Emerg Med Clin N Am
22 (2004) 749–773
Ultrasound guidance for vascular access
Paul-André C. Abboud, MDa, John L. Kendall, MD,
FACEPb,*
a
Department of Emergency Medicine, Kaiser Permanente Medical Center—Oakland,
280 West MacArthur Boulevard, Oakland, CA 94611, USA
b
Division of Emergency Medicine, University of Colorado Health Sciences Center;
Assistant Professor, Department of Emergency Medicine, Denver Health Medical Center,
777 Bannock Street, Denver, CO 80204, USA
The ability to establish central venous access efficiently is a fundamental
skill for emergency physicians. Central venous access is essential for
hemodynamic monitoring, volume resuscitation, and the delivery of
vasoactive drugs [1]. It is important in the management of shock and other
conditions such as renal failure and complete heart block because it
contributes to temporizing and life-saving therapies.
Traditionally, central venous access has been guided only by palpable
anatomic landmarks such as bony prominences, muscle surfaces, and
arterial pulsations. This ‘‘blind’’ approach to the central veins assumes
anatomic homogeneity, does not account for the possibility of thrombosis,
and depends on correct discernment of the relationship among multiple
anatomic landmarks [2].
Research in emergency department (ED) and intensive care settings has
supported the efficacy of traditional landmark approaches to the internal
jugular vein (IJV), subclavian vein (SV), and femoral vein (FV) in adult [3–
12] and pediatric patients [13–16]. Failure rates, however, have been
reported as high as 30% in some series [17]. The failure rate has been
demonstrated to be greater for emergent cases and highest for patients in
cardiopulmonary arrest [18]. Nonrandomized studies of central venous
cannulation specifically for critical trauma [4,6,11] or cardiopulmonary
resuscitation [8,10,11] have reported success rates ranging from 62% to
99%. One study of failed cardiopulmonary resuscitation cases demonstrated
that 31% of attempted FV catheters were not in the FV [19].
* Corresponding author.
E-mail address: [email protected] (J.L. Kendall).
0733-8627/04/$ - see front matter Ó 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.emc.2004.04.003
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Complication rates related to central line placement are reported to range
from 0.3% to 18.8%, depending on the site of insertion, patient population,
and definition of complications [17,20–22]. Acute complications associated
with the landmark approach commonly include pneumothorax, arterial
puncture, hemothorax, hematoma (subcutaneous or mediastinal), misplaced
catheter tip, nerve injury, and dysrhythmia [16,17,23–25]. Cases of transient
Horner syndrome and dysphonia after IJV catheterization have been
reported in some series [21,26]. Death due to complications from a central
venous line also has been reported [27]. The complication rate depends on
the time needed for catheter insertion [22], the number of needle passes [28],
the extremes of body habitus, previous central venous cannulation, prior
surgery or radiation therapy in the area of the vein, and operator
inexperience [20]. Characteristics associated with difficult or complicated
central access include limited sites for access attempts (other catheters
already in place, pacemaker, local surgery, or infection), known vascular
abnormality, coagulopathy, mechanical ventilation or severely diminished
pulmonary function (leading to worse morbidity from a possible pneumothorax), severe peripheral vascular disease, soft tissue edema, chronic
intravenous drug use, and patient intolerance of supine position (orthopnea,
increased intracranial pressure) [29–34]. Under these circumstances in which
the margin for error is small, central venous access must be undertaken
carefully.
Emergency medicine has developed an expanding familiarity with
portable two-dimensional (2-D) real-time ultrasound (US) over the past
decade [35]. In that time, a body of research has developed that supports US
for guidance of central venous cannulation. Descriptions of US guidance for
central venous access first were published in the anesthesiology literature
and, subsequently, in the surgery, radiology, nephrology, critical care, and
emergency medicine literature.
In 1978, Ullman and Stoelting [36] first described the use of a ‘‘pencilshaped Doppler probe’’ to identify the ‘‘windstorm’’ sounds of the IJV to
mark the overlying skin site for cannulation. Legler and Nugent [37]
published the first experience with Doppler localization of the IJV before
catheterization. In 1986, Yonei et al [38] first reported the use of 2-D realtime US guidance for cannulation of the IJV.
The first case series of 2-D US for central venous access in the ED was
published in 1997 [39]. The reported technique involved two operators: one
for line placement and one to hold the US probe. Since then, emergency
physicians have published four studies on the use of US for vascular access
in the ED [33,40–42]. These studies, which are reviewed below, reported
favorable experiences and improved success rates for venous access with US
guidance.
In 1997, the American College of Emergency Physicians (ACEP)
published a policy statement on the use of US imaging by emergency
physicians. In 2001, a revised policy statement and accompanying ACEP
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guidelines specifically included US guidance for central venous access in a list
of ‘‘primary applications for emergency ultrasound’’ [43].
