Ultrasound Guidance for Central Venous Catheter Placement · phy. The Seldinger technique for central venous cath-eter (CVC) placement is ubiquitous in medical prac-tice and the procedure

n 1952, Sven-Ivar Seldinger developed an innova-tive technique for the percutaneous insertion oflarge-bore catheters into blood vessels that allowedfor the application of angiocatheters for angiogra-

phy. The Seldinger technique for central venous cath-eter (CVC) placement is ubiquitous in medical prac-tice and the procedure is well known. Briefly, theprocedure involves introducing a percutaneous needleinto the vessel, passing a guidewire through the needle,and then placing the catheter over the guidewire andinserting it into the blood vessel. In addition to revolu-tionizing the fields of cardiology and interventionalradiology, this technique has had a profound impactthrough its contribution to the development of centralvenous infusion catheters.1

CVC placement is common in the United States, withan estimated several million catheters placed annually.2

Data from the European Prevalence of Infection inIntensive Care study, which included 10,038 patient casereports, showed that 78% of critically ill patients had aCVC placed.3

Traditionally, the site of initial needle insertion dur-ing CVC placement is determined by using palpable orvisible anatomic structures with known relationships tothe desired vein as landmarks.1 However, ultrasound isincreasingly being used to identify vessels and guide nee-dle insertion for CVC placement. Real-time ultrasound-guided CVC placement is employed by a variety of med-ical specialties, and there is ample support for its use inthe medical literature.4–10 This review discusses the prac-tice and techniques of real-time ultrasound guidancefor CVC insertion.

EVIDENCE FOR UTILITY OF ULTRASOUND GUIDANCE

The clinical utility of CVC placement is well estab-lished, but its associated complications are an importantconsideration given the prevalence of this technique.Evidence has shown that landmark-guided percutane-ous CVC insertion is associated with significant compli-cations, including arterial puncture, pneumothorax,hemothorax, brachial plexus injury, and catheter malpo-

sition.11 – 13 The frequency of these complications isdependent on such factors as selection of insertion site,operator experience, and patient anatomy.12,14

Studies have established the indications and benefitsof employing ultrasound guidance for CVC placementin a range of clinical settings (eg, intensive care units,emergency departments).15–17 Most of these studieshave explored and supported the utility of ultrasound-guided access for the internal jugular vein (IJV), particu-larly in the pediatric population.4,5 Several meta-analysesthat reviewed landmark versus ultrasound-guided IJV

Dr. Gibbs is director of emergency ultrasound, Department of EmergencyMedicine, Rhode Island Hospital, Providence, RI, and an assistant profes-sor of emergency medicine, Brown Medical School, Providence, RI. Dr.Murphy is a resident physician in emergency medicine, Rhode Island Hos-pital, Providence, RI.

www.turner-white.com Hospital Physician March 2006 23

C l i n i c a l R e v i e w A r t i c l e

Ultrasound Guidance for Central Venous Catheter Placement

Frantz J. Gibbs, MD, FACEPMichael C. Murphy, MD

I TAKE HOME POINTS

• Landmark-guided central venous catheter (CVC)placement is associated with significant complica-tions, including arterial puncture.

• Ultrasound-guided CVC placement is associatedwith reductions in complications, mean insertionattempts, and placement failure rates.

• Specific groups of patients, such as those with pooranatomic landmarks or coagulopathies, particular-ly benefit from the use of ultrasound to guide CVCplacement.

• Short-axis and long-axis sonographic views aremost useful in targeting and cannulating a prospec-tive vessel.

• Ultrasound guidance enables direct visualization ofneedle advancement and entrance into the targetvessel to accomplish the Seldinger technique forcentral venous catheterization.

CVC placement demonstrated significant relative riskreductions in complications, mean insertion attempts,and failed catheter insertions when ultrasound was em-ployed.7,18,19 Additional studies that demonstrated thebenefits of ultrasound guidance for IJV CVC placementare reviewed in the following section (Indications forUltrasound Guidance).

