Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine
PREPROCEDURE
1) We recommend that providers should be familiar with the operation of their specific ultrasound machine prior to initiation of a vascular access procedure.
2) We recommend that providers should use a high-frequency linear transducer with a sterile sheath and sterile gel to perform vascular access procedures.
3) We recommend that providers should use two-dimensional ultrasound to evaluate for anatomical variations and absence of vascular thrombosis during preprocedural site selection.
4) We recommend that providers should evaluate the target blood vessel size and depth during preprocedural ultrasound evaluation.
TECHNIQUES
General Techniques
5) We recommend that providers should avoid using static ultrasound alone to mark the needle insertion site for vascular access procedures.
6) We recommend that providers should use real-time (dynamic), two-dimensional ultrasound guidance with a high-frequency linear transducer for central venous catheter (CVC) insertion, regardless of the provider’s level of experience.
7) We suggest using either a transverse (short-axis) or longitudinal (long-axis) approach when performing real-time ultrasound-guided vascular access procedures.
8) We recommend that providers should visualize the needle tip and guidewire in the target vein prior to vessel dilatation.
9) To increase the success rate of ultrasound-guided vascular access procedures, we recommend that providers should utilize echogenic needles, plastic needle guides, and/or ultrasound beam steering when available.
Central Venous Access Techniques
10) We recommend that providers should use a standardized procedure checklist that includes the use of real-time ultrasound guidance to reduce the risk of central line-associated bloodstream infection (CLABSI) from CVC insertion.
11) We recommend that providers should use real-time ultrasound guidance, combined with aseptic technique and maximal sterile barrier precautions, to reduce the incidence of infectious complications from CVC insertion.
12) We recommend that providers should use real-time ultrasound guidance for internal jugular vein catheterization, which reduces the risk of mechanical and infectious complications, the number of needle passes, and time to cannulation and increases overall procedure success rates.
13) We recommend that providers who routinely insert subclavian vein CVCs should use real-time ultrasound guidance, which has been shown to reduce the risk of mechanical complications and number of needle passes and increase overall procedure success rates compared with landmark-based techniques.
14) We recommend that providers should use real-time ultrasound guidance for femoral venous access, which has been shown to reduce the risk of arterial punctures and total procedure time and increase overall procedure success rates.
Peripheral Venous Access Techniques
15) We recommend that providers should use real-time ultrasound guidance for the insertion of peripherally inserted central catheters (PICCs), which is associated with higher procedure success rates and may be more cost effective compared with landmark-based techniques.
16) We recommend that providers should use real-time ultrasound guidance for the placement of peripheral intravenous lines (PIV) in patients with difficult peripheral venous access to reduce the total procedure time, needle insertion attempts, and needle redirections. Ultrasound-guided PIV insertion is also an effective alternative to CVC insertion in patients with difficult venous access.
17) We suggest using real-time ultrasound guidance to reduce the risk of vascular, infectious, and neurological complications during PIV insertion, particularly in patients with difficult venous access.
Arterial Access Techniques
18) We recommend that providers should use real-time ultrasound guidance for arterial access, which has been shown to increase first-pass success rates, reduce the time to cannulation, and reduce the risk of hematoma development compared with landmark-based techniques.
19) We recommend that providers should use real-time ultrasound guidance for femoral arterial access, which has been shown to increase first-pass success rates and reduce the risk of vascular complications.
20) We recommend that providers should use real-time ultrasound guidance for radial arterial access, which has been shown to increase first-pass success rates, reduce the time to successful cannulation, and reduce the risk of complications compared with landmark-based techniques.
POSTPROCEDURE
21) We recommend that post-procedure pneumothorax should be ruled out by the detection of bilateral lung sliding using a high-frequency linear transducer before and after insertion of internal jugular and subclavian vein CVCs.
22) We recommend that providers should use ultrasound with rapid infusion of agitated saline to visualize a right atrial swirl sign (RASS) for detecting catheter tip misplacement during CVC insertion. The use of RASS to detect the catheter tip may be considered an advanced skill that requires specific training and expertise.
TRAINING
23) To reduce the risk of mechanical and infectious complications, we recommend that novice providers should complete a systematic training program that includes a combination of simulation-based practice, supervised insertion on patients, and evaluation by an expert operator before attempting ultrasound-guided CVC insertion independently on patients.
