Principles of ultrasound-guided venous access
- Erica Mitchell, MD, FACS
Erica Mitchell, MD, FACS
- Professor of Surgery
- Division of Vascular Surgery
- Oregon Health & Science University
- Jeremiah J Sabado, MD
Jeremiah J Sabado, MD
- Clinical Instructor of Radiology and Pediatrics
- Sidney Kimmel Medical College of Thomas Jefferson University
- Section Editors
- David L Cull, MD
David L Cull, MD
- Section Editor — Arterial and Venous Access
- Clinical Professor, Department of Surgery
- University of South Carolina School of Medicine
- Allan B Wolfson, MD
Allan B Wolfson, MD
- Section Editor — Adult Procedures
- Professor of Emergency Medicine
- University of Pittsburgh
- Anne M Stack, MD
Anne M Stack, MD
- Section Editor — Pediatric Procedures
- Associate Professor, Department of Pediatrics
- Harvard Medical School
Establishing venous access is critically important and is sometimes technically challenging. Among the many indications for bedside ultrasound, ultrasound-guided venous catheter placement is well described and increasingly used [1,2].
The principles of ultrasound-guided venous access will be reviewed here. General considerations and techniques for central venous access at specific sites are discussed separately. (See "Overview of central venous access" and "Vascular (venous) access for pediatric resuscitation and other pediatric emergencies" and "Placement of femoral venous catheters" and "Placement of subclavian venous catheters" and "Placement of jugular venous catheters".)
Randomized trials and observational studies in children and adults have found that real-time ultrasound imaging during needle placement reduces time to venous cannulation and reduces the risk of complications during central venous and peripheral venous access [3-9]. The level of benefit varies depending upon operator skill and the anatomic site.
Ultrasound-guided venous access is indicated in any patient for whom central vascular access via the internal jugular vein or femoral vein is necessary when equipment and operator expertise is available [5,10]. Static vein localization and/or dynamic ultrasound guidance is also helpful for identifying or confirming a patent vein site prior to central vein catheter or peripherally-inserted central catheter (PICC) placement, or for establishing peripheral intravenous access in adults and children when difficulty is expected or when the traditional blind technique has failed [11,12].
Central venous access — Based upon randomized trials, we recommend that when equipment and expertise are available, children and adults undergoing central venous access at internal jugular or femoral access sites have the procedure guided by dynamic ultrasound rather than using the landmark technique alone [5,6,13-15]. Ultrasound is also commonly used to place peripherally-inserted central catheters (PICC) via the brachial or basilic vein in adults, children, and sedated neonates [16-18].
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- Levy JA, Noble VE. Bedside ultrasound in pediatric emergency medicine. Pediatrics 2008; 121:e1404.
- Lalu MM, Fayad A, Ahmed O, et al. Ultrasound-Guided Subclavian Vein Catheterization: A Systematic Review and Meta-Analysis. Crit Care Med 2015; 43:1498.
- Byon HJ, Lee GW, Lee JH, et al. Comparison between ultrasound-guided supraclavicular and infraclavicular approaches for subclavian venous catheterization in children--a randomized trial. Br J Anaesth 2013; 111:788.
- Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 2003; 327:361.
- Rabindranath KS, Kumar E, Shail R, Vaux E. Use of real-time ultrasound guidance for the placement of hemodialysis catheters: a systematic review and meta-analysis of randomized controlled trials. Am J Kidney Dis 2011; 58:964.
- Rabindranath KS, Kumar E, Shail R, Vaux EC. Ultrasound use for the placement of haemodialysis catheters. Cochrane Database Syst Rev 2011; :CD005279.
- Sigaut S, Skhiri A, Stany I, et al. Ultrasound guided internal jugular vein access in children and infant: a meta-analysis of published studies. Paediatr Anaesth 2009; 19:1199.
- Stolz LA, Stolz U, Howe C, et al. Ultrasound-guided peripheral venous access: a meta-analysis and systematic review. J Vasc Access 2015; 16:321.