Relatively few studies have explored the utility ofultrasound-guided access to the femoral vein. In a smallprospective, randomized study that examined ultra-sound for identifying and accessing the femoral vein,this technique significantly reduced the number ofvenipuncture attempts (2.3 versus 5.0; P = 0.0057) andthe rate of complications (0% versus 20%; P = 0.025).20

There are few studies of ultrasound guidance for thesupraclavicular and infraclavicular axillary approaches,and more studies examining the feasibility of thesetechniques are needed before they can be recommend-ed.7,18,19 A randomized controlled study compared thelandmark and ultrasound-guided techniques for in-fraclavicular subclavian vein catheter placement. Theultrasound group had a significantly higher success rate(92% versus 44%; P = 0.003), lower complication rate(4% versus 41%; P = 0.002), and fewer venipuncturesbefore access was attained (1.4 versus 2.5; P = 0.0007).21

In addition, 80% of failed landmark-guided attemptswere salvaged by use of ultrasound.

INDICATIONS FOR ULTRASOUND GUIDANCE

Real-time ultrasound guidance for CVC insertion isindicated to ameliorate the risks associated with thelandmark-guided technique. A 1996 meta-analysisfound that compared with the landmark technique, ul-trasound guidance resulted in a significant reductionin CVC placement failures (relative risk, 0.32) andcomplications during placement (relative risk, 0.22).9

In a prospective study comparing the ultrasound andlandmark techniques, the rate of carotid artery punc-ture decreased by approximately 7% with ultrasoundguidance.22 In a study that evaluated IJV cannulation ininfants, the incidence of carotid artery punctures was25% in the landmark group, while no punctures oc-curred in the ultrasound group (P < 0.0001).5

Ultrasound guidance may also be indicated for clini-cal scenarios requiring expedient and efficient place-ment of a CVC. In a prospective study of the 2 tech-niques for IJV access,23 the ultrasound group had asignificantly shorter average access time (9.8 s versus44.5 s; P < 0.0001) and a higher proportion of successfulcannulations on the first attempt (77.8% versus 38.4%; P < 0.001). Verghese et al5 also found that ultrasound-guided cannulation of the IJV was superior to the land-

mark technique in terms of overall success (100% versus77%) and speed (10 min versus 3.3 min). Hrics et al15

performed a prospective study of ultrasound-guided IJVcannulation in patients requiring urgent intravenousvasopressors, fluids, and pacing in the emergency de-partment. Compared with the landmark technique,ultrasound guidance led to significantly higher rates ofsuccessful first attempts (50% versus 12.5%) and com-pleted cannulations (81.3% versus 62.5%).

There are specific groups of patients in which landmark-guided access could be considered relativelycontraindicated if ultrasound guidance is available. Skol-nick24 recommended that CVC placement should be per-formed under sonographic guidance if patients areobese or have a swollen neck or upper extremity thatwould obscure anatomic landmarks; this author alsonoted that ultrasound guidance has benefits in patientswith coagulopathies and patients being treated with anti-coagulants. Denys and Uretsky23 recommended consid-ering ultrasound-guided access in patients with shortnecks, patients with Cushingoid appearance, and pa-tients who have undergone surgical interventions or radi-ation therapy to the neck area that may alter landmarksand anatomy. Fry et al25 expanded these recommenda-tions to include patients who are unable to assume thesupine position, those who are hypovolemic, and thosewith severe respiratory compromise. The aforemen-tioned classes of patients are reasonably considered to bewithin the “difficult access” category, and ultrasound hasbeen shown to facilitate a higher success rate and lowercomplication rate in these patient groups.8