24) We recommend that cognitive training in ultrasound-guided CVC insertion should include basic anatomy, ultrasound physics, ultrasound machine knobology, fundamentals of image acquisition and interpretation, detection and management of procedural complications, infection prevention strategies, and pathways to attain competency.
25) We recommend that trainees should demonstrate minimal competence before placing ultrasound-guided CVCs independently. A minimum number of CVC insertions may inform this determination, but a proctored assessment of competence is most important.
26) We recommend that didactic and hands-on training for trainees should coincide with anticipated times of increased performance of vascular access procedures. Refresher training sessions should be offered periodically.
27) We recommend that competency assessments should include formal evaluation of knowledge and technical skills using standardized assessment tools.
28) We recommend that competency assessments should evaluate for proficiency in the following knowledge and skills of CVC insertion: (a) Knowledge of the target vein anatomy, proper vessel identification, and recognition of anatomical variants; (b) Demonstration of CVC insertion with no technical errors based on a procedural checklist; (c) Recognition and management of acute complications, including emergency management of life-threatening complications; (d) Real-time needle tip tracking with ultrasound and cannulation on the first attempt in at least five consecutive simulation.
29) We recommend a periodic proficiency assessment of all operators should be conducted to ensure maintenance of competency.
© 2019 Society of Hospital Medicine
16. We recommend that providers should use real-time ultrasound guidance for the placement of peripheral intravenous lines (PIV) in patients with difficult peripheral venous access to reduce the total procedure time, needle insertion attempts, and needle redirections. Ultrasound-guided PIV insertion is also an effective alternative to CVC insertion in patients with difficult venous access.
Rationale: Difficult venous access refers to patients that have had two unsuccessful attempts at PIV insertion using landmarks or a history of difficult access (i.e. edema, obesity, intravenous drug use, chemotherapy, diabetes, hypovolemia, chronic illness, vasculopathy, multiple prior hospitalizations). A meta-analysis of seven randomized controlled studies concluded that ultrasound guidance increases the likelihood of successful PIV insertion (pooled OR 2.42, 95% CI 1.26 to 4.68; P < .008).18 A second meta-analysis that pooled data from seven studies (six randomized controlled studies) confirmed that ultrasound guidance improves success rates of PIV insertion (OR 3.96, 95% CI 1.75 to 8.94).19 Approximately half of these studies had physician operators while the other half had nurse operators.
In one prospective observational study of emergency department patients with two failed attempts of landmark-based PIV insertion, ultrasound guidance with a modified-Seldinger technique showed a relatively high success rate (96%), fewer needle sticks (mean 1.32 sticks, 95% CI 1.12 to 1.52), and shorter time to obtain access (median time 68 seconds).114 Other prospective observational studies have demonstrated that ultrasound guidance for PIV insertion has a high success rate (87%),115 particularly with brachial or basilic veins PIV insertion, among patients with difficult PIV access, defined as having had ≥2 failed attempts.58
Since insertion of PIVs with ultrasound guidance has a high success rate, there is potential to reduce the reliance on CVC insertion for venous access only. In a study of patients that had had two failed attempts at PIV insertion based on landmarks, a PIV was successfully inserted with ultrasound guidance in 84% of patients, obviating the need for CVC placement for venous access.116 A prospective observational study showed ultrasound-guided PIV insertion was an effective alternative to CVC placement in ED patients with difficult venous access with only 1% of patients requiring a CVC.117 Use of ultrasound by nurses for PIV placement has also been shown to reduce the time to obtain venous access, improve patient satisfaction, and reduce the need for physician intervention.118 In a prospective observational study of patients with difficult access, the majority of patients reported a better experience with ultrasound-guided PIV insertion compared to previous landmark-based attempts with an average satisfaction score of 9.2/10 with 76% of patients rating the experience a 10.119 A strong recommendation has been made for use of ultrasound guidance in patients with difficult PIV placement by la Société Française d’Anesthésie et de Réanimation (The French Society of Anesthesia and Resuscitation).95
17. We suggest using real-time ultrasound guidance to reduce the risk of vascular, infectious, and neurological complications during PIV insertion, particularly in patients with difficult venous access.
Rationale: The incidence of complications from PIV insertion is often underestimated. Vascular complications include arterial puncture, hematoma formation, local infiltration or extravasation of fluid, and superficial or deep venous thrombosis. The most common infectious complications with PIV insertion are phlebitis and cellulitis.120 One observational study reported PIV complications occurring in approximately half of all patients with the most common complications being phlebitis, hematoma formation, and fluid/blood leakage.121