Evidence for ultrasound-guided central venous access
In 2001, the Agency for Healthcare Research and Quality published an
evidence-based report on patient safety practices. This report, which has
been highly publicized in professional and lay media, includes a chapter on
US guidance for central venous access. US guidance for central venous
access was listed among 11 practices with the most highly rated ‘‘strength of
evidence for supporting more widespread implementation’’ [44]. This report
based its findings on much of the same literature that previously had been
reviewed in a meta-analysis by Randolph et al [1]. The meta-analysis,
published in 1996, reviewed eight randomized controlled trials of 2-D or
Doppler US guidance versus the landmark method for central venous
access. No studies of FV access were included. A significant decrease in the
failure rate, complication rate, and number of attempts for successful access
of the SV and the IJV were reported. A subsequent meta-analysis
commissioned by the British National Institute for Clinical Excellence
(NICE) was published in 2003 [45]. It included 18 randomized controlled
trials published through October 2001. These trials compared 2-D real-time
or Doppler US with the landmark method for central venous access. The
meta-analysis considered risk of failed placement, complications, failure on
the first attempt, number of attempts to successful access, and time to
successful access as outcome measures. These outcome measures were
analyzed by type of vein studied (IJV, SV, and FV), by US method (2-D and
Doppler), and by age category (adult and infant). This meta-analysis
concluded that 2-D US guidance was more effective than the landmark
method for all outcomes for IJV access in adults. The relative risks of failed
attempts, complications, and failed first attempts were reduced by 86%,
57%, and 41%, respectively. Significantly fewer attempts were required for
success, and the IJV was successfully accessed more quickly when using US.
Limited evidence suggested that 2-D US guidance reduced the relative risk
of failed access in the SV and FV.
The three studies of IJV access in infants included in the meta-analysis
were limited by small sample size [46–48]; however, the analysis suggested
that 2-D US was more effective in these studies. Using US, the relative risk
of failed placements and complications in infants was reduced by 85% and
73%, respectively. No studies of SV or FV access among infants were
included in the meta-analysis. The investigators [45] also undertook a costeffectiveness analysis of 2-D US guidance based on the evidence from their
systematic review of the literature. The analysis of a simple decision analytic
model suggested that US guidance avoided 90 arterial punctures for every
1000 patients and reduced costs by a negligible amount (approximately $5)
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per patient. Given the evidence for its superior efficacy, the recent Agency
for Healthcare Research and Quality mandate for improving patient safety,
and the 2001 ACEP emergency US guidelines, US guidance for central
venous access has been transformed from an interesting novelty to an
important skill for emergency physicians to acquire.
General technical issues
There are several commonly accepted variations of US guidance: indirect,
direct or real-time, free-hand, mechanical guide, and Doppler. Choosing
among these approaches mostly depends on the location of the vessel to be
cannulated and the specific characteristics of the operator, patient, and the
equipment at hand. In addition, vessel visualization can be obtained in two
different ways: in the long axis or the short axis. A solid understanding of
these technical issues is necessary to successfully cannulate a vessel, regardless of the approach used or the location of the vessel.
Indirect method
The indirect method employs the least amount of actual guidance. With
this approach, US is used only to identify the vessel and then center it on the
US screen (Fig. 1). Next, a temporary mark is placed on the skin that
corresponds to the vessel’s subcutaneous position. This mark is used for the
puncture site after US identifies the target vessel’s location, dimensions, and
depth below the skin. The easiest way to accurately make this mark is to
identify the point where the center of the transducer overlies the skin surface
just above the center of the vessel (Figs. 2 and 3).
Fig. 1. IJV and carotid artery viewed in their short axes.
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Fig. 2. Subcutaneous location of IJV is identified on the skin surface.
There is no direct visualization of the needle as it enters the vessel,
however. This technique has been used for localization and cannulation of
larger structures but has been criticized for not taking full advantage of the
potential of US for greater precision [49]. Mansfield et al [20] compared the
indirect method of US guidance with the standard landmark approach for
SV cannulation. This study was closed after an interim analysis of 824
patients showed that US guidance by the indirect method had no effect on
the rate of complications or failures.
Real-time visualization
The alternative to the indirect method is to perform needle placement
under direct, or real-time, US guidance so that the entire procedure is
visualized continuously. With this technique, a sterile sheath whose tip is
filled with transmission gel is unrolled over the transducer (Fig. 4). The
Fig. 3. Subcutaneous location of IJV is marked on the skin surface.
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Fig. 4. Sterile barrier covering transducer and cable.
transducer is then placed on the skin and the target vessel is identified and
centered on the viewing screen. With the other hand, local anesthetic is
injected at a point corresponding to the middle of the US transducer. After
anesthesia is achieved, the cannulation needle is advanced through the skin.
