Ultrasound-Guided Central Venous Catheter Placement

A Structured Review and Recommendations for Clinical Practice

Bernd Saugel; Thomas W. L. Scheeren; Jean-Louis Teboul

Disclosures

Crit Care. 2017;21(225) 

In This Article

Limitations of Ultrasound-guided Central Venous Catheter Placement

Although US is noninvasive and thus does not bear a risk to directly harm the patient, some limitations and disadvantages of US during central venous access are worth considering.

One might argue that the risk of catheter-related bloodstream infections might be higher if US is used for CVC placement without applying a strict aseptic approach as already described.[47] In addition, an insufficient number of US machines in a certain unit (intensive care unit or anesthesia induction area) might cause procedural delays.[47] Moreover, it is expensive to purchase and maintain US machines and to provide adequate training for all operators involved in CVC placement.[47]

US might give the inexperienced user a false sense of security and mislead him/her to neglect traditionally taught principles with regard to needle direction. It is key to visualize the needle (or needle tip) constantly during needle advancement to avoid accidental arterial puncture, posterior wall penetration, or pneumothorax. In addition, rapid movements with the needle during "searching the needle on the US screen" must be avoided rigorously. To overcome these problems related to insufficient US skills and to ensure high-quality care, formal education and training (including simulation) with a structured certification of US skills for vascular access and the development of a consensus standard for these training programs has been suggested.[13]

Moreover, concerns have been expressed that routine US use will result in a "de-skilling" with regard to the landmark techniques because these techniques will not be taught and practiced anymore, thus resulting in higher complication rates when CVCs need to be placed when US is not available (e.g., in emergencies).[47]

Besides these general limitations, different problems specific for the different anatomical sites for CVC placement might occur during US-guided CVC placement. In patients with a shorter neck anatomy, the long-axis US view of the IJV might be difficult to obtain. Although the FV can usually be visualized easily using US in adults, in severely obese patients a second operator might be necessary to provide access to the inguinal region. In addition, a curved-array abdominal US probe can be necessary for visualizing deeper anatomic structures. In comparison to the IJV and FV, the anatomic location and course of the SV under the clavicle bone can be more difficult to visualize using US. Smaller US probes can facilitate US-guided access to the SV.[48,49] Of note, the use of US to puncture the SV results in a puncture site that is usually more lateral compared to the landmark puncture technique. The close proximity of the vessels and the pleura must be kept in mind also during US-guided puncture of the SV. Because the angle of cannulation is usually steeper when using US, it is especially important to align and constantly visualize the needle to avoid pleural injury.

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