EQUIPMENTB-Mode Ultrasound

B-Mode ultrasound allows for detailed evaluation ofvascular anatomy and structural characteristics and hasbeen employed to outline the vascular system and lo-cate blood vessels. This modality can provide informa-tion on vessel size, the presence of luminal obstruc-tions, and morphologic abnormalities. As a real-timeimaging modality, ultrasound can update image framesat a rate of at least 30 frames per second, which allowsthe operator to visualize vessel compliance and observechanges in vessel caliber when variable pressure is ap-plied to the overlying tissue.26

The tissues comprising vascular structures determinetheir sonographic appearance. With thicker tunica me-dia and generous smooth muscle walls, arteries appearto have relatively thick hyperechoic (white) walls and ane-choic (black) lumens. Veins, which consist of less smoothmuscle and have more compliant walls, appear to havethin hypoechoic (grey) walls and an anechoic lumen

24 Hospital Physician March 2006 www.turner-white.com

G i b b s & M u r p h y : U l t r a s o u n d - G u i d e d C V C P l a c e m e n t : p p . 2 3 – 3 1

(Figure 1). The ability to compress and collapse theveins is a particularly useful characteristic that helps dis-tinguish between arterial and venous images.27

Transducer

The ultrasound transducer is the component of theultrasound system that contacts the patient and is heldwithin the sonographer’s hand. The transducer emitsultrasound energy into biologic tissues and detects thereflected echoes, which are then processed into sono-graphic images. The essential components of the trans-ducer are the housing, an electrode, backing material,piezoelectric crystals, and a matching layer. The piezo-electric crystal elements in an ultrasound transducerare made of a ceramic material and usually consist oflead zirconate titanate, a material that shows a markedpiezoelectric effect. Arrayed within the transducer, thecrystals mediate the conversion of electrical energyinto mechanical vibration energy to produce the ultra-sound waves. The crystals then convert the returningultrasound echoes into small electrical signals.28 Thebacking material and matching layers, located oneither side of the piezoelectric material, regulate theemission of ultrasound energy.29

Transducers differ in terms of the size and positionof their contact surface (ie, footprint) and the orienta-tion of the sonographic beam emitted. Linear trans-ducers provide optimal visualization of vascular struc-tures and greatly facilitate ultrasound-guided venousaccess. Linear transducers have a flat footprint and typ-ically allow for a larger sonographic field of view in thenear field of the ultrasound image compared withother types of transducers (ie, sector and curvilineartransducers). Moreover, due to their linear arrays ofpiezoelectric crystals, linear transducers allow the oper-ator to focus the ultrasound beam at various depths,which increases their utility in tracking and cannulat-ing prospective vessels.29

A 7.5-MHz linear transducer is most often used forultrasound-guided CVC placement,18 although trans-ducers in the range of 6 to 10 MHz are also suitable.These high-frequency transducers facilitate imagingof superficial structures and allow more accurate real-time monitoring of the advancing needle employed inCVC placements.26 To ensure appropriate imagingand ultrasound resolution, the highest frequencyshould be selected to maximize definition of the vesselimage while maintaining adequate depth penetrationof the ultrasound signal. Moreover, the ultrasoundbeam should be directed essentially perpendicular tothe vessel.

Sterile Barriers

Maintenance of sterile technique is imperative in allCVC placement procedures due to the potential mor-bidity and mortality associated with catheter-relatedinfections.2 Sterile barriers manufactured to facilitatethe preservation of a sterile field during an ultrasound-guided procedure are usually designed to cover boththe transducer and its cable. Many types of transducercovers are available, and they are usually made of rub-ber or plastic materials. An assistant is required to prop-erly prepare and set up a sterile sheath, but once inplace it often can be maintained by a single operator.23

When specifically designed sheath barriers are not avail-able, alternative barriers can be used. The most com-monly used alternative is a sterile glove, although bootcovers intended for use with endovaginal ultrasoundprobes may also be used for linear transducers.30

Needles

There are no set requirements for needle types usedin CVC placement, and preference is often operator orprocedure dependent. The main caveat to keep inmind is that needles must be of a sufficient gