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
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.
Rationale: The use of real-time ultrasound guidance for CVC insertion has repeatedly demonstrated better outcomes compared to a landmark-based approach in adults.13 Several randomized controlled studies have demonstrated that real-time ultrasound guidance for IJV cannulation reduces the risk of procedure-related mechanical and infectious complications, and improves first-pass and overall success rates in diverse care settings.27,29,45,50,53,65,75,85-90 Mechanical complications that are reduced with ultrasound guidance include pneumothorax and carotid artery puncture.4,5,45,46,53,62,75,86-93 Currently, several medical societies strongly recommend the use of ultrasound guidance during insertion of IJV CVCs.10-12,14,94-96
A meta-analysis by Hind et al. that included 18 randomized controlled studies demonstrated use of real-time ultrasound guidance reduced failure rates (RR 0.14, 95% CI 0.06 to 0.33; P < .0001), increased first-attempt success rates (RR 0.59, 95% CI 0.39 to 0.88; P = .009), reduced complication rates (RR 0.43, 95% CI 0.22 to 0.87; P = .02) and reduced procedure time (P < .0001), compared to a traditional landmark-based approach when inserting IJV CVCs.5
A Cochrane systematic review compared ultrasound-guided versus landmark-based approaches for IJV CVC insertion and found use of real-time ultrasound guidance reduced total complication rates by 71% (RR 0.29, 95% CI 0.17 to 0.52; P < .0001), arterial puncture rates by 72% (RR 0.28, 95% CI 0.18 to 0.44; P < .00001), and rates of hematoma formation by 73% (RR 0.27, 95% CI 0.13 to 0.55; P = .0004). Furthermore, the number of attempts for successful cannulation was reduced (mean difference -1.19 attempts, 95% CI -1.45 to -0.92; P < .00001), the chance of successful insertion on the first attempt was increased by 57% (RR 1.57, 95% CI 1.36 to 1.82; P < .00001), and overall procedure success rates were modestly increased in all groups by 12% (RR 1.12, 95% CI 1.08 to 1.17; P < .00001).46
An important consideration in performing ultrasound guidance is provider experience. A prospective observational study of patients undergoing elective CVC insertion demonstrated higher complication rates for operators that were inexperienced (25.2%) versus experienced (13.6%).54 A randomized controlled study comparing experts and novices with or without the use of ultrasound guidance for IJV CVC insertion demonstrated higher success rates among expert operators and with the use of ultrasound guidance. Among novice operators, the complication rates were lower with the use of ultrasound guidance.97 One study evaluated the procedural success and complication rates of a two-physician technique with one physician manipulating the transducer and another inserting the needle for IJV CVC insertion. This study concluded that procedural success rates and frequency of complications were directly affected by the experience of the physician manipulating the transducer and not by the experience of the physician inserting the needle.98
The impact of ultrasound guidance on improving procedural success rates and reducing complication rates is greatest in patients that are obese, short necked, hypovolemic, or uncooperative.93 Several studies have demonstrated fewer needle passes and decreased time to cannulation compared to the landmark technique in these populations.46,49,53,86-88,92,93
Ultrasound-guided placement of IJV catheters can safely be performed in patients with disorders of hemostasis and those with multiple previous catheter insertions in the same vein.9 Ultrasound-guided placement of CVCs in patients with disorders of hemostasis is safe with high success and low complication rates. In a case series of liver patients with coagulopathy (mean INR 2.17 ± 1.16, median platelet count 150K), the use of ultrasound guidance for CVC insertion was highly successful with no major bleeding complications.99
A study of renal failure patients found high success rates and low complication rates in the patients with a history of multiple previous catheterizations, poor compliance, skeletal deformities, previous failed cannulations, morbid obesity, and disorders of hemostasis.100 A prospective observational study of 200 ultrasound-guided CVC insertions for apheresis showed a 100% success rate with a 92% first-pass success rate.101
The use of real-time ultrasound guidance for IJV CVC insertion has been shown to be cost effective by reducing procedure-related mechanical complications and improving procedural success rates. A companion cost-effectiveness analysis estimated that for every 1,000 patients, 90 complications would be avoided, with a net cost savings of approximately $3,200 using 2002 prices.102
