Let the resident try: Evaluation of central venous catheter placement in patients with hypotensive trauma using trauma video review

Abstract

Background

Intraosseous access has the greatest initial success rate in patients with hypotensive trauma and is significantly faster than central venous catheter access. However, central venous catheters play a critical role in the resuscitation of patients with hypotensive trauma. We sought to identify factors associated with successful placement of central venous catheter and hypothesized that attending surgeons would be more successful than trainees in the placement of central venous catheters.

Methods

We analyzed data abstracted from audiovisual recordings from a multicenter study of intravascular access in hypotensive (initial systolic blood pressure <90 mm Hg) injured patients. The primary exposure of interest was practitioner type (attendings compared with trainees [residents/fellows]). The primary outcome of interest was central venous catheter access attempt success rate. We also examined success rates stratified by site of attempt (femoral compared with subclavian) and the association between attempt success and patient factors.

Results

A total of 242 central venous catheter access attempts occurred in 171 patients (median age, 38 years [interquartile range, 27–53], 84% male, Injury Severity Score of 26 [interquartile range, 17–41], initial systolic blood pressure 59 [interquartile range, 0–78] mm Hg) across 15 centers. Trainees performed 170 of 242 (70%) of central venous catheter attempts. Success did not differ between groups (attendings 60% vs trainees 59%, P = .96). Patient factors including age, sex, mechanism, and Injury Severity Score were not associated with central venous catheter success rates, but success rates were greater in patients with measurable systolic blood pressure (71% vs 45%, P < .001). Attendings were more successful than trainees at subclavian attempts (66% vs 44%, P = .04).

Conclusion

No significant difference was found in overall central venous catheter success rate by practitioner type, but attendings were more successful at subclavian lines, and, on average, approximately 1 minute faster. Patient condition and skill level should be considered when providing trainees with the opportunity to place central venous catheter in hypotensive patients, particularly at the subclavian location.