After the skin has been punctured, the operator can switch visual focus to
the US monitor where the needle will appear sonographically as an
echogenic line with a ring-down artifact (Fig. 5). Advancement of the
needle is then guided by viewing its progression on the US monitor. When
the operator visualizes the needle piercing the anterior wall of the vessel
(Fig. 6) and after the subsequent flash of blood into the syringe, the
transducer is placed aside and the remaining aspects of the procedure can be
completed normally.
Few studies have compared indirect and real-time US guidance methods
for insertion of venous catheters. Nadig et al [50] randomized 73 patients to
an external landmark or a real-time US guidance of IJV cannulation. There
were 87 unsuccessful attempts among 37 patients in whom cannulation was
performed using the indirect method. In comparison, there were only 10
Fig. 5. Advancing needle and ring-down artifact.
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Fig. 6. Needle visualized advancing through anterior (ant.) vessel wall.
unsuccessful attempts among the 36 patients who underwent real-time US
guidance.
Mechanical guides
A mechanical guide is an attachment to the US transducer that controls
the depth, angle, and trajectory of the needle during cannulation (Fig. 7). In
addition to venous cannulation, mechanical guides are used for many other
US-guided invasive procedures, including amniocentesis, follicle retrieval,
cordocentesis, biopsies, and fluid aspiration [51–54]. The approach uses an
attachment to the transducer that provides a fixed trajectory for the needle.
Advancement of the needle through the designated path ensures a predictable, uniform trajectory of the needle relative to the transducer. This
stability may be particularly advantageous for inexperienced operators
Fig. 7. Ultrasound transducer with needle inserted through a mechanical guide.
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because it incorporates control of the transducer’s placement with the
needle’s angle of entry [55].
The use of mechanical guides has some notable disadvantages. It requires
investing in an additional piece of equipment that makes large, linear
transducers even bulkier. Mechanical guides restrict the angle of the needle
and the skin entry point. This restriction prevents the operator from
continuously redirecting the needle as may be needed in certain cases [56].
Lastly, the fixed angle of entry may make some superficial structures difficult
to access [57].
The largest study to evaluate needle-guided US was published by Denys
et al [58]. This nonrandomized study reported a 100% success rate for US
guidance among 928 patients. In comparison, the success rate for the
landmark approach was 88% among 302 patients. With needle-guided US,
there also was a significant improvement in venous access time (9.8 versus
44.5 seconds), carotid puncture rate (1.7% versus 8.3%), brachial plexus
irritation (0.4% versus 1.7%), hematoma development (0.2% versus 3.3%),
and average number of attempts to success (1.3 versus 2.5).
Free-hand method
The alternative to using a needle-guide system is to perform the
procedure using the free-hand technique. In this situation, the transducer
and the advancing needle are positioned and stabilized with the operator’s
or an assistant’s hands (Fig. 8). Continuous fine adjustments can be made in
the needle’s direction and in the transducer’s view. Although it generally is
considered to be a more technically demanding procedure, this approach
offers more flexibility for the operator. In addition, if an assistant is
available, he or she can hold the transducer on a site distant from the needle
entry point, thereby removing it from the sterile field [57] and potentially
increasing the speed with which the target vein can be cannulated.
Fig. 8. Free-hand technique.
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Fig. 9. Short-axis approach to needle insertion.
Short-axis versus long-axis approach
Another variable to consider is the axis of visualization for the target
vessel. For the short-axis approach, the vessel is identified in the transverse
plane and centered under the transducer (see Fig. 1). The midpoint of the
transducer then becomes a reference point for insertion of the needle. The
needle is inserted at a 45( angle to the transducer (Fig. 9). As the needle is
advanced, the tip is visualized as it approaches the anterior wall of the
vessel. After contacting the anterior wall of the vessel, further insertion of
the needle will cause posterior displacement of the vessel wall (Fig. 10). A
flash of blood in the syringe signifies that the needle has entered the vessel.
At this point, the transducer can be set aside and the rest of the procedure
performed normally.
Fig. 10. Posterior displacement of vessel wall by advancing needle viewed in the short axis.
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Fig. 11. IJV visualized in the long axis.
In contrast, the long-axis approach identifies the vessel in its long axis
and involves lining up the transducer over the greatest anterior–posterior
diameter of the vessel (Fig. 11). The needle is then inserted through the skin
just off one end of the transducer in a plane that is in line with the long axis
of the transducer and at an approximate 30( angle to the skin surface
(Fig. 12). As the needle is advanced, its progress through the subcutaneous
tissue is monitored in real-time on the US screen (Fig. 13). After the needle
has punctured the anterior wall of the vessel and a flash of blood is apparent
in the syringe, the transducer can be set aside and the rest of the procedure
completed normally.
