Introduction
Ultrasound (US) guidance has become an increasingly common technique for vascular access in the Emergency Department (ED), with applications for both central and peripheral lines [1-4]. Initially adopted for central venous catheter (CVC) insertion, particularly in the internal jugular vein, US improved placement success rates, decreased complication rates, and shortened insertion times. As US technology and training advanced, its use expanded to peripheral intravenous line (PIV) placement, where studies have demonstrated increased success rates, reduced complications, and less pain, especially for patients with difficult access [1-4]. Difficult IV access, occurring in 10% to 30% of ED patients—particularly those with morbid obesity, IV drug use, hypovolemia, or chronic illness—can delay cannulation due to multiple failed attempts [5]. Ultrasound-guided PIV placement can mitigate these challenges, with one study reporting an 85% reduction in the need for CVCs in non-critical patients through the implementation of a US-guided PIV catheter program [6]. The overall benefits of US-guided vascular access include improved success rates, fewer complications, decreased pain, reduced time to cannulation, fewer attempts required, and improved patient satisfaction [1-4]. While it may add some complexity compared to landmark or “blind” approaches, the ability to directly visualize target vessels makes US-guided vascular access a highly effective and patient-centered technique.
Indications
Intravenous (IV) access is often critically important for many aspects of patient care in the ED [1-3]. These include:
US-Guided Peripheral IV Access:
- Patients who have had three or more blind attempts without successful cannulation.
- Patients with a history of difficult IV access.
- Always evaluate the patient using traditional visual inspection and palpation before preparing for US-guided peripheral IV access. Factors that contributed to difficult IV access during previous encounters, such as hypovolemia, may not be present during subsequent visits.
- Patients who have previously required central line placement solely for IV access.
- As mentioned above, when the clinical situation permits, patients with a history of requiring US-guided vascular access should be evaluated for landmark-based IV sites and/or US-guided peripheral IV sites before proceeding to the more invasive procedure of central venous access.
US-Guided Central Venous Access:
Whenever possible, it is highly recommended to use ultrasound guidance for invasive vascular access procedures, such as central venous cannulation, due to its demonstrated ability to decrease the occurrence of severe complications and increase success rates. The primary indication for ultrasound guidance in central venous access is the need for central venous access itself. Below is a list of specific indications for central venous access [1-4]:
- Inability to obtain peripheral IV access required for critical interventions or investigations.
- Long-term administration of vasoactive substances (e.g., norepinephrine/epinephrine infusions).
- Administration of high-concentration or potentially caustic medications (e.g., hypertonic saline, concentrated or large volumes of potassium chloride).
- High-pressure or large-volume infusions, such as massive transfusions in trauma patients with hemorrhagic shock.
- Emergent dialysis or plasmapheresis access in patients without established arteriovenous fistulas or other dialysis-capable access.
- Transvenous pacemaker placement.
Contraindications
Although there are many benefits of US-guided venous access, some contraindications and considerations should be kept in mind [3,4,7]:
- Presence of cellulitis, burns, massive edema, or injuries at or proximal to the proposed insertion sites.
- Other injuries, diseases, or anatomical distortions of the affected limb/site that may lead to complications during or after access (e.g., compartment syndrome, extravasation, bleeding from neoplasms, etc.).
- Risk of compromised vascular flow distal to the site.
- Coagulopathy (considered a relative contraindication).
- A capacitated patient declines to undergo the procedure after demonstrating an understanding of the risks and benefits as explained by the care team.
Equipment and Patient Preparation
While the materials and equipment required for peripheral IV access are very similar to those needed for central vascular access, we have separated them into two lists to highlight some key differences. Regardless of the procedure, adherence to hand hygiene practices and the universal use of personal protective equipment are absolutely essential for every procedure.
Equipment for Peripheral IV Access
- Ultrasound machine equipped with a high-frequency linear probe.
- Examination gloves.
- Skin disinfectant (e.g., alcohol swabs, chlorhexidine swabs, povidone-iodine, etc.).
- Occlusive ultrasound probe cover.
