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
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.
Rationale: Bedside echocardiography is a reliable tool to detect catheter tip misplacement during CVC insertion. In one study, catheter misplacement was detected by bedside echocardiography with a sensitivity of 96% and specificity of 83% (positive predictive value 98%, negative predictive value 55%) and prevented distal positioning of the catheter tip.140 A prospective observational study assessed for RASS, which is turbulent flow in the right atrium after a rapid saline flush of the distal CVC port, to exclude catheter malposition. In this study with 135 CVC placements, visualization of RASS with ultrasound was able to identify all correct CVC placements and three of four catheter misplacements. Median times to complete the ultrasound exam vs CXR were 1 vs 20 minutes, respectively, with a median difference of 24 minutes (95% CI 19.6 to 29.3, P < .0001) between the two techniques.141
A prospective observational study assessed the ability of bedside transthoracic echocardiography to detect the guidewire, microbubbles, or both, in the right atrium compared to transesophageal echocardiography as the gold standard. Bedside transthoracic echocardiography allowed visualization of the right atrium in 94% of patients, and both microbubbles plus guidewire in 91% of patients.142 Hence, bedside transthoracic echocardiography allows adequate visualization of the right atrium. Another prospective observational study combining ultrasonography and contrast enhanced RASS resulted in 96% sensitivity and 93% specificity for the detection of a misplaced catheter, and the concordance with chest radiography was 96%.143
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.
Rationale: Cumulative experience has been recognized to not be a proxy for mastery of a clinical skill.144 The National Institute for Clinical Excellence (NICE) has recommended that providers performing ultrasound-guided CVC insertion should receive appropriate training to achieve competence before performing the procedure independently.7 Surveys have demonstrated that lack of training is a commonly reported barrier for not using ultrasound.145,146
Structured training programs on CVC insertion have been shown to reduce the occurrence of infectious and mechanical complications.74,143,147-149 The use of ultrasound and checklists, bundling of supplies, and practice with simulation models, as a part of a structured training program, can improve patient safety related to CVC insertion.9,140,150-154
Simulation-based practice has been used in medical education to provide deliberate practice and foster skill development in a controlled learning environment.155-158 Studies have shown transfer of skills demonstrated in a simulated environment to clinical practice, which can improve CVC insertion practices.159,160 Simulation accelerates learning of all trainees, especially novice trainees, and mitigates risks to patients by allowing trainees to achieve a minimal level of competence before attempting the procedure on real patients.152,161,162 Residents that have been trained using simulation preferentially select the IJV site,147 and more reliably use ultrasound to guide their CVC insertions.160,163
Additionally, simulation-based practice allows exposure to procedures and scenarios that may occur infrequently in clinical practice.
Although there is evidence on efficacy of simulation-based CVC training programs, there is no broadly accepted consensus on timing, duration, and content of CVC training programs for trainees or physicians in practice. The minimum recommended technical skills a trainee must master include the ability to (1) manipulate the ultrasound machine to produce a high-quality image to identify the target vessel, (2) advance the needle under direct visualization to the desired target site and depth, (3) deploy the catheter into the target vessel and confirm catheter placement in the target vessel using ultrasound, and (4) ensure the catheter has not been inadvertently placed in an unintended vessel or structure.153
A variety of simulation models are currently used to practice CVC insertion at the most common sites: the internal jugular, subclavian, basilic, and brachial veins.164,165 Effective simulation models should contain vessels that mimic normal anatomy with muscles, soft tissues, and bones. Animal tissue models, such as turkey or chicken breasts, may be effective for simulated practice of ultrasound-guided CVC insertion.166,167 Ultrasound-guided CVC training using human cadavers has also been shown to be effective.168
