Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice

Abstract

The use of ultrasound (US) has been proposed to reduce the number of complications and to increase the safety and quality of central venous catheter (CVC) placement. In this review, we describe the rationale for the use of US during CVC placement, the basic principles of this technique, and the current evidence and existing guidelines for its use. In addition, we recommend a structured approach for US-guided central venous access for clinical practice. Static and real-time US can be used to visualize the anatomy and patency of the target vein in a short-axis and a long-axis view. US-guided needle advancement can be performed in an "out-of-plane" and an "in-plane" technique. There is clear evidence that US offers gains in safety and quality during CVC placement in the internal jugular vein. For the subclavian and femoral veins, US offers small gains in safety and quality. Based on the available evidence from clinical studies, several guidelines from medical societies strongly recommend the use of US for CVC placement in the internal jugular vein. Data from survey studies show that there is still a gap between the existing evidence and guidelines and the use of US in clinical practice. For clinical practice, we recommend a six-step systematic approach for US-guided central venous access that includes assessing the target vein (anatomy and vessel localization, vessel patency), using real-time US guidance for puncture of the vein, and confirming the correct needle, wire, and catheter position in the vein. To achieve the best skill level for CVC placement the knowledge from anatomic landmark techniques and the knowledge from US-guided CVC placement need to be combined and integrated.

Keywords: Central venous access; Femoral vein; In plane; Internal jugular vein; Long axis; Out of plane; Short axis; Subclavian vein; Ultrasound.

Fig. 1

Ultrasound probe orientation and view of the needle. Ultrasound guidance during needle advancement can be performed using a short-axis probe orientation and an out-of-plane view of the needle (a) or a long-axis probe orientation and an in-plane view of the needle (b)

Fig. 2

Ultrasound views to identify the anatomy of the target vein. Short-axis (transverse) view (a) and long-axis (longitudinal) view (b) of the right internal jugular vein (*) and its anatomic relation to the carotid artery (#)

Fig. 3

Ultrasound view of a small internal jugular vein. Short-axis (transverse) view of a small right internal jugular vein (*) and its anatomic relation to the carotid artery (#) (e.g., in a patient with intravascular hypovolemia)

Fig. 4

Color Doppler imaging and Doppler flow measurements. Short-axis (transverse) view of the right internal jugular vein (blue) and the carotid artery (red) using color Doppler imaging and Doppler flow measurements of the venous (a) and arterial (b) blood flow profile (Color figure online)

Fig. 5

Practical aspects of ultrasound-guided central venous catheter placement in the internal jugular vein using the "single-operator technique”. An aseptic approach including covering the puncture site with a large sterile drape, using sterile barriers (hat, mask, sterile gloves, sterile body gown), and covering the ultrasound probe and cable with a sterile cover is shown. The position of the operator (who holds the ultrasound probe with the nondominant hand while advancing the needle with the dominant hand) allows aligning the insertion site, the needle, and the ultrasound screen in the line of sight during needle insertion (red lines) (Color figure online)

Fig. 6

Ultrasound to confirm needle, wire, and catheter position in the vein. Ultrasound images during real-time ultrasound-guided central venous catheter placement in the right internal jugular vein. Ultrasound guidance should include confirmation of the needle position in the vein before approaching the guide wire (short-axis/out-of-plane view (a) and long-axis/in-plane view (b)). In addition, the correct position of the guide wire in the vein (short-axis (c) and long-axis (d)) and the correct position of the catheter in the vein (short-axis (e) and long-axis (f)) should be confirmed

Fig. 7

Six-step approach to ultrasound-guided central venous catheter placement