- Sterile ultrasound gel.
- Elastic tourniquet.
- IV catheter.
- IV securement device and dressing.
- IV extension tubing and IV port.
- Normal saline flush.
- Sharps disposal device/container.
- Stool or chair (recommended).
Equipment for Central Venous Access
- Ultrasound machine with a high-frequency linear probe.
- Sterile gloves.
- Eye protection.
- Central Venous Catheter Kit (if available), which often includes:
- Sterile gown.
- Face mask.
- Bouffant or scrub cap.
- Skin disinfectant swabs (e.g., chlorhexidine, povidone-iodine, etc.).
- Vial of local anesthetic, needle, and syringe.
- 18-gauge introducer needle and syringe.
- #11-blade scalpel.
- Gauze.
- Guidewire.
- Dilator(s).
- Central venous catheter.
- Sterile saline flush syringes.
- Needle driver.
- Suture.
- Dressing.
- Sharps disposal hub.
- Sterile occlusive ultrasound probe cover sheath.
- Sterile ultrasound gel.
- IV ports.
Patient Preparation
Proper patient preparation is essential to ensure the accuracy of line placement and minimize patient discomfort or complications.
Introduction and Identification
Begin by introducing yourself to the patient and confirming their full name.
Patient History and Consent
Inquire about any allergies, phobias, or a history of fainting during previous IV line procedures. Clearly explain the purpose, benefits, and potential risks of the procedure in simple terms. Once the patient or their next of kin fully understands the information, obtain verbal consent. Note that written consent is not required in emergency situations unless mandated by institutional policy.
Alleviating Anxiety
Address any patient concerns and provide reassurance to help alleviate fear or anxiety. Ensuring the patient is calm can significantly improve their experience and the procedure’s success.
Procedure Steps
Here, we will describe the procedural steps for both ultrasound-guided peripheral intravenous access and ultrasound-guided central vascular access. For each procedure, ensure that the ultrasound machine and probes are in good working order and that there is sufficient power or a reliable power source to successfully and safely complete the procedure. Ultrasound probes should be disinfected before and after each use to protect both patients and providers from exposure to bloodborne and other pathogens, even when sterile probe covers are used. For an overview of the procedural steps for ultrasound-guided peripheral IV access, please review the accompanying video.
Image Acquisition in Vascular Access Procedures
Optimizing the image of the target vessel is critical for procedural safety and success in ultrasound-guided vascular access. This section will describe the general principles and equipment needed to obtain and optimize target visualization.
The high-frequency linear ultrasound probe is most commonly used for vascular access procedures as it provides high-resolution images of superficial structures in the body (Figure 2). Although this resolution comes at the cost of limited penetration into deeper tissues, this limitation is rarely an issue due to specific factors influencing the appropriate depth of target vessels for cannulation, as discussed below.
The next step is to ensure proper left-right probe orientation. This is accomplished prior to image acquisition by aligning the probe indicator on the ultrasound screen with the probe indicator on the linear probe itself. According to standard convention, the probe indicator on the device screen will appear as a dot, arrow, manufacturer logo, or other marking on the upper left side of the screen (Figure 3a).
The image nearest the probe indicator on the screen corresponds to the signal emitted from the probe transducer head closest to the physical probe indicator, typically a raised marking or similar feature. A simple technique to confirm orientation involves applying a small amount of ultrasound gel to one side of the probe face, touching this area with a gloved finger, and observing where the movement appears on the screen (Video 1). Once the two markers are aligned, rightward movement on the screen will correspond to movement away from the probe indicator in physical space.
Once orientation is established, perform a survey scan of the site. After applying an elastic tourniquet (if peripheral IV access is being attempted), position the probe perpendicular to the long axis of the extremity or the anticipated course of the target vessel (Figure 4).
This generates a “transverse,” “short-axis,” or “cross-sectional” image of the vessel. If the screen appears too dark to delineate structures, increase the gain setting to brighten the image. Conversely, if the screen is too bright, decrease the gain setting. Vessels should appear as circular structures with a dark or “anechoic” center, indicating blood within the lumen that allows the ultrasound beam to pass through easily (Figure 5).