In the authors’ experience, the advantages of the short-axis over the longaxis approach are that it is easier to perform in anatomic areas where space
Fig. 12. Long-axis approach to needle insertion.
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Fig. 13. Real-time visualization of needle through subcutaneous tissue.
is limited (eg, neck), inexperienced users can acquire proficiency more
quickly, and smaller vessels (eg, deep brachial vein) are more consistently
visualized. On the other hand, performing the procedure along the vessel’s
long axis allows much better visualization of the advancing needle tip and,
therefore, may avoid inadvertent punctures of the posterior vessel wall
(Fig. 14). A study that compared the short- and long-axis approaches with
vascular access found that novice users could perform cannulation more
quickly using the short-axis approach. There was, however, no statistically
Fig. 14. Needle visualized perforating posterior (post.) vessel wall.
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significant difference in terms of mean difficulty, number of skin breaks, and
mean number of needle redirections [59].
Doppler method
Historically, Doppler US for venous access has not been used in many
American EDs, most likely because these EDs purchased real-time 2-D US
machines. These multipurpose machines have been favored over purchasing
additional equipment that is needed to implement the Doppler method. In
the interim, research has shown 2-D real-time US to be superior to Doppler
for central venous access [45]. The authors expect most future research on
US-guided techniques to focus on 2-D real-time US.
Internal jugular vein approach
Anatomic considerations
The IJV is the most studied vein for US-guided catheterization. It usually
lies anterior and slightly lateral to the carotid artery. It normally is larger in
diameter than the carotid artery and expands in diameter with a Valsalva
maneuver [60]. Many studies have documented its anatomic variations with
regard to potential complications. Yonei et al [38] first reported the use of
real-time US guidance for IJV cannulation in 1986. In this series, central lines
were placed successfully in 160 intensive care patients without complication.
In 1991, Denys and Uretsky [61] reported a series of 200 patients who
underwent IJV cannulation in the cardiac catheterization laboratory,
coronary care unit, and intensive care unit. The investigators found anatomic
anomalies of the IJV (small diameter, unresponsiveness to Valsalva
maneuver, and unexpected lateral or medial displacement) in 8% of patients.
Troianos et al [62] reported the largest case series for determining the
anatomic relationship between the IJV and carotid artery. Among 1009
patients admitted for surgery, 54% had an IJV overlying the carotid artery,
rather than coursing it laterally, as expected. This anomalous anatomy might
predispose the patients to arterial punctures if the needle traversed the IJV.
In a prospective series of 31 patients with known difficult central venous
access, Hatfield and Bodenham [29] reported a success rate of 100% using
real-time US guidance for 22 patients. Among the remaining 9 patients, for
whom indirect US guidance was used, 66% were cannulated successfully
within three attempts. Of 23 patients who had been referred specifically
because of prior difficulties with or complications from cannulation, 16 had
an anatomic reason for difficulty that was determined by US.
Docktor et al [63] reported a 100% success rate with real-time US
guidance in a prospective series of 150 patients referred for nonemergent
central venous access. Using US, the investigators were able to document
the phenomenon of double wall puncture among 30 patients. Double wall
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puncture occurs in cases of an IJV with low pressure. The anterior wall is
pushed against the posterior wall before the needle punctures it. If the
carotid artery is located underneath the vein along the needle tract, then
a double wall puncture can extend into the carotid artery. In this study, the
IJV was visualized directly over the carotid artery in 25% of cases. The
investigators surmised that this high rate was partially due to variable
transducer positioning and different degrees of head rotation. The only
complications were two cases of carotid artery puncture. These occurred
among patients whose IJV was visualized to lie directly over the carotid
artery. Based on their findings, the investigators recommended using realtime US to visualize the anatomic relationship between the IJV and carotid
artery and then determining the optimal needle track that would miss the
carotid artery in the event of a double wall puncture.
Denys et al [58] compared real-time US guidance that used a transducer
needle guide with the landmark approach in 1230 patients who had IJV
cannulation. Among patients in the US-guidance group, 3.4% had a right
IJV that was not visualized or was deemed too small to cannulate. In all of
these cases, the left IJV was successfully cannulated. The investigators also
recognized the double wall phenomenon, commenting, ‘‘the IJV is actually
compressed completely by the needle before the vessel is penetrated. The
needle must be advanced a little deeper and then retracted slightly to be
positioned in the center of the lumen.’’ This finding underscores the need to
identify an underlying carotid artery.
