Ultrasound-guided Central venous catheterization

Introduction

Central venous catheterization is a vital technique to facilitate care of critically ill patients. Whether it is for fluid resuscitation, vasopressor administration, multiple drug infusions, hemodialysis or other indication, it is vital that front-line health care providers are able to perform this skill safely and competently. In the following video clips and images, we will highlight selected fundamental points to enhance your understanding and performance of this procedure.

Procedural video from NEJM

Please check out this excellent video tutorial by New England Journal of Medicine. While this video discusses internal jugular cannulation exclusively, the Seldinger technique (over-the-wire technique) and execution of the procedure is similar regardless of site.

ABaCCUS procedural video

This video tutorial delves further into the practical use of ultrasound to guide venous cannulation. While ultrasound offers much benefit, technical mastery can optimize safety and increase the chance of successful placement.

Key pearls to ensure successful placement

Pre-performance venous assessment

Prior to set-up sonographically interrogate the access site to ensure patency of internal jugular vein and optimal access site. Many beginners turn the head to the contra-lateral side, which can lead to significant anatomical distortion.


Creep technique

Ensure your probe is always capturing the tip of the needle, as it easy to confuse the shaft. In this clip, we see in short axis we don't appear to enter the vein, but in the long axis we are. Be careful!

Confirmation of wire placement

After insertion of the wire, it should be visualized in two planes along its anatomical course. While this practice does not have a robust evidence base, it is evident that unequivocal intra-vascular visualization is reassuring prior to dilatation and final catheter insertion.

References

Hoffman T, Du Plessis M, Prekupec MP, et al. Ultrasound-guided central venous catheterization: A review of the relevant anatomy, technique, complications, and anatomical variations. Clin Anat. 2017;30(2):237-250.

Lamperti M, Bodenham AR, Pittiruti M, et al. International evidence-based recommendations on ultrasound-guided vascular access. Intensive Care Med. 2012;38(7):1105-1117. doi:10.1007/s00134-012-2597-x.

Ortega R.Song M.Hansen C.J.Barash P. Ultrasound-Guided Internal Jugular Cannulation. N Engl J Med 2010; 362:e57.

Saugel B, Scheeren TWL, Teboul J-L. Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Crit Care. 2017;21(1):225. doi:10.1186/s13054-017-1814-y.