Several critical aspects of the target vessel must be assessed during imaging to ensure suitability for cannulation, including vessel type (venous vs. arterial), diameter, depth, patency, and proximity to other structures.
Vessel Assessment: Begin by verifying that the target is a vein. Veins have thinner walls compared to arteries and are compressible. Gentle pressure applied to the vein should cause the walls to collapse inward and meet, confirming its venous nature. Compression also ensures there is no intraluminal obstruction, such as a venous clot (Video 2).
Video 2 – applying pressure to the vessels
Next, assess the vessel’s depth using the depth markers displayed on the ultrasound screen, which typically indicate depth in centimeters. For example, a vessel aligned with the second hash mark from the top of the screen would be located at a depth of 2 cm from the skin surface (Figure 6).
Once the depth is measured, determine the vessel diameter, which is essential for selecting the appropriate catheter size for peripheral IV access. Finally, rotate the transducer 90 degrees to visualize the vessel in its long axis, ensuring that the target location is not near a branch point or valve.
Catheter Selection: In peripheral IV access, depth and diameter measurements determine the appropriate catheter size. Peripheral IV catheters vary in diameter (gauge), with smaller gauge numbers indicating larger catheter diameters (e.g., 16G is larger than 22G). A vessel diameter greater than 4 mm (0.4 cm) can accommodate an 18G or smaller catheter without occlusion.
Catheters also come in various lengths, which affect their stability and suitability for deeper vessels. The depth of the target vessel determines the required catheter length, as longer catheters provide greater stability within the vein [2,3].
The needle length required to reach the target vessel can be approximated using the Pythagorean theorem:
a2 + b2 = c2,
where c represents the needle track (hypotenuse. figure 8), a is the vessel depth, and b is the distance from the probe to the needle insertion point. For example, for a vessel 1.2 cm deep with a needle insertion point 1.2 cm distal to the probe, the calculation would be:
1.22 + 1.22 = c2,
resulting in c = 1.69 cm. A simpler method is to multiply the vessel depth by 1.4 (e.g., 1.2 cm × 1.4 = 1.68 cm). To ensure catheter stability within the vein, use the following formula to estimate the necessary catheter length:
Catheter Length = (Vein Depth × 1.4) × 3
This formula accounts for 1/3 of the catheter length reaching the vessel and 2/3 residing within the vein lumen. For example, a 6 cm catheter should not be used for vessels deeper than 1.6 cm.
For peripheral venous access, the following characteristics define an appropriate target vessel for US-guided peripheral IV access:
- Easily compressible with light pressure applied using the ultrasound probe.
- Follows a straight path as it travels proximally.
- Lacks valves that would impede the passage of the cannula or flow after insertion.
- Diameter greater than 0.4 cm.
- Close to the skin surface, at a depth of less than 1.6 cm.
For central venous access, the same general principles apply. Regarding vessel diameter and depth, large-diameter vessels that are as superficial as possible are optimal. However, given the nature of these vessels in adult patients and the equipment used for central venous access, the exact parameters regarding diameter and depth mentioned for peripheral vein characteristics do not rigidly apply. Large-diameter vessels such as the internal jugular veins, subclavian veins, and femoral veins are preferred, and access should ideally be attempted at the point where the vessel is located as superficially as possible [4].
Regardless of whether peripheral or central IV access is utilized, the procedure under ultrasound guidance involves dynamically guiding the needle tip to prevent complications. Dynamic cannulation can be performed using either a transverse, out-of-plane approach or a longitudinal, in-plane approach. The transverse view, also known as the out-of-plane approach, is the most commonly used and involves visualizing the needle as a hyperechoic (bright) dot on the ultrasound screen. In contrast, the in-plane approach allows direct visualization of the entire needle length in a long-axis plane but is more challenging for novices, as the needle must remain within the ultrasound beam.
As the metallic needle within the catheter is hyperechoic, it appears as a white dot in the transverse plane and a long hyperechoic line in the longitudinal plane (Figure 9).
