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

How to Perform Ultrasound-guided Central Venous Catheter Placement? Recommendations for Clinical Practice—a Systematic Approach

For clinical practice, we recommend a systematic approach including the following steps:

  1. Identify anatomy of the insertion site and localization of the vein.

  2. Confirm patency of the vein.

  3. Use real-time US guidance for puncture of the vein.

  4. Confirm needle position in the vein.

  5. Confirm wire position in the vein.

  6. Confirm catheter position in the vein.

Identify anatomy of the insertion site and localization of the vein

As a first step, one should use US to identify the anatomy of the insertion site (vein and artery, adjacent anatomic structures) and the localization of the target vein. This includes checking for anatomic variations of the vessels (both vein and artery) and the localization of the vein in relation to the artery. This step requires combining a profound knowledge about anatomic structures and landmarks with the competencies required for US-guided CVC placement (such as knowledge about probe orientation and image display, converting the 2D US image into 3D reality, and hand–eye coordination).[31] Given the variability in anatomic structures, this first step of US assessment is best performed before prepping and draping of the puncture site and the US probe.

The location of the vein and its anatomic relation to the artery is best identified when using both a short-axis (transverse) and a long-axis (longitudinal) view of the vessels (Figure 2a, b). This also allows identifying hypoplastic veins or underfilling of the veins due to intravascular hypovolemia (Figure 3). To exactly differentiate between venous and arterial vessels one can additionally perform color Doppler imaging and apply Doppler flow measurements to derive venous and arterial Doppler flow profiles (Figure 4a, b).

Figure 2.

Ultrasound views to identify the anatomy of the target vein. Short-axis (transverse) view (a) and long-axis (longitudinal) view (b) of the right internal jugular vein (*) and its anatomic relation to the carotid artery (#)

Figure 3.

Ultrasound view of a small internal jugular vein. Short-axis (transverse) view of a small right internal jugular vein (*) and its anatomic relation to the carotid artery (#) (e.g., in a patient with intravascular hypovolemia)

Figure 4.

Color Doppler imaging and Doppler flow measurements. Short-axis (transverse) view of the right internal jugular vein (blue) and the carotid artery (red) using color Doppler imaging and Doppler flow measurements of the venous (a) and arterial (b) blood flow profile (Color figure online)

Confirm patency of the vein

By applying pressure to the vein and thus testing its compressibility with the US probe, one can confirm the patency of the vein and thus exclude venous thrombosis. Of note, in patients with very low arterial blood pressure (systolic arterial pressure < 60 mmHg), the artery might also be compressible.[14]

To further confirm the patency of the vein and to quantify venous and arterial blood flow, color Doppler imaging and Doppler flow measurements should be performed (Figure 4a, b).

Use real-time ultrasound guidance for puncture of the vein

CVC placement should be performed using US guidance. This requires an aseptic approach to avoid catheter-related bloodstream infections. An aseptic technique includes: prepping and covering the puncture site with a large sterile drape; wearing a hat, a mask, sterile gloves, and a sterile body gown; covering the US probe and cable with a sterile cover/shield; and using a sterile conductive medium (US gel).[13,32]

The position of the operator performing US-guided CVC placement should be such that he/she has the insertion site, the needle, and the US screen in their line of sight during needle insertion.[13] Usually, the operator should hold the US probe with the nondominant hand while advancing the needle with the dominant hand. This approach is referred to as the "single-operator technique" and allows the operator to optimally align the US plane and the direction of the needle.

These practical aspects of US-guided CVC placement are illustrated in Figure 5.

Figure 5.

Practical aspects of ultrasound-guided central venous catheter placement in the internal jugular vein using the "single-operator technique". An aseptic approach including covering the puncture site with a large sterile drape, using sterile barriers (hat, mask, sterile gloves, sterile body gown), and covering the ultrasound probe and cable with a sterile cover is shown. The position of the operator (who holds the ultrasound probe with the nondominant hand while advancing the needle with the dominant hand) allows aligning the insertion site, the needle, and the ultrasound screen in the line of sight during needle insertion (red lines) (Color figure online)

While advancing the needle, its tip should be constantly identified with US during the needle approach to the vein and puncture of the vein. This can be done using a short-axis/out-of-plane view or a long-axis/in-plane view.

Confirm needle position in the vein

The use of real-time US then allows confirmation that the needle tip is placed centrally in the vein before approaching the guide wire (Figure 6a, b).

Figure 6.

Ultrasound to confirm needle, wire, and catheter position in the vein. Ultrasound images during real-time ultrasound-guided central venous catheter placement in the right internal jugular vein. Ultrasound guidance should include confirmation of the needle position in the vein before approaching the guide wire (short-axis/out-of-plane view (a) and long-axis/in-plane view (b)). In addition, the correct position of the guide wire in the vein (short-axis (c) and long-axis (d)) and the correct position of the catheter in the vein (short-axis (e) and long-axis (f)) should be confirmed

Confirm wire position in the vein

As a next step after wire advancement, the correct position of the guide wire should be confirmed in both a short-axis and a long-axis US view (Figure 6c, d).

Confirm catheter position in the vein

Finally, after placement of the CVC over the guide wire, the correct position of the CVC in the vein can be visualized with US, again in a short-axis and a long-axis view (Figure 6e, f).

Figure 7 summarizes the six-step approach to US-guided CVC insertion.

Figure 7.

Six-step approach to ultrasound-guided central venous catheter placement

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