or expertise might not be immediately available. Consequently, the Committee thought it important that operators maintain their ability to use the landmark method and that the method continues to be taught alongside the 2-D-ultrasound-guided technique.

Study synopsis

It is a French study that looked at the ability of junior doctors to perform central venous catheters (CVC) via the traditional landmark technique. For the first 3 months they placed CVCs via ultrasound. In the next three months they were allowed to use the landmark technique. Initially there was a reduction in the success rate and an increase in the complication rate compared to using ultrasound. After 10 landmark CVCs placements the success rate and complication were at parity with the ultrasound technique.

They have a number of key messages:

•          The real-time ultrasound-guided technique is the recommended procedure for central vein catheterization. However, in emergency situations ultrasound machine may be unavailable.

•          To ensure that physicians are adequately skilled in all situations, they must be able to perform catheter placement without ultrasound.

•          Training in the ultrasound-guided technique provides the resident with certain, but insufficient skills for catheter placement by the landmark technique.

•          A training program comprising at least 10 landmark procedures is required to achieve optimal skills.

The paper raises some interesting ethical and training issues. It doesn’t seek to address them though. These issues are by no means specific to CVC placement.

Interested to hear your thoughts.


3 thoughts on “A landmark paper?

  1. An important topic. I take a moment before needle insertion to say to myself – if the ultrasound machine stopped working and this was a landmark insertion would i be happy i knew where i was? I think it helps me. So many operators still don’t use ultrasound though: See this survey

  2. Landmarks are always important to know even if using the ultrasound. I commonly use landmarks to position and decide where my needle placement is going to be and then confirm with ultrasound if necessary. If using landmarks always remember finger on the pulse. That way you know where the carotid/femoral artery is. Also remember that when using landmark technique you appreciate the depth of your needle. The jugular is very superficial and you should hit it within the first few centimetres. If you’ve advanced the whole 10cm then you know you’ve missed it and likely given them a pneumothorax.

  3. Excellent post. I have two questions though.

    1. Is it ethical to perform, or train, in landmark techniques when an ultrasound machine is available?

    2. When do you really need to put in an “emergency blind” central line? I would argue:
    A) hypotension needing vasopressors- not strictly urgent. Use peripheral pressors (see http://www.emcrit.org)
    B) massive transfusion. A large peripheral line or IO will surely suffice while the ultrasound is being sourced?

    Would love to hear other’s comments.

    DOI: have caused retroperitoneal haematoma from a blind femoral line

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