Removal of central venous catheters.

incidences in the landmark group of carotid artery puncture (10.6%), hemothorax (1.7%), and pneumothorax (2.4%) greater than most anesthesiologists would accept. Thus it is not surprising that meta-analysis of these disparate studies (which have not been scored by traditional methods to assess for bias and scientific rigor) would find statistical significance only in success of line insertion. Given this weak supportive evidence, it is further surprising to conclude that ASA members “agree” with the presented recommendation (table 5). In fact, only 48.2% agree in any form with the statement that real-time ultrasound should be used (table 3, item 35), which even by partisan estimation is not a majority. The vigorous discussion at the 2010 and 2011 ASA House of Delegates and reference committees, including more anecdotal comments than evidentiary discussion, is testimony to the discomfort that many ASA members have with the supportive level of evidence. As users of ultrasound for central line insertion when indicated by prudent physician judgment and experience, we call for additional quality prospective, randomized investigations of ultrasound use for internal jugular placement by the anesthesia community before uniform adoption of guidelines based on data from nonanesthesiologists.