- Rothschild, JM. Ultrasound guidance of central vein catheterization. In: Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment, No. 43, Shojania, KG, Duncan, BW, McDonald, KM, et al (Eds), Agency for Healthcare Research and Quality, Rockville, MD 2001. p.245. http://www.ahrq.gov/clinic/ptsafety/chap21.htm (Accessed on September 26, 2009).
- Keyes LE, Frazee BW, Snoey ER, et al. Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access. Ann Emerg Med 1999; 34:711.
- Doniger SJ, Ishimine P, Fox JC, Kanegaye JT. Randomized controlled trial of ultrasound-guided peripheral intravenous catheter placement versus traditional techniques in difficult-access pediatric patients. Pediatr Emerg Care 2009; 25:154.
- Bruzoni M, Slater BJ, Wall J, et al. A prospective randomized trial of ultrasound- vs landmark-guided central venous access in the pediatric population. J Am Coll Surg 2013; 216:939.
- Mehta N, Valesky WW, Guy A, Sinert R. Systematic review: is real-time ultrasonic-guided central line placement by ED physicians more successful than the traditional landmark approach? Emerg Med J 2013; 30:355.
- Shime N, Hosokawa K, MacLaren G. Ultrasound Imaging Reduces Failure Rates of Percutaneous Central Venous Catheterization in Children. Pediatr Crit Care Med 2015; 16:718.
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- Fragou M, Kouraklis G, Dimitriou V, Karakitsos D. Risk factors for acute adverse events during ultrasound-guided central venous cannulation in the emergency department. Acad Emerg Med 2011; 18:443.
- Hilty WM, Hudson PA, Levitt MA, Hall JB. Real-time ultrasound-guided femoral vein catheterization during cardiopulmonary resuscitation. Ann Emerg Med 1997; 29:331.
- Kwon TH, Kim YL, Cho DK. Ultrasound-guided cannulation of the femoral vein for acute haemodialysis access. Nephrol Dial Transplant 1997; 12:1009.
- Aouad MT, Kanazi GE, Abdallah FW, et al. Femoral vein cannulation performed by residents: a comparison between ultrasound-guided and landmark technique in infants and children undergoing cardiac surgery. Anesth Analg 2010; 111:724.
- Griswold-Theodorson S, Farabaugh E, Handly N, et al. Subclavian central venous catheters and ultrasound guidance: policy vs practice. J Vasc Access 2013; 14:104.
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- Fragou M, Gravvanis A, Dimitriou V, et al. Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study. Crit Care Med 2011; 39:1607.
- O'Leary R, Ahmed SM, McLure H, et al. Ultrasound-guided infraclavicular axillary vein cannulation: a useful alternative to the internal jugular vein. Br J Anaesth 2012; 109:762.
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- Shokoohi H, Boniface K, McCarthy M, et al. Ultrasound-guided peripheral intravenous access program is associated with a marked reduction in central venous catheter use in noncritically ill emergency department patients. Ann Emerg Med 2013; 61:198.
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- Ball RD, Scouras NE, Orebaugh S, et al. Randomized, prospective, observational simulation study comparing residents' needle-guided vs free-hand ultrasound techniques for central venous catheter access. Br J Anaesth 2012; 108:72.
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- Central venous access
- - Internal jugular vein
- - Femoral vein
- - Subclavian vein
- Peripheral intravenous access
- - Use in children
- Intraosseous access
- CONTRAINDICATIONS AND PRECAUTIONS
- ULTRASOUND EQUIPMENT
- ULTRASOUND ANATOMY
- Probe orientation
- - Transverse (short axis) view
- - Longitudinal (long axis) view
- PATIENT PREPARATION
- ULTRASOUND MACHINE PREPARATION
- ULTRASOUND-GUIDED TECHNIQUES
- Dynamic ultrasound to guide vein cannulation
- PITFALLS AND COMPLICATIONS
- ADDITIONAL RESOURCES
- SUMMARY AND RECOMMENDATIONS