In the transverse plane, it is critical to track the needle tip as it pierces the ultrasound beam, as the appearance of the needle looks the same regardless of its position along the beam. This tracking is achieved by alternating movements of the transducer and the needle. By “leading” with the transducer, then advancing the needle, the tip can be visualized first. Once the needle is seen, advancement should pause, and the transducer should slide slightly proximal up the vein where the needle is no longer visible, after which the needle can be advanced again (Figure 10). This alternating movement allows visualization of the tip as it progresses through the soft tissue and can be repeated until the vein is cannulated (Video 3).
Video 3 – Walking down the vein
Once the needle is visualized within the vein, the transducer can be rotated to ensure that the needle tip is within the vein lumen and has not pierced the back wall of the vessel. This visualization also allows for redirection of the needle before catheter insertion, ensuring smooth placement when the catheter is advanced off the needle (Video 4). For central venous catheters, a guidewire is inserted after confirming the needle’s position within the vein lumen.
Video 4 – provided by authors
After successfully inserting the IV line, blood return should be verified, and the catheter should be secured in place. As a final confirmation, flush the line. For peripheral IVs, place the ultrasound transducer proximally from the IV site, flush the line, and observe for turbulence or a “glitter artifact” caused by fluid rushing through the vein (Video 5).
Video 5 – provided by authors
This step confirms successful IV cannulation and can also assist in troubleshooting. If the “glitter” does not appear within the vein, the IV catheter is outside the vessel and unusable. For central lines, this confirmation can be performed by visualizing the “glitter” artifact in the right ventricle using the subxiphoid plane within three seconds of flushing the distal port of the line (Video 6).
Video 6 – Glitter Artifact [the video was provided by authors]
Step by Step Guide for US-Guided Peripheral IV Access [3,8]
- Verify the identity of the patient who is to undergo IV access and explain the procedure to the patient/healthcare surrogate (when possible).
- Position the ultrasound machine on the same side of the patient as the operator.
- Don examination gloves.
- Clean the ultrasound probe with institution-approved disinfectant.
- Remove gloves and replace with clean gloves.
- Position stool/chair and adjust the ultrasound machine for the best screen viewing when obtaining access.
- Apply an elastic tourniquet proximal to the site to be screened for potential access sites.
- Apply ultrasound gel to the target area and orient the probe perpendicularly to the patient’s extremity to obtain a transverse/short-axis view of the target vessels.
- Orient the probe indicator to match the orientation displayed on the ultrasound screen, with both conventionally indicating the patient’s right side (Figure 3a).
- Assess potential veins for appropriate depth, diameter, and patency.
- Veins should:
- Be greater than or equal to 0.4 cm in diameter for an 18G catheter.
- Be less than 1.6 cm in depth for a 6 cm length catheter.
- Be easily compressible without evidence of clots, valves, or other obstructions to blood flow.
- Clean off ultrasound gel and release the tourniquet.
- Clean the selected site with skin disinfectant and allow it to air dry per manufacturer instructions.
- Set up supplies (prepare IV catheter, securement device, port, flush, and dressing).
- Cover the ultrasound probe with an occlusive cover.
- Avoid touching the head of the probe or the portion of the cover that will contact the patient’s skin.
- Reapply the tourniquet and ensure the patient’s arm remains in the appropriate position.
- Apply sterile ultrasound gel to the site.
- Do not touch the site with gloves or allow uncleaned materials/surfaces to come into contact with the site.
- If the site is potentially contaminated, remove the gel and clean the site again before attempting vascular access.
- Position the probe and locate the target vein again.
- At approximately a 45-degree angle, puncture the skin underneath the ultrasound probe head, observing on ultrasound for the needle tip in the subcutaneous tissue.
- Once the needle tip has been visualized, slide the probe proximally away from the needle tip.
- Once the needle tip is no longer visualized on ultrasound, carefully advance the needle in 1-2 mm increments until the needle tip returns into view on ultrasound.
- Repeat this alternating probe-needle advance until the needle has been advanced into the target vessel (Video 3).