Evidence-based analysis
Eleven of the 18 articles included in the 2003 NICE-sponsored metaanalysis investigated the IJV approach in adults [45]. Of these 11 studies, 7
used real-time US guidance and 4 used Doppler US guidance. Notable
improvements over the landmark approach were demonstrated with realtime US guidance. The relative risk of failed first attempts was 0.59 (95%
confidence interval: 0.39–0.88, P = 0.009) and the relative risk of failed
catheter placement was 0.14 (95% confidence interval: 0.06–0.33, P\0.0001).
The relative risk of complications decreased by 57%, the mean number of
attempts to successful cannulation decreased by 1.5, and the mean time to
successful cannulation decreased by almost 70 seconds (all P\0.02).
Subsequent to the meta-analysis, another randomized trial that compared
real-time US with the landmark approach among intubated patients
undergoing elective surgery was published [64]. This study investigated the
use of indirect US guidance with two different frequency transducers: 7.5
MHz and 3.75 MHz. In measuring the number of successful first attempts,
mean number of attempts to success, and rate of complications, the
investigators discovered no significant differences between the two frequencies. They noted that the 7.5-MHz transducer visualized structures with
higher resolution but that ‘‘the image quality of 3.75 MHz was acceptable
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for the purpose of locating the IJV and CA.’’ When the results of two US
groups were pooled for comparison to the landmark group, the rate of
successful first attempts showed improvement (73% versus 86%, P\0.05);
however, no statistically significant differences were found regarding the
overall success or complication rates. The investigators noted that in a subset
of 52 patients who lacked the anatomic landmark of respiratory jugular
venodilation (visible bulging of the vein beneath the skin synchronized with
inspiration of positive-pressure ventilation) on which they traditionally
depended, US guidance was superior to the landmark approach for all
outcomes. The number of successful first attempts was almost tripled (86%
versus 30%, P\0.001) and the number of successful cannulations was
greatly improved (100% versus 78%, P\0.05). There were no complications
among the US-guided attempts, whereas the landmark approach was
associated with three carotid artery punctures. These results, although not
surprising, further support the use of US guidance, especially for patients
with poor percutaneous landmarks.
Emergency medicine literature
Hudson and Rose [39] first reported the use of US guidance for IJV
cannulation specifically in the ED in 1997. In this article, they described their
successful experience in 2 patients with challenging percutaneous landmarks
due to severe skin graft scarring or morbid obesity. Since then, two prospective
studies of ED patients have been published. Hrics et al [41] reported a small
case series in which patients who needed central venous access within 1 hour of
arrival to the ED underwent cannulation either with real-time or indirect US
guidance. The success rates were 87.5% among the 8 patients in the real-time
US group and 71% among the 24 patients in the indirect US group.
Miller et al [33] have published the only trial as yet of real-time US versus
a landmark approach in the ED setting. This trial was pseudorandomized. It
used odd- and even-day assignment of 122 patients to real-time US guidance
or to the landmark approach to the IJV, SV, FV, or peripheral vein. It did
not analyze results by the type of vein cannulated; however, the largest
subgroup (55%) of the US-guided cases were for IJV cannulation. The
investigators noted an overall decrease in the mean time to successful
cannulation and number of attempts when using US. These improvements
occurred across the range of operator experience.
Subclavian vein approach
Anatomic considerations
As with the IJV, the SV offers ideal size for central access. Its proximity
to structures such as the lung, subclavian artery, and brachial plexus,
however, can lead to significant morbidity. Other challenges for accessing
the SV with US guidance are its deeper location and the presence of the
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clavicle bone. Because bone does not transmit US waves, placing the
transducer over it provides no information to guide the operator.
US guidance can be used to cannulate the SV in its midportion as is most
commonly taught with the landmark approach. In this case, the apex of the
lung can be less than 1 cm away from the SV [65]. Attempting US visualization
of the SV in short axis also can be challenging in this location because it
involves holding the transducer on top of the clavicle. Maintaining appropriate pressure for the transducer over the clavicle can be uncomfortable for
the patient and may add to the technical difficulty of this approach.
Supraclavicular approach
Due to its inherent anatomy, the supraclavicular approach to the SV is
troublesome to achieve with US guidance. In most patients, little space is
available for the transducer to be placed concurrently with needle insertion,
which makes real-time US guidance difficult at best. Two alternatives for
successful US-guided supraclavicular approach exist. The first is to use the
indirect method (previously described). Another alternative is to use the lowIJV approach. This approach has been found to be a safe and direct route to
the superior vena cava and right atrium for US-guided central venous access.
Silberzweig and Mitty [66] investigated 116 low-IJV punctures among 109
patients in the interventional radiology suite. They reported no complications and an average of 1.2 attempts (range, 1–3) needed for success.
