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
Arterial Catheterization
Arterial catheters are commonly used for reliable blood pressure monitoring, frequent arterial blood
RECOMMENDATIONS
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.
Rationale: There is strong consensus that providers must be familiar with the knobs and functions of the specific make and model of ultrasound machine that will be utilized for a vascular access procedure. Minimizing adjustments to the ultrasound machine during the procedure may reduce the risk of contaminating the sterile field.
2. We recommend that providers should use a high-frequency linear transducer with a sterile sheath and sterile gel to perform vascular access procedures.
Rationale: High-frequency linear-array transducers are recommended for the vast majority of vascular access procedures due to their superior resolution compared to other transducer types. Both central and peripheral vascular access procedures, including PIV, PICC, and arterial line placement, should be performed using sterile technique. A sterile transducer cover and sterile gel must be utilized, and providers must be trained in sterile preparation of the ultrasound transducer.13,26,27
The depth of femoral vessels correlates with body mass index (BMI). When accessing these vessels in a morbidly obese patient with a thigh circumference >60 cm and vessel depth >8 cm, a curvilinear transducer may be preferred for its deeper penetration.28 For patients who are poor candidates for bedside insertion of vascular access catheters, such as uncooperative patients, patients with atypical vascular anatomy or poorly visualized target vessels, we recommend consultation with a vascular access specialist prior to attempting the procedure.
3. We recommend that providers should use two-dimensional ultrasound to evaluate for anatomical variations and absence of vascular thrombosis during preprocedural site selection.
Rationale: A thorough ultrasound examination of the target vessel is warranted prior to catheter placement. Anatomical variations that may affect procedural decision-making are easily detected with ultrasound. A focused vascular ultrasound examination is particularly important in patients who have had temporary or tunneled venous catheters, which can cause stenosis or thrombosis of the target vein.
For internal jugular vein (IJV) CVCs, ultrasound is useful for visualizing the relationship between the IJV and common carotid artery (CCA), particularly in terms of vessel overlap. Furthermore, ultrasound allows for immediate revisualization upon changes in head position.29-32 Troianos et al. found >75% overlap of the IJV and CCA in 54% of all patients and in 64% of older patients (age >60 years) whose heads were rotated to the contralateral side.30 In one study of IJV CVC insertion, inadvertent carotid artery punctures were reduced (3% vs 10%) with the use of ultrasound guidance vs landmarks alone.33 In a cohort of 64 high-risk neurosurgical patients, cannulation success was 100% with the use of ultrasound guidance, and there were no injuries to the carotid artery, even though the procedure was performed with a 30-degree head elevation and anomalous IJV anatomy in 39% of patients.34 In a prospective, randomized controlled study of 1,332 patients, ultrasound-guided cannulation in a neutral position was demonstrated to be as safe as the 45-degree rotated position.35
Ultrasound allows for the recognition of anatomical variations which may influence the selection of the vascular access site or technique. Benter et al. found that 36% of patients showed anatomical variations in the IJV and surrounding tissue.36 Similarly Caridi showed the anatomy of the right IJV to be atypical in 29% of patients,37 and Brusasco found that 37% of bariatric patients had anatomical variations of the IJV.38 In a study of 58 patients, there was significant variability in the IJV position and IJV diameter, ranging from 0.5 cm to >2 cm.39 In a study of hemodialysis patients, 75% of patients had sonographic venous abnormalities that led to a change in venous access approach.40
To detect acute or chronic upper extremity deep venous thrombosis or stenosis, two-dimensional visualization with compression should be part of the ultrasound examination prior to central venous catheterization. In a study of patients that had undergone CVC insertion 9-19 weeks earlier, 50% of patients had an IJV thrombosis or stenosis leading to selection of an alternative site. In this study, use of ultrasound for a preprocedural site evaluation reduced unnecessary attempts at catheterizing an occluded vein.41 At least two other studies demonstrated an appreciable likelihood of thrombosis. In a study of bariatric patients, 8% of patients had asymptomatic thrombosis38 and in another study, 9% of patients being evaluated for hemodialysis catheter placement had asymptomatic IJV thrombosis.37
