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
Rationale: In clinical practice, the phrases transverse, short-axis, or out-of-plane approach are synonymous, as are longitudinal, long-axis, and in-plane approach. The short-axis approach involves tracking the needle tip as it approximates the target vessel with the ultrasound beam oriented in a transverse plane perpendicular to the target vessel. The target vessel is seen as a circular structure on the ultrasound screen as the needle tip approaches the target vessel from above. This approach is also called the out-of-plane technique since the needle passes through the ultrasound plane. The advantages of the short-axis approach include better visualization of adjacent vessels or nerves and the relative ease of skill acquisition for novice operators.9 When using the short-axis approach, extra care must be taken to track the needle tip from the point of insertion on the skin to the target vessel. A disadvantage of the short-axis approach is unintended posterior wall puncture of the target vessel.55
In contrast to a short-axis approach, a long-axis approach is performed with the ultrasound beam aligned parallel to the vessel. The vessel appears as a long tubular structure and the entire needle is visualized as it traverses across the ultrasound screen to approach the target vessel. The long-axis approach is also called an in-plane technique because the needle is maintained within the plane of the ultrasound beam. The advantage of a long-axis approach is the ability to visualize the entire needle as it is inserted into the vessel.14 A randomized crossover study with simulation models compared a long-axis versus short-axis approach for both IJV and subclavian vein catheterization. This study showed decreased number of needle redirections (relative risk (RR) 0.5, 95% confidence interval (CI) 0.3 to 0.7), and posterior wall penetrations (OR 0.3, 95% CI 0.1 to 0.9) using a long-axis versus short-axis approach for subclavian vein catheterization.56
A randomized controlled study comparing a long-axis or short-axis approach with ultrasound versus a landmark-based approach for IJV CVC insertion showed higher success rates (100% vs 90%; P < .001), lower insertion time (53 vs 116 seconds; P < .001), and fewer attempts to obtain access (2.5 vs 1.2 attempts, P < .001) with either the long- or short-axis ultrasound approach. The average time to obtain access and number of attempts were comparable between the short-axis and long-axis approaches with ultrasound. The incidence of carotid puncture and hematoma was significantly higher with the landmark-based approach versus either the long- or short-axis ultrasound approach (carotid puncture 17% vs 3%, P = .024; hematoma 23% vs 3%, P = .003).57
High success rates have been reported using a short-axis approach for insertion of PIV lines.58 A prospective, randomized trial compared the short-axis and long-axis approach in patients who had had ≥2 failed PIV insertion attempts. Success rate was 95% (95% CI, 0.85 to 1.00) in the short-axis group compared with 85% (95% CI, 0.69 to 1.00) in the long-axis group. All three subjects with failed PIV placement in the long-axis group had successful rescue placement using a short-axis approach. Furthermore, the short-axis approach was faster than the long-axis approach.59
For radial artery cannulation, limited data exist comparing the short- and long-axis approaches. A randomized controlled study compared a long-axis vs short-axis ultrasound approach for radial artery cannulation. Although the overall procedure success rate was 100% in both groups, the long-axis approach had higher first-pass success rates (1.27 ± 0.4 vs 1.5 ± 0.5, P < .05), shorter cannulation times (24 ± 17 vs 47 ± 34 seconds, P < .05), fewer hematomas (4% vs 43%, P < .05) and fewer posterior wall penetrations (20% vs 56%, P < .05).60
Another technique that has been described for IJV CVC insertion is an oblique-axis approach, a hybrid between the long- and short-axis approaches. In this approach, the transducer is aligned obliquely over the IJV and the needle is inserted using a long-axis or in-plane approach. A prospective randomized trial compared the short-axis, long-axis, and oblique-axis approaches during IJV cannulation. First-pass success rates were 70%, 52%, and 74% with the short-axis, long-axis, and oblique-axis approaches, respectively, and a statistically significant difference was found between the long- and oblique-axis approaches (P = .002). A higher rate of posterior wall puncture was observed with a short-axis approach (15%) compared with the oblique-axis (7%) and long-axis (4%) approaches (P = .047).61
