From the Guidelines
Ultrasound guidance should be used for all central venous catheter (CVC) placements to reduce complications and improve safety, as evidenced by the most recent and highest quality study available 1. When considering CVC insertion techniques, it is essential to prioritize methods that minimize risks and optimize outcomes. The use of ultrasound guidance has been consistently shown to reduce arterial puncture and catheter failure rates, particularly for internal jugular vein access. This approach is supported by guidelines from medical societies, which strongly recommend the use of ultrasound for CVC placement in the internal jugular vein.
Key benefits of ultrasound guidance include:
- Reduced risk of mechanical complications, such as pneumothorax and subclavian artery puncture
- Improved success rates for CVC placement
- Enhanced safety and quality of care for patients requiring central venous access
- Potential for reduced catheter-related thrombosis, a significant complication affecting up to 20% of patients with long-term catheters
To further improve outcomes, it is crucial to:
- Choose the appropriate vein for CVC placement, taking into account factors such as venepuncture technique, risk of mechanical complications, and feasibility of nursing care
- Use maximal barrier precautions during CVC insertion to reduce the risk of infection
- Select the most suitable CVC device and material, considering factors such as catheter-related sepsis and patient-specific needs
- Implement proper education and training for healthcare staff on CVC placement and care, as well as adherence to evidence-based guidelines and protocols.
By prioritizing ultrasound guidance and evidence-based best practices, healthcare providers can optimize CVC placement techniques and improve patient outcomes, particularly for critically ill patients requiring central venous access 1.
From the Research
Ultrasound Guidance for CVC Insertion
- The use of real-time ultrasound guidance for central venous catheter (CVC) insertion has been shown to improve safety and success rates compared to the landmark technique 2.
- A Cochrane review found that real-time ultrasound significantly reduces arterial puncture and catheter failure, especially with internal jugular vein access 2.
- Techniques like the “bubble test” can quickly verify catheter tip placement at the cavoatrial junction and exclude pneumothorax, often more efficiently than X-ray 3, 4.
Complications of CVC Insertion
- Catheter-related thrombosis is a common complication of CVC insertion, affecting up to 20% of patients with long-term catheters 5.
- Risk factors for catheter-related thrombosis include larger catheter size and malignancy 5.
- Choosing the right internal jugular vein and minimizing dwell time are key preventive strategies for reducing the risk of catheter-related thrombosis [@6@].
Operator Training and Variability
- Variability in operator training is a limitation to the routine use of ultrasound guidance for CVC insertion 6.
- A national survey of intensivists and hospitalists found that the use of ultrasound guidance for CVC insertion varied by site, with internal jugular vein insertion being the most common site for ultrasound guidance 5.
- The most frequently reported barriers to the use of ultrasound guidance were limited availability of ultrasound equipment, perception of increased total procedure time, and concern for loss of landmark skills 5.
Best Practices for CVC Insertion
- The use of real-time ultrasound guidance with a high-frequency linear transducer is recommended for CVC insertion, regardless of the provider's level of experience 2.
- A standardized procedure checklist that includes the use of real-time ultrasound guidance can help reduce the risk of central line-associated bloodstream infection (CLABSI) from CVC insertion 2.
- Providers should be familiar with the operation of their specific ultrasound machine prior to initiation of a vascular access procedure 2.