I read with great interest the excellent article by Dr. Hove et al.  1detailing their closed claims review of deaths related to anesthesia in Denmark (1996–2004). The accompanying editorial highlights the preventable deaths related to the conduct of central venous cannulation (CVC).1,2 

There has been a significant lag in quality improvement for CVC since its role in patient mortality and morbidity was highlighted in 1999 by the Institute of Medicine Report To Err Is Human .*It is time for the worldwide anesthesia community to develop and implement evidence-based guidelines, teaching, and standardization for the practice of CVC.

To my knowledge, there is no published practice guideline for perioperative CVC, despite the fact that it is a common perioperative procedure associated with significant medical error and consequent serious patient risk. The literature review that would be part of this guideline's development would quickly prove the pivotal role of ultrasound guidance. The discussion points at this juncture are not about whether ultrasound guidance is required, but rather about the aspects of its application, such as the superiority of real-time imaging, the role of a needle guide, Doppler imaging, and/or two-dimensional imaging.3,4 

Furthermore, there are initiatives in progress that will greatly assist in achieving the consistently safe practice of CVC throughout medical practice. One example of these initiatives is instructive procedural videos available through the Internet, such as the series launched recently by the New England Journal of Medicine .5Perhaps the leading anesthesia journals would follow this example and include not only CVC but all procedures relevant to perioperative medicine. Another example is the development and validation of standardized teaching methods for CVC such as the tissue model technique from internal medicine.6This avenue of endeavor might be a fruitful application for anesthesia simulation as well.

I congratulate Dr. Hove et al.  on their excellent article, which adds further emphasis to the perioperative imperative to make CVC safe for all of our patients all of the time.

Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. yiandoc@hotmail.com

Hove LD, Steinmetz J, Christoffersen JC, Moller A, Nielsen J, Schmidt H: Analysis of deaths related to anesthesia in the period 1996–2004 from closed claims registered by the Danish Patient Insurance Association. Anesthesiology 2007; 106:675–80
Heitmiller E, Martinez E, Pronovost P: Identifying and learning from mistakes. Anesthesiology 2007; 106:654–56
Augoustides JG: Evidence-based decision-making in ultrasound-guided central venous cannulation: Choosing between the eye and the ear. J Clin Anesth 2006; 18:165–66
Augoustides JG, Horak J, Ochroch EA, Vernick WJ, Gambone AJ, Weiner J, Pinchasik D, Kowalchuk D, Savino JS, Jobes DR: A randomized controlled clinical trial of real-time needle-guided ultrasound for internal jugular venous cannulation in a large university anesthesia department. J Cardiothorac Vasc Anesth 2005; 19:310–5
McMahon GT, Ingelfinger JR, Campton EW: Videos in clinical medicine: A new journal feature. N Engl J Med 2006; 354:1635
Ault MJ, Rosen BT, Ault B: The use of tissue models for vascular access training: Phase 1 of the procedural patient safety quality initiative. J Gen Intern Med 2006; 21:514–7