Axillary approach
Yet another approach is to access the SV more laterally on the shoulder
so that the needle cannulates the axillary vein. This more distal approach
eliminates the problem of holding the transducer over the uneven surface of
the clavicle and removes the potential for the placed catheter to be pinched
between the subclavius muscle and the costoclavicular ligament complex
associated with the standard approach [67]. It also decreases the risk of
pneumothorax because the lung generally is farther away from the vascular
structures in the lateral shoulder. A misplaced needle passing through the
axillary vein will travel posteriorly through the axillary fat and layers of
muscle and, finally, to the scapula, thereby missing the pleural space [68].
The landmark approach to the axillary has been demonstrated to be safe in
adults [69] and critically ill infants and children [70].
Potential advantages for using the axillary approach specifically in the
ED include easier access for patients in cervical collars or with neck trauma.
Using this more lateral approach in critical trauma patients may also allow
for more efficient simultaneous management of the airway and acquisition
of central access. In addition, the landmark approach to the axillary vein has
been reported to be efficacious among severe burn victims who often present
with burns of the face, neck, and proximal shoulders [71].
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Drawbacks of the axillary approach include the decreased diameter and
deeper location of the axillary vein compared with the SV. Smaller caliber
and deeper location may lead to difficulty visualizing it with a high-frequency
transducer, especially in larger patients, and may increase the need for
a longer catheter to reach the vena cava in larger patients. No studies
specifically comparing the axillary and SV approaches have been published.
Evidence-based analysis
Four studies of SV access were included in the 2003 NICE-sponsored
meta-analysis [45]. Of these, three used Doppler US guidance and one used
real-time US guidance. The real-time US study evaluated 53 cannulation
attempts among 32 critically ill patients in a combined trauma and medical
intensive care unit [55]. The investigators used the axillary vein approach for
US guidance and reported an improved success rate compared with the
landmark method (92% versus 44%, P = 0.003). With US guidance, there
was also a decrease in the complication rate (4% versus 41%, P = 0.002), the
mean number of attempts (1.4 versus 2.5, P = 0.0007), and the mean number
of insertion kits used (1.0 versus 1.4, P = 0.0003). Malpositioned catheters in
the landmark group also led to the need for additional chest radiographs.
Fry et al [30] reported 100% success with the US-guided placement of 43
SV catheters in patients who had relative contraindications to the landmark
approach. The investigators subjectively noted that awake patients who have
US-guided access ‘‘seem less apprehensive.’’ The investigators further
suggested that ‘‘the ability to watch what is going on via the ultrasound
video screen, a decrease in the number of attempts, and better local
anesthesia along the intended needle path’’ contribute to improved patient
satisfaction with US guidance.
Femoral vein approach
Anatomic considerations
Modern study of the FV has discovered variations from generally
accepted anatomy. Reviewing CT scans of the pelvis in 100 patients, Baum
et al [72] discovered that a portion of the FV and the femoral artery overlaps
in the anteroposterior plane 65% of the time. A subsequent study that used
US in 50 intensive care unit patients confirmed this finding: ‘‘in most
patients there was overlap of the artery over the vein far closer to the
inguinal ligament than conventional anatomical textbooks would indicate’’
[73]. Furthermore, landmarks were not predictive of the underlying
anatomy that was documented on US.
Evidence-based analysis
Only one randomized trial of US guidance for FV access has been
published. This trial was undertaken among 20 patients undergoing cardio-
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pulmonary resuscitation in the ED [40]. Compared with the landmark approach, real-time US had a higher success rate (90% versus 65%, P = 0.058),
a lower mean number of needle passes (2.3 3 versus 5.0 5, P = 0.006), and
a lower rate of arterial catheterization (0% versus 20%, P = 0.025). The
investigators suggested that the better performance of US was due to the
ability to localize a nonpalpable FV by visualizing it instead. They also noted
that chest compressions were associated with changes in FV diameter
visualized on US. This finding is contrary to the expectation of arterial
pulsations with chest compressions. It implies that palpating for a pulse
during cardiopulmonary resuscitation as part of the landmark approach may
be misleading. Furthermore, the color and pulsatility of returning blood may
be unreliable for predicting arterial or venous source, especially in patients
whose oxygen saturation is low [74]. This study demonstrated the ability of
US to accurately identify the FV without dependence on these traditional
signs. In a prospective series, Kwon et al [75] reported a 100% success rate
among 28 patients who needed acute hemodialysis access. Compared with 38
patients with the landmark approach, these patients experienced a higher
a rate of successful first attempts (92.9% versus 55.3%, P\0.05) and
improved mean total procedure time (45.1 18.8 versus 79.4 61.7 seconds,
P\0.05). Femoral artery puncture occurred in 7.1% of US cases compared
with 15.8% of landmark cases.
