Environmental crimes: profiting at earth's expense.

Karakitsos and coworkers, in this journal, reported further compelling evidence on the value of ultrasound in guiding internal jugular vein catheterization. In a large, prospective, randomized study of 900 patients, comparisons were made between patients in whom the procedure was performed using landmark-based techniques and those assigned to ultrasound guidance. The key benefits from use of ultrasound included reduction in needle puncture time, increased overall success rate (100% versus 94%), reduction in carotid puncture (1% versus 11%), reduction in carotid haematoma (0.4% versus 8.4%), reduction in haemothorax (0% versus 1.7%), decreased pneumothorax (0% versus 2.4%) and reduction in catheter-related infection (10% versus 16%). The implications of these findings are discussed, and a compelling case for routine use of ultrasound to guide central venous access is made. Karakitsos and coworkers [1], in this journal, reported further compelling evidence on the value of ultrasound in guiding internal jugular vein catheterization. Their work follows other series demonstrating similar results [2,3]. This study differs from previous studies for the following reasons. First, it is much larger (900 patients), prospective and randomized. Also, comparisons were made between patients in whom the procedure was performed using landmark-based techniques (following use of a small seeker needle) and those in whom ultrasound guidance was utilized. Operators in both groups had significant experience in both techniques. Significant key benefits obtained with routine use of ultrasound were as follows: reduction in needle puncture time, increased overall success rate (100% versus 94%), dramatic reduction in the frequency of carotid puncture (1% versus 11%), reduction in carotid haematoma (0.4% versus 8.4%), reduction in haemothorax (0% versus 1.7%), decreased pneumothorax (0% versus 2.4%) and reduction in central venous catheter associated bloodstream infection (10% versus 16%). The reported reductions in complications are in accordance with the findings of previous studies. Ultrasound was used to salvage and diagnose the problem in all failed procedures in the group in which the landmark-based technique was used. The overall failure rate and frequency of serious complications in the landmark-based technique once again refute comments from sceptics who claim that the very low frequency of complications in their hands means that they do not need to take steps to learn to use ultrasound and acquire appropriate equipment for their department. Can you realistically claim that you and your colleagues or trainees would perform better than this group of senior and experienced clinicians in a number of different international units? …