What are the recommendations for ultrasound-guided Central Venous Line (CVL) insertion?

Ultrasound-Guided Central Venous Line Insertion

Real-time ultrasound guidance should be used routinely for all central venous catheter insertions, as it significantly reduces mechanical complications, arterial punctures, and improves first-pass success rates compared to landmark techniques. 1, 2

Evidence-Based Recommendations by Insertion Site

Internal Jugular Vein (Strongest Evidence)

• Use real-time ultrasound guidance for all internal jugular vein catheterizations (Level 1-A evidence) 1, 2
• This approach reduces mechanical and infectious complications, decreases needle passes, shortens time to cannulation, and increases overall success rates 2, 3
• The American College of Critical Care Medicine, EFSUMB, and Association of Anaesthetists of Great Britain and Ireland all give strong (1-A) recommendations for ultrasound use at this site 1

Subclavian Vein

• Use real-time ultrasound guidance for subclavian vein catheterization to reduce mechanical complications and needle passes 1, 2
• The American College of Critical Care Medicine gives a strong (1-A) recommendation for internal jugular and femoral sites but a conditional recommendation (2-C) for subclavian 1
• The infraclavicular longitudinal "in-plane" technique is preferred as it allows direct visualization of needle advancement 4
• Despite evidence supporting ultrasound use, only 31% of intensivists routinely use it for subclavian access, with 59% reporting discomfort with real-time needle tracking at this site 5

Femoral Vein

• Use real-time ultrasound guidance for femoral venous access to reduce arterial punctures, decrease procedure time, and increase success rates 1, 2
• The American College of Critical Care Medicine gives a strong (1-A) recommendation for this site 1

Systematic Six-Step Approach to Ultrasound-Guided CVC Insertion

Step 1: Identify Anatomy and Localize the Target Vein (Before Prepping)

• Perform this assessment BEFORE sterile prepping and draping to account for anatomic variability 1, 6
• Use both short-axis (transverse) and long-axis (longitudinal) views to identify the vein and its relationship to adjacent structures 1, 6
• Check for anatomic variations, which occur in a significant proportion of patients and cannot be identified using landmark techniques 1
• Use color Doppler imaging to definitively differentiate venous from arterial vessels 1, 6

Step 2: Confirm Vein Patency

• Apply pressure with the ultrasound probe to test vein compressibility, confirming patency and excluding venous thrombosis 6
• Caveat: In patients with systolic arterial pressure <60 mmHg, the artery may also be compressible, potentially causing confusion 6

Step 3: Real-Time Ultrasound Guidance for Vein Puncture

• Maintain strict aseptic technique: hat, mask, sterile gloves, sterile body gown, large sterile drape, sterile ultrasound probe cover with sterile gel 1, 6, 2
• Use a high-frequency linear array probe (5-15 MHz) with a scanning surface of 20-50 mm 1
• Hold the ultrasound probe with your nondominant hand while advancing the needle with your dominant hand 1, 6
• Position yourself so the insertion site, needle, and ultrasound screen are all within your line of sight 1, 6
• Constantly identify the needle tip during the entire approach to and puncture of the vein 6

Step 4: Confirm Needle Position in the Vein

• Use real-time ultrasound to confirm the needle tip is placed centrally in the vein before advancing the guidewire 1, 6
• Verify positioning in both short-axis and long-axis views 1, 6
• Verify venous (not arterial) placement using ultrasound, manometry, or pressure waveform analysis 6

Step 5: Confirm Guidewire Position in the Vein

• After wire advancement, confirm correct guidewire position using both short-axis and long-axis ultrasound views 1, 6
• If the complete guidewire cannot be located in the procedural field, order chest radiography to check for wire retention 6

Step 6: Confirm Catheter Position in the Vein

• After placing the catheter over the guidewire, visualize correct catheter position using ultrasound in both short-axis and long-axis views 1, 6

Technical Considerations: Short-Axis vs. Long-Axis Approaches

Short-Axis/Out-of-Plane View

• Allows better visualization of the vein in relation to the artery and other anatomic structures, helping to avoid accidental arterial puncture 1
• Easier to learn for physicians not familiar with ultrasound 1
• Results in higher first-attempt success rates among experienced users for internal jugular and subclavian veins 1
• Limitation: The needle is only visualized as an echogenic point, not the entire needle shaft 1

Long-Axis/In-Plane View

• Allows visualization of the entire needle as an echogenic line with ring-down artifacts 1
• An international expert panel recommended the long-axis/in-plane technique for vascular access 1
• Both approaches are acceptable; the choice depends on operator experience and preference 2

Patient Positioning Strategies

For Internal Jugular Vein Access

• Position the patient in Trendelenburg (head-down) position to increase venous filling and cross-sectional lumen 1, 6
• Minimize head rotation to reduce overlap between the internal jugular vein and carotid artery 1, 6

For Femoral Vein Access

• Position patients in head-up (reverse Trendelenburg) position to increase femoral vein lumen 1
• Position the leg in an abducted and externally rotated position to maximize cross-sectional diameter 1

Common Pitfalls and How to Avoid Them

Static vs. Real-Time Ultrasound

• Avoid using static ultrasound alone to mark the needle insertion site 2
• Static ultrasound (preprocedural assessment only) is inferior to real-time ultrasound guidance (permanent visualization during needle advancement) 1
• Real-time ultrasound guidance is the standard of care 1, 2

Unintended Arterial Cannulation

• If unintended arterial cannulation with a large-bore catheter occurs, leave the catheter in place and immediately consult vascular surgery or interventional radiology 6
• Do not remove the catheter, as this can lead to uncontrolled bleeding

Equipment Availability

• The most frequently reported barrier to ultrasound use is limited availability of ultrasound equipment (28% of respondents) 5
• Other barriers include perception of increased procedure time (22%) and concern for loss of landmark skills (13%) 5

Training and Competency Requirements

Minimum Training Standards

• Novice providers should complete a systematic training program that includes simulation-based practice, supervised insertion on patients, and evaluation by an expert operator before attempting independent insertion 2
• Cognitive training should include basic anatomy, ultrasound physics, machine operation, image acquisition and interpretation, complication management, and infection prevention 2

Competency Assessment Criteria

• Trainees should demonstrate minimal competence before placing ultrasound-guided CVCs independently 2
• Competency assessments should evaluate: (1) knowledge of target vein anatomy and recognition of anatomical variants, (2) demonstration of CVC insertion with no technical errors, (3) recognition and management of acute complications, and (4) real-time needle tip tracking with cannulation on first attempt in at least five consecutive simulations 2
• Periodic proficiency assessment of all operators should be conducted to ensure maintenance of competency 2

Post-Procedural Verification

Pneumothorax Detection

• Rule out post-procedure pneumothorax by detecting bilateral lung sliding using ultrasound before and after insertion of internal jugular and subclavian vein CVCs 2

Catheter Tip Position Verification

• Use ultrasound with rapid infusion of agitated saline to visualize a right atrial swirl sign (RASS) for detecting catheter tip misplacement 2
• This is considered an advanced skill requiring specific training and expertise 2

Clinical Practice Patterns

Despite strong guideline recommendations, adoption varies significantly. Among U.S. intensivists surveyed in 2016, moderate to very frequent ultrasound use was reported for internal jugular vein (80%), femoral vein (45%), and subclavian vein (31%) 5. Nearly all physicians (99%) who insert internal jugular CVCs daily use ultrasound guidance, whereas only 46% of physicians who insert subclavian CVCs daily use ultrasound guidance 5. This gap between evidence and practice highlights the need for improved training and equipment availability.