Peripheral veins
The subset of ED patients with poor peripheral access is well known to
many emergency nurses and physicians. US offers a potential alternative to
central venous access, surgical cutdowns, and blind, deep brachial vein
catheterization for patients who need simple intravenous access but have no
palpable or visible peripheral veins. Studies of peripherally inserted central
venous catheter lines have shown that real-time US guidance is safe and
successful in adult [76,77] and pediatric populations [78].
A case series of US-guided brachial and basilic vein cannulation among 100
ED patients with difficult intravenous access demonstrated a 91% overall
success rate and a 73% rate of success on first attempt [42]. Two cases of
brachial artery puncture were reported. The mean time to successful cannulation was 77 129 seconds (range, 4–600 seconds). No trials that have
compared US guidance with the landmark approach have been published.
Issues in pediatric patients
Procedural challenges
Central venous access in infants and children is challenging under any
circumstances. There are various possible reasons for the greater morbidity
associated with central venous cannulation in pediatric patients: superficial
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anatomic landmarks may be less distinct, vessel diameters are generally
smaller, the proximity of important anatomic structures may be greater,
there may be less patient cooperation than among adults, anatomic
anomalies may be present, and nonpediatric specialists may not be as
experienced with pediatric vascular access [46,79]. For these reasons, US
guidance should be integrated into methods of central venous access for
pediatric patients in the ED.
Evidence for ultrasound guidance in pediatric patients
Studies of real-time US guidance for central vein cannulation in pediatric
patients currently are found mainly in the anesthesia literature. Three
randomized trials of US guidance versus landmark method for IJV
cannulation among infants and children have been published [46–48]. These
trials and at least four case series [34,79–81] constitute the current body of
evidence that supports the application of US guidance in pediatric patients.
The 2003 NICE-sponsored meta-analysis used the three trials to determine
overall relative risk reductions of 85% for failed placement and 73% for
complications of IJV cannulation in pediatric patients [45].
Anatomic factors contribute to complications of the landmark approach
to IJV cannulation in children. Alderson et al [46] determined that 18% of
patients aged 3 days to 5.5 years had anatomic variations of the IJV. The
investigators reported a superior success rate (100% versus 80%), shorter
mean time to successful cannulation (27.4 versus 48.9 seconds), and lower
mean number of attempts (1.37 versus 2.0) with US guidance. Two patients
in the landmark group and one in the US group suffered a carotid artery
puncture.
In comparing real-time US to the landmark approach for IJV cannulation among 95 infants aged 12 months or less who underwent elective
cardiovascular surgery, Verghese et al [47] found that the US approach
significantly improved success and complication rates. US guidance was
successful and had no associated carotid artery punctures. In contrast, the
landmark method had a 77% success rate and a 25% rate of carotid artery
puncture. Almost half of the patients with carotid artery puncture sustained
additional complications, including hemothorax, pneumothorax, jugular
venous hematoma, catheter kinking, and threading difficulty. Among the
subset of patients with unsuccessful landmark attempts, 25% were subsequently successfully catheterized under US guidance.
In a subsequent study, Verghese et al [48] found statistically significant
improvements in the success rate and median number of attempts with realtime US guidance over the landmark approach. The small sample size of 16
patients in each group, however, limited the statistical evaluation of trends
toward improved time to successful cannulation and complication rates.
Three carotid artery punctures occurred using the landmark approach
compared with one using real-time US guidance.
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767
Limitations of pediatric emergency department ultrasound-guided venous
cannulation
The three existing trials have been criticized for their relatively small
sample sizes of less than 100 patients each. Because these trials reported
results only with IJV access, definitive conclusions regarding other venous
sites presently are impossible. No studies have been reported on SV
cannulation and only one small study reported the successful use of realtime US to facilitate FV catheterization [34]. Although the pediatric studies
consistently have reported positive findings for IJV cannulation, the
importation of their success in the well-controlled, elective setting of
scheduled surgery to the acute circumstances in the ED has yet to be
demonstrated. To date, no studies of US-guided venous cannulation
conducted in the pediatric ED setting have been published.
Limitations of emergency department ultrasound-guided venous access
Transducer type
Most US-guided vascular access is performed using a linear, highfrequency (6–10 MHz) transducer. The linear transducer provides a larger
field of view compared with a sector transducer. This larger field of view
allows visualization of the advancing needle through its entire course. In
addition, because most of the target vessels are superficial, a high-frequency
transducer can be used that yields superior resolution of the subcutaneous
tissues, the advancing needle, and the vessels to be cannulated or avoided.
As a separate purchase, the cost of a linear, high-frequency transducer
can be prohibitive. Some EDs may not have budgeted for additional
transducers when they originally acquired US equipment. Consequently,
many emergency physicians do not have access to this transducer.