- Decrease the angle of the needle as needed to continue advancing the needle in the alternating probe-needle manner within the vessel, keeping the needle tip in the center of the vessel lumen.
- Once the needle has been advanced several millimeters into the target vessel, anchor the hand holding the needle to ensure it does not advance further and lay down the ultrasound probe.
- Keeping the needle still, advance the catheter over the needle into the vessel.
- Once the catheter has been advanced, keep the catheter in place with the hand which advanced the catheter and use the other hand to carefully remove the needle.
- Ensure the safety needle capping mechanism on the needle has activated (if automatic upon needle removal from catheter) or activate the safety needle capping mechanism (if not designed to engage automatically) and dispose of the needle into a designated sharps container.
- Attach extension tubing and port to the catheter hub (some catheters come with the extension tubing and hub pre-attached).
- Clean any remaining ultrasound gel or blood from the access site and secure the catheter with an occlusive dressing.
- Attach a saline flush to the hub.
- If any air remains in the catheter extension tubing (if applicable), be sure to aspirate any air prior to attempting to flush the line.
- Retrieve the ultrasound probe and place it along the vessel proximal on the extremity to the catheter.
- After confirming the absence of air in the catheter and extension tubing, flush several cc’s of crystalloid solution through the catheter.
- If the catheter is in the correct position and functioning correctly, a “glitter” artifact effect should be visualized within several seconds of pushing the fluid through the catheter (Video 6).
- Dispose of supplies in appropriate containers and clean the ultrasound probe with disinfectant wipes.
- Remove gloves and wash hands.
- Document the access site in the patient’s chart, including site location, catheter gauge, time placed, and operator placing the line.
- Ensure you and your team frequently assess the site and extremity for evidence of extravasation, hematoma formation, or other complications.
Step by Step Guide for US-Guided Central Venous Access [4,9]
- Verify the identity of the patient who is to undergo IV access and explain the procedure to the patient/healthcare surrogate (when possible).
- Position the ultrasound machine on the opposite side of the patient as the operator in the operator’s line of sight.
- Don examination gloves.
- Clean the ultrasound probe with institution-approved disinfectant.
- Remove gloves and replace with clean gloves.
- Apply ultrasound gel to the target area and orient the probe perpendicularly to the patient’s extremity to obtain a transverse/short-axis view of the target vessels.
- Orient the probe indicator to match the orientation displayed on the ultrasound screen, with both conventionally indicating the patient’s right side (Figure 3a).
- Assess potential veins for appropriate depth, diameter, and patency:
- Veins should:
- Be greater than or equal to 0.4 cm in diameter for an 18G catheter.
- Be less than 1.6 cm in depth for a 6 cm length catheter.
- Be easily compressible without evidence of clots, valves, or other obstructions to blood flow.
- Clean off ultrasound gel.
- Clean the selected site with skin disinfectant and allow it to air dry per manufacturer instructions.
- Open the central venous catheter kit (or, if unavailable, establish a sterile field upon which to place sterile equipment).
- Don eye protection, face mask, and bouffant/scrub cap.
- Don a sterile gown and gloves.
- Drape the patient in a sterile fashion.
- Place the dominant hand within a sterile ultrasound probe cover (if rubber bands to secure the sheath to the probe are included, consider applying rubber bands around the thumb of the dominant hand before placing the hand within the sheath).
- Apply sterile gel to the inside of the sheath, which will contact the ultrasound probe head.
- Have an assistant pass the linear probe and grab the probe head with the dominant hand surrounded by the ultrasound probe sheath.
- Carefully extend the sheath around the probe. Once able, ask an assistant to grab the open end of the probe sheath and pull it toward them along the probe’s wire until it is well away from the sterile field. The assistant can gently release the probe wire now covered in the sheath, being careful not to let the contaminated end of the probe cover touch the sterile field.
- Apply the rubber bands (if applicable) to the head of the probe and smooth any air bubbles or irregularities which may have formed along the transducer surface while inserting the probe.
- Draw up several cc’s of local anesthetic into a syringe.
- Apply sterile ultrasound gel to the target site and confirm there has been no change in positioning of the target vessel during setup.
- Inject the local anesthetic into the skin and along the track of the needle to the target vessel, being sure to aspirate before each injection.
- It is recommended that the injection of the local anesthetic be performed under active ultrasound guidance to minimize the chance of accidental injection into the vessel and to confirm the anesthetic is applied along the intended tract of the needle.
- Ensure that air bubbles have been removed from the local anesthetic solution prior to injection, as these air bubbles will distort visualization of the target vessel area due to scattering of the ultrasound beam as it comes into contact with air.
- While the local anesthetic takes effect, flush the lumens of the catheter with saline to prevent the introduction of air into the patient’s vasculature and test that the guidewire feeds smoothly and is free of kinks or defects.
- With the introducer needle at an approximately 45-degree angle, puncture the skin underneath the ultrasound probe head, observing on ultrasound for the needle tip in the subcutaneous tissue.
- Once the needle tip has been visualized, slide the probe proximally away from the needle tip.
- Once the needle tip is no longer visualized on ultrasound, carefully advance the needle in 1-2 mm increments until the needle tip returns into view on ultrasound (Figure 8).
- Repeat this alternating probe-needle advance until the needle has been advanced into the target vessel, pulling back on the needle plunger to aspirate blood upon entry into the vessel.
- Decrease the angle of the needle as needed to continue advancing the needle in the alternating probe-needle manner within the vessel, keeping the needle tip in the center of the vessel lumen.
- Once the needle has been advanced several millimeters into the target vessel, anchor the hand holding the needle to ensure it does not advance further and lay down the ultrasound probe.
- Keeping the needle still, lay down the ultrasound probe, remove the syringe from the needle, and retrieve the guidewire.
- Advance the guidewire through the introducer needle approximately 20 cm, ensuring that it passes freely without resistance. If resistance is encountered, stop advancing immediately and assess the situation.
- Keeping one hand on the guidewire at all times, withdraw the introducer needle over the guidewire and place it in a sharps disposal device or bin.
- Confirm that the guidewire is in the target vessel using ultrasound to visualize the guidewire in the vessel in long-axis (Figure 9).
- Place gauze nearby the guidewire insertion site for use in the upcoming step.
- Place the dilator over the guidewire and advance it toward the skin, stopping several centimeters above the skin.
- Using the scalpel, make a small linear incision with the blade directed away from the guidewire and the patient. Consider placing gauze over the site after the incision to minimize bleeding.
- Using the dominant hand, insert the dilator to the approximate depth of the vessel visualized on ultrasound, using the other hand to hold the guidewire.
- It is recommended to use a twisting motion while advancing the dilator with the hand gripping the dilator just above the patient’s skin.
- Ensure that the guidewire remains stationary during dilatory insertion.
- Remove the dilator over the guidewire and thread the central venous catheter over the guidewire.
- Advance the catheter into the vessel over the guidewire while keeping one hand on the guidewire at all times.
- The guidewire should emerge from the distal port of the catheter (typically marked with a brown hub and located in the center of the available ports).
- Once the catheter has been placed at the appropriate depth into the target vessel, aspirate blood using a syringe from all ports to ensure patency.
- Flush all ports with saline to minimize the chance of clotting.
- Use the needle driver and suture to secure the line in place.
- Clean the site once more and apply an institution-approved antimicrobial dressing.
- If the line was placed in an internal jugular or subclavian vein site, obtain a post-procedural chest radiograph to confirm appropriate placement and assess for complications (e.g., pneumothorax).
Complications
Ultrasound-guided venous access, while generally safer than traditional landmark techniques, still carries potential complications, both for peripheral and central line placement.
Complications of US-Guided Peripheral IV Access [1-3,8]
Infiltration/Extravasation: This is a common complication where IV fluid or medication leaks into the surrounding tissue instead of flowing into the vein. It is a leading cause of catheter failure and may occur more frequently with deep brachial veins compared to other antecubital veins. Using a longer catheter can help minimize the risk of infiltration.
Catheter Dislodgement: Catheter dislodgement occurs when the catheter moves out of the vein, leading to loss of venous access and potential extravasation. This complication is more common with deep veins compared to superficial veins. To reduce the risk, it is essential to ensure that a sufficient length of the catheter is properly positioned within the vessel.
Thrombophlebitis: Thrombophlebitis refers to the inflammation of the vein, which may occur during or after IV placement.
Infection: Although studies have shown no increased infection rates with ultrasound guidance compared to traditional methods, the risk of infection remains. Using sterile gel and adhering to proper cleaning techniques can significantly reduce this risk.
Damage to Adjacent Structures: There is a risk of damaging nearby structures, such as arteries and nerves, during peripheral IV placement. This risk is heightened when using deep veins, which are often located closer to these critical structures.
Posterior Vessel Wall Puncture: The short-axis technique, commonly used during ultrasound-guided IV access, has been associated with a higher risk of puncturing the posterior (back) wall of the vessel.
Hematoma: Bleeding and hematoma formation can occur as a result of vein trauma during catheter placement.
Premature Catheter Failure (PCF): Premature catheter failure occurs when the catheter fails within 24 hours of placement. Studies suggest that PCF rates are higher in ultrasound-guided cannulations compared to traditional methods. Common causes include infiltration, dislodgement, and thrombophlebitis.
Complications of Ultrasound-Guided Central Venous Catheter (CVC) Access [4,9,10]
Arterial Puncture/Cannulation: Accidental puncture or cannulation of an artery, such as the carotid artery during internal jugular vein access, is a serious complication. This risk can be mitigated by using real-time ultrasound guidance and ensuring careful visualization of surrounding structures.
Hematoma: Bleeding and hematoma formation are potential complications during central venous catheter placement, especially if there is accidental puncture of surrounding tissues.
Pneumothorax: A collapsed lung (pneumothorax) is a known complication, particularly during subclavian vein access. Ensuring proper technique and real-time imaging can help reduce this risk.
Hemothorax: Bleeding into the pleural space (hemothorax) may occur during central venous access, especially if there is inadvertent damage to vascular structures near the pleural cavity.
Infection: Catheter-related bloodstream infections are a significant risk associated with central lines. Adherence to strict aseptic technique, including the use of sterile drapes, gloves, and probe covers, is essential to minimize this risk.
Thrombosis: Deep vein thrombosis and catheter-related bloodstream infections can occur as a result of CVC placement. Proper placement, routine monitoring, and prompt intervention are critical in reducing this risk.
Nerve Injury: There is a risk of nerve damage, such as brachial plexus injury, during internal jugular vein catheterization. Careful visualization of anatomical landmarks using ultrasound is critical to avoid this complication.
Catheter Malposition: The catheter may be unintentionally placed in an incorrect location, leading to functional and clinical complications. Real-time imaging during and after placement can ensure proper positioning of the catheter.
Air embolism: It is a rare but serious complication associated with both peripheral and central vein catheterization, which can cause significant neurological deficits and seizures if not promptly diagnosed and treated. The pathophysiology involves air entering the venous system due to a pressure gradient between the atmosphere and the veins, which can occur during catheter insertion, maintenance, or removal. The risk of air embolism is heightened by improper patient positioning. In cases of massive air embolism, immediate interventions such as resuscitation, positioning the patient in the left lateral decubitus and Trendelenburg position, and using hyperbaric oxygen therapy or extracorporeal membrane oxygenation can be life-saving.
Hints and Pitfalls
Universal safety precautions are critical for every procedure. This includes the consistent use of personal protective equipment (PPE) and cleaning all equipment before and after use. These practices are essential to protect both the operator and the patient from harm, including the risk of infections or cross-contamination.
Preparation is paramount to ensuring procedural success and minimizing complications. Proper assessment of the target vessel, including its depth, diameter, and patency, along with setting up the necessary equipment in advance, significantly increases the chances of success during cannulation. Needle tip visualization is also crucial throughout the procedure to prevent iatrogenic injuries caused by inadvertently advancing the needle tip into non-target structures near the vessel.
If a cannulation attempt fails or if the intravenous (IV) line fails due to infiltration, subsequent attempts should ideally be made at a different site to avoid cumulative damage to the same area. If a new site cannot be used, attempts should occur proximal to the initial site.
Strategies to Reduce Complications [1-3, 7-10]
Adequate training is a cornerstone of safe and successful ultrasound-guided venous access. Providers must be proficient in real-time ultrasound guidance techniques, which allow precise needle advancement and proper placement. Additionally, sterile technique is essential during all stages of the procedure, including the use of sterile gel and probe covers to minimize infection risk.
Choosing the appropriate vein for cannulation is another key strategy to reduce complications. This decision should be based on careful vein selection, including evaluating its accessibility and suitability for the intended catheter size. Proper catheter length and size selection are equally important, with tools like the Pythagorean theorem aiding in determining the optimal catheter length for stable placement within the vessel.
Visualization of the needle tip during insertion is vital to avoid injury to surrounding structures. The long-axis approach can provide continuous visualization of the needle tip, ensuring accurate placement within the vessel lumen. After catheter placement, ultrasound can confirm the catheter’s position and patency, reducing the risk of complications such as malposition or infiltration.
Post-procedural monitoring is just as important as the procedure itself. Regular assessment of the insertion site is necessary to detect early signs of infection, thrombophlebitis, or other complications, allowing for timely intervention if needed.
Special Patient Groups
Pediatrics
US-guided venous access in pediatric patients has been shown to significantly enhance the success rates and reduce complications associated with vascular access procedures. A retrospective analysis of 1028 US-guided central vascular access procedures in children demonstrated a high success rate of 97.2%, with the left brachiocephalic vein showing a higher success rate than the right [11]. The integration of ultrasound guidance in pediatric venous access procedures is associated with improved outcomes, emphasizing its role as a preferred method in clinical practice.
Geriatrics
US-guided venous access in geriatric patients has been shown to be a highly effective and safe method for catheter placement. The use of ultrasound guidance significantly reduces failure (success rate of 96.36%) and complication rates (7.27%) [12]. US-guided peripherally inserted central catheter insertion in elderly patients also reported high success rate, with minimal complications [13]. The use of ultrasound guidance for internal jugular vein catheterization further supports its efficacy in reducing failure and complication rates for central venous port placement [14]. Overall, the integration of ultrasound guidance in venous access procedures for geriatric patients enhances safety, reliability, and patient outcomes, making it a valuable tool in the management of this vulnerable population [12-14].
Pregnant patients
US-guided venous access provides significant benefits for pregnant patients, particularly by reducing complications and improving procedural success. Real-time ultrasonographic imaging enables clear visualization of target vessels, which is especially critical in cases of challenging anatomy during pregnancy [15]. This approach aligns with the growing adoption of point-of-care ultrasound (POCUS) to enhance success rates in both peripheral and central venous catheterization. By improving patient safety and minimizing complications, ultrasound guidance has become an essential tool for optimizing venous access procedures and ensuring safer care for pregnant patients [16].
Authors
Zackary Funk
Petra Duran-Gehring
Petra Duran-Gehring M.D., graduated from medical school at LSU Health Sciences Center in New Orleans, and completed her residency in emergency medicine at the University of Florida College of Medicine – Jacksonville. She achieved certification through the American Registry of Diagnostic Medical Sonographers and founded the emergency ultrasound program for the department of emergency Medicine at UFCOMJ. She is a nationally recognized leader in emergency ultrasound education and research, including serving as co-director of the ACEP Ultrasound Management Course, and director for the SEMPA Ultrasound Course. She has lectured throughout the country, and has received numerous teaching awards. When not teaching ultrasound, she loves spending time with her husband and three young sons.
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References
- Duran-Gehring P. Ultrasound-Guided IV Access. The Essential Emergency Ultrasound Course; 2019. Accessed August 5, 2023.
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Reviewed and Edited By
Arif Alper Cevik, MD, FEMAT, FIFEM
Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.
