6
Ultrasound guided vascular access: efficacy and safety

https://doi.org/10.1016/j.bpa.2009.02.006Get rights and content

Central venous catheterisation and arterial catheterisation are common procedures performed by anaesthetists. Traditionally, the technique of locating surface landmarks and palpation was used to assist in vascular access. The introduction of perioperative ultrasonography in the past decade has dramatically changed this procedure. In the United States and United Kingdom, guidelines have recommended the use of ultrasound guidance to reduce complications and improve success in central venous catheterisation. This article summarises the literature on complication rates, efficacy and safety of ultrasound-guided vascular access procedures and describes a practical method of ultrasound-guided central venous access and arterial catheterisation.

Section snippets

Complications of central venous catheterisation

Mechanical complications of CVC insertion may be defined as direct needle trauma causing arterial puncture, stroke after arterial puncture, haematoma, pneumothorax, haemothorax, brachial plexus injury and damage to the stellate ganglion or phrenic nerve.

Reported complication rates vary due to differences in definitions, methodology and inclusion of proceduralists with diverse experience levels. The estimates in adults range from 0.5% to 10%1, 2% to 15%2 and 10% to 15%.3 Complication rates for

Efficacy and safety of ultrasound-guided central venous catheterisation

The original method of US-assisted venous cannulation used acoustic Doppler techniques, but is now superseded by two-dimensional (2D) US imaging. The superior benefits of 2D imaging include real-time visualisation of patient anatomy and a more accurate method of needle guidance compared to the landmark or Doppler techniques.

The earliest meta-analysis in 1996 by Randolph14 included eight trials of dynamic US guidance (mixed acoustic Doppler and real-time 2D US studies) versus landmark methods,

Impact of US-guided central venous catheterisation guidelines

In 2001, the Agency for Healthcare Research and Quality in the United States recommended the use of 2D US-guided CVC access.1 The following year, the National Institute for Clinical Excellence (NICE) in the United Kingdom issued a guidance statement on 2D US as the preferred method of IJV CVC insertion in adults and children.4

Response to these recommendations has polarised opinions and implementation is inconsistent. In the United States, 18% still do not have access to US equipment, and 67%

Efficacy and safety of US-guided arterial catheterisation

Arterial access can be complicated by haemorrhage, haematoma, vasospasm, thrombosis and injury to adjacent nerves. Rates of complications have not been published but are probably uncommon. Closed claim reports have recorded limb ischaemia with amputation, and other serious morbidity, after attempted arterial catheterisation.36 In two prospective randomised trials, real-time 2D US was found to be superior to landmark for arterial catheterisation in adults. In the Levin et al. study37, the

Ultrasound-guided vascular access curriculum

The authors teach a core curriculum covering applicable aspects of ultrasound physics, equipment orientation (knobology), sterility and infection control practices and regional sonoanatomy. Practice in obtaining good images and discriminating vascular structures is easily taught at the patient bedside. The gold standard is real-time 2D US and visualising the needle throughout the cannulation process. This implies a higher standard of training, but we believe that only 5–10 supervised attempts

(A) Anatomy of the internal jugular vein

The anatomy of the IJV was first described by the Roman physician Claudius Aelius Galenus (Galen of Pergamum, 129–200 AD), and percutaneous central catheterisation of the IJV was demonstrated in 1969.41 Classically, the IJV is described as lateral to the common carotid artery (CCA) at the level of the cricothyroid cartilage.42 Subsequently, it is known that anatomical deviation and unreliability of external surface anatomy are implicated as significant causes of difficulty in CVC access using a

Ultrasound-guided radial arterial catheterisation

The radial artery at the level of the wrist is superficial and lateral to the flexor carpi ulnaris tendon. Several anatomical variations have been described and are not rare.48 Theoretically, radial arterial cannulation at the wrist may compromise blood supply to the hand if there is inadequate contribution by the deep branch of the ulnar artery to the deep palmar anastomosis.49 Traditionally, ‘Allen's test’ is performed to identify risk of compromise prior to radial catheterisation, but there

Summary

In the United Kingdom and United States, US guidance for internal jugular central venous catheterisation is recommended. Despite reluctance to adopt these guidelines, there is sufficient evidence to support routine use, as even proceduralists skilled in landmark techniques commonly encounter complications. Serious morbidity and mortality may result, which arguably is avoidable, if ultrasonography was used. Real-time 2D US demonstrates patient anatomy and anatomical variability in a manner not

Conflict of interest

AC has received honoraria from SonoSite and AstraZeneca as a workshop tutor for teaching ultrasound-guided procedures.

References (51)

  • M.A. Jarvis et al.

    Reliability of Allen's test in a selection of patients for radial artery harvest

    The Annals of Thoracic Surgery

    (2000)
  • J.M. Rothschild

    Ultrasound guidance of central vein catheterization. In agency for healthcare research and quality. Making health care safer: a critical analysis of patient safety practices

    Evidence Report/Technology Assessment

    (July 2001)
  • P.L. Bailey et al.

    A survey of the use of ultrasound during central venous catheterization

    Anesthesia and Analgesia

    (2007)
  • National Institute for Clinical Excellence. Guidance on the use of ultrasound locating devices for placing central...
  • W. Schummer et al.

    Mechanical complications and malpositions of central venous cannulations by experienced operators. A prospective study of 1794 catheterizations in critically ill patients

    Intensive Care Medicine

    (2007)
  • T. Maecken et al.

    Ultrasound imaging in vascular access

    Critical Care Medicine

    (2007)
  • L.A. Eisen et al.

    Mechanical complications of central venous catheters

    Journal of Intensive Care Medicine

    (2006)
  • A.P. Hall et al.

    Towards safer central venous access: ultrasound guidance and sound advice

    Anaesthesia

    (2005)
  • K.B. Domino et al.

    Injuries and liability related to central vascular catheters. A closed claims analysis

    Anesthesiology

    (2004)
  • T.A. Bowdle

    Central line complications from the ASA closed claims project

    ASA Newsletter

    (1996)
  • T.A. Bowdle

    Central line complications from the ASA closed claims project: an update

    ASA Newsletter

    (2002)
  • K.G. Callum et al.

    Interventional vascular radiology and interventional neurovascular radiology

    (November 2000)
  • A.G. Randolph et al.

    Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature

    Critical Care Medicine

    (1996)
  • D. Hind et al.

    Ultrasonic locating devices for central venous cannulation: meta-analysis

    BMJ

    (2003)
  • D. Karakitsos et al.

    Real-time ultrasound-guided catheterization of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients

    Critical Care

    (2006)
  • Cited by (73)

    • Comparison of the diameter, cross-sectional area, and position of the left and right internal jugular vein and carotid artery in adults using ultrasound

      2016, Journal of Clinical Anesthesia
      Citation Excerpt :

      Common uses for a central venous catheter include central venous pressure transduction, administration of inotropes, fluid therapy, and secure venous access. Although the incidence of complications from central venous cannulation has been significantly reduced by the use of ultrasound, the hazards of arterial puncture, hematoma formation, hemothorax, and pneumothorax remain [2–12]. Cannulation of the left IJV (LIJV) is associated with a higher complication rate and a perceived increased level of difficulty when compared with cannulation of the right IJV (RIJV) [13,14].

    View all citing articles on Scopus
    View full text