Use of real-time ultrasound guidance for the placement of hemodialysis catheters: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Insertion of percutaneous hemodialysis catheters is an invasive procedure with a small but definite risk of morbidity and mortality.

OBJECTIVES: Assessing potential benefits of using real-time 2-dimensional Doppler ultrasound imaging guidance for the insertion of hemodialysis catheters compared with insertion based solely on anatomic landmarks.

STUDY DESIGN: Systematic review and meta-analysis of randomized controlled trials.

DATA SOURCES: MEDLINE (1966 to July 2010), EMBASE (1980 to July 2010), Cochrane Renal Group Specialised Register, and Cochrane Central Register of Controlled Trials (CENTRAL).

SETTING & POPULATION: Patients requiring hemodialysis catheter insertion.

SELECTION CRITERIA FOR STUDIES: We included all randomized controlled trials regardless of publication status or language.

INTERVENTIONS: Real-time 2-dimensional Doppler ultrasound image guidance.

OUTCOMES: Catheter placement failures, catheters failed to be placed in the first attempt, attempts per catheter inserted, time taken for successful venous puncture, and complications (carotid artery puncture, pneumo- or hemothorax, neck hematoma, and brachial plexus injury). Treatment effects were summarized with the RR measure for dichotomous outcomes and mean difference for continuous outcomes.

RESULTS: 7 trials with 830 catheters were identified. Ultrasound guidance significantly decreased the risk of the following outcomes: catheter placement failure (7 studies, 830 catheters; RR, 0.12; 95% CI, 0.04-0.37), failure to place catheter on first attempt (5 studies, 595 catheters; RR, 0.40; 95% CI, 0.29-0.56), arterial punctures (6 trials, 785 catheters; RR, 0.22; 95% CI, 0.06-0.81), and hematoma formation (4 trials, 323 catheters; RR, 0.27; 95% CI, 0.08-0.88). It also significantly decreased the time to cannulate the vein (1 trial, 73 catheters; mean difference, -1.40; 95% CI, -2.17 to -0.63), and number of attempts per catheter insertion (1 trial, 110 catheters; mean difference, -0.35; 95% CI, -0.54 to -0.16).

LIMITATIONS: Only 7 studies were identified, of which 3 were reported in only a conference abstract form. Some outcomes were reported in only 1 study.

CONCLUSIONS: Use of real-time Doppler ultrasound guidance has benefits with respect to several important clinical outcomes, and its routine use in the insertion of hemodialysis catheters is strongly recommended.