Ultrasound-Guided Central Venous Catheter Placement

A Structured Review and Recommendations for Clinical Practice

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


Crit Care. 2017;21(225) 

In This Article

How to Integrate Knowledge From Landmark and Ultrasound Techniques?

To achieve the personal best skill level for CVC placement, it is crucial that one combines and integrates the anatomic knowledge from landmark techniques and the knowledge gained from US-guided vascular access (knowledge about image display and converting the 2D image into 3D reality, and hand–eye coordination).[31] In this context, previous US studies provided important information on the effect of different interventions on the venous puncture sites.

It has been demonstrated repeatedly that positioning of the patient in a head-down (Trendelenburg) position increases the filling and thus the cross-sectional lumen of the IJV.[33] On the contrary, to increase the lumen of the FV, patients can be positioned in a head-up (reverse Trendelenburg) position.[34] Positioning of the leg in an abducted and externally rotated position also can help to maximize the cross-sectional diameter of the FV.[35]

For the IJV, imaging studies showed that the position of the head plays an important role in optimizing the conditions during CVC placement. Several studies demonstrated that rotation of the head to the opposite side increases the overlap of the IJV and the carotid artery.[36,37,38] In a US study, Miki et al.[37] investigated in 30 volunteers the anatomical relationship between the IJV and the carotid artery during head rotation. The overlap of the IJV and the carotid artery gradually increased with increasing rotation of the head to the left. In parallel, however, the flattening of the IJV decreased with head rotation to the left. DeAngelis et al.[39] described that the IJV becomes more vertically separated from the carotid artery at more extreme angles of contralateral head rotation. These findings underline that US should be used in each individual patient to assess the optimal angle of head rotation and best approach to the IJV.