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
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.
Rationale: In clinical practice, the term ultrasound-guided subclavian vein CVC insertion is commonly used. However, the needle insertion site is often lateral to the first rib and providers are technically inserting the CVC in the axillary vein. The subclavian vein becomes the axillary vein at the lateral border of the first rib where the cephalic vein branches from the subclavian vein. To be consistent with common medical parlance, we use the phrase ultrasound-guided subclavian vein CVC insertion in this document.
Advantages of inserting CVCs in the subclavian vein include reliable surface anatomical landmarks for vein location, patient comfort, and lower risk of infection.103 Several observational studies have demonstrated the technique for ultrasound-guided subclavian vein CVC insertion is feasible and safe.104-107 In a large retrospective observational study of ultrasound-guided central venous access among a complex patient group, the majority of patients were cannulated successfully and safely. The subset of patients undergoing axillary vein CVC insertion (n = 1,923) demonstrated a low rate of complications (0.7%), proving it is a safe and effective alternative to the IJV CVC insertion.107
A Cochrane review of ultrasound-guided subclavian vein cannulation (nine studies, 2,030 participants, 2,049 procedures), demonstrated that real-time two-dimensional ultrasound guidance reduced the risk of inadvertent arterial punctures (three studies, 498 participants, RR 0.21, 95% CI 0.06 to 0.82; P = .02) and hematoma formation (three studies, 498 participants, RR 0.26, 95% CI 0.09 to 0.76; P = .01).46 A systematic review and meta-analysis of 10 randomized controlled studies comparing ultrasound-guided versus landmark-based subclavian vein CVC insertion demonstrated a reduction in the risk of arterial punctures, hematoma formation, pneumothorax, and failed catheterization with the use of ultrasound guidance.105
A randomized controlled study comparing ultrasound-guided vs landmark-based approaches to subclavian vein cannulation found that use of ultrasound guidance had a higher success rate (92% vs 44%, P = .0003), fewer minor complications (1 vs 11, P = .002), fewer attempts (1.4 vs 2.5, P = .007) and fewer catheter kits used (1.0 vs 1.4, P = .0003) per cannulation.108
Fragou et al. randomized patients undergoing subclavian vein CVC insertion to a long-axis approach versus a landmark-based approach and found a significantly higher success rate (100% vs 87.5%, P < .05) and lower rates of mechanical complications: artery puncture (0.5% vs 5.4%), hematoma (1.5% vs 5.4%), hemothorax (0% vs 4.4%), pneumothorax (0% vs 4.9%), brachial plexus injury (0% vs 2.9%), phrenic nerve injury (0% vs 1.5%), and cardiac tamponade (0% vs 0.5%).109 The average time to obtain access and the average number of insertion attempts (1.1 ± 0.3 vs 1.9 ± 0.7, P < .05) were significantly reduced in the ultrasound group compared to the landmark-based group.95
A retrospective review of subclavian vein CVC insertions using a supraclavicular approach found no reported complications with the use of ultrasound guidance vs 23 mechanical complications (8 pneumothorax, 15 arterial punctures) with a landmark-based approach.106 However, it is important to note that a supraclavicular approach is not commonly used in clinical practice.