One alternative is to use the large curvilinear transducer commonly used
for abdominal imaging; however, this transducer has some drawbacks for
real-time US guidance. Typically, the large curvilinear probe is bulkier than
a linear transducer, and its lower-frequency images can make the procedure
more technically challenging. The curvilinear transducer’s greatest obstacle
is its curved visual field. Although the center of the visual field is relatively
linear, the lateral aspects of the screen are curved to the extent that
advancement of the needle under real-time US guidance is distorted. One
possibility is to use the curvilinear transducer for indirect guidance, but this
approach has not been formally studied.
Another approach is to use an endovaginal transducer for US-guided
vascular access. This transducer is a common component of many ED US
systems and its use for venous access has been promoted in the gynecologic
and emergency medicine literature [82,83]. It has been described only for the
short-axis approach to the IJV, and efficacy was not studied. For physicians
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with access to only the curvilinear or endovaginal transducer, the endovaginal transducer may be the superior choice.
Sterile barrier
Another equipment issue unique to US-guided vascular access is that
a sterile barrier typically is needed. Such barriers usually are designed to
cover both the transducer and its cable (see Fig. 4) and allow sterile
performance by a single operator.
Although there are many relatively inexpensive varieties of sterile
transducer covers, occasionally, one may not be available. In this case,
other alternatives can be employed. The easiest method is to use a sterile
glove. A conducting agent is placed inside the glove wherever the largest
uninterrupted flat surface is located. An assistant can then place the
transducer inside the glove. The operator then folds back the fingers of
the glove and holds the transducer so that the flat surface of the glove forms
the scanning surface for the transducer. It is important to eliminate any air
bubbles that may be interposed between the glove and the transducer’s
scanning surface because they would compromise image quality severely.
Mechanical guides
Mechanical guides typically come in two forms. The first is a built-in
needle slot within the central or side portion of the transducer that directs
the needle at a predetermined angle within the plane of view of the US beam.
Another form is a separate guide that can be fitted to a transducer (see
Fig. 7). Presently, these guides are not interchangeable among different
transducers. Most companies manufacture them for each linear transducer
that they produce. Mechanical guides may not be necessary, especially for
experienced operators [55].
Education and training aids
A significant issue pertaining to US-guided vascular access is the time and
cost of training new operators. It is unfortunate that practical education for
US-guided venous access currently is not available, and standard methods
for teaching other US examinations, such as normal or dialysis models,
cadavers, swine, or simulators, have significant limitations.
Because the procedure is invasive, practicing on normal or dialysis
models is problematic. Although the anatomy of cadavers may demonstrate
vascular structures well [84], the entry site would be revealed after the initial
puncture, thereby limiting the educational benefits for subsequent students.
Swine or other animal models not only have unique vascular anatomy but
ethical and cost issues also limit their use. Lastly, although simulation would
seem to be an attractive alternative, only one vascular model currently
exists. This model is limited to teaching peripheral vein cannulation using
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769
landmarks, not US guidance [85]. A newer development in the area of USguided vascular access education is the use of phantoms. Phantoms are
generally easy and inexpensive to produce. They simulate vessels well and,
hence, the mechanics of US-guided cannulation.
Time to cannulation and operator experience
The time required to set up and complete the procedure commonly is
considered a drawback to US-guided vascular access. As with any novel
procedure, there is a learning curve; however, this curve has been shown to
be short and steep [58]. Improved results have been demonstrated across the
spectrum of operator experience [86]. Furthermore, due to fewer failed
attempts, the average time to vessel cannulation is the same as or is
decreased with US guidance versus the landmark technique.
Hilty et al [40] compared US-guided FV cannulation with the landmark
approach in 20 patients presenting in cardiac arrest. The average time to
flash of blood under US guidance was 30.8 32 seconds versus 33.8 35
seconds for the landmark technique. Time to cannulation also was
decreased with US guidance (121.0 60 versus 124.2 69 seconds). In
another study that compared the short- and long-axis approaches on a US
phantom, the mean time to cannulation was 2.36 minutes versus 5.02
minutes, which was statistically significant [59]. Although it did not compare
landmark and US-guided approaches, this study suggests that shorter
intervals to vessel cannulation can be obtained, especially for inexperienced
operators, when the vessel is approached in the short axis.
Summary
The evidence that supports the general application of US guidance for
venous access in the ED has reached a critical mass. The increasing
familiarity of emergency physicians with US and the recent focus on patient
safety and clinical outcomes has intensified attention on the capacity for US
to improve patient care in the ED. US guidance can increase the safety and
efficiency of venous access procedures and offers improved outcomes. The
potential for these improvements is compelling, especially among certain
types of ED patients such as those with difficult or complicated access.
Varying levels of evidence support the use of US guidance over the
traditional landmark approach for venous access in adult and pediatric
populations and for central and peripheral veins. Many different techniques
may be applied, depending on the clinical situation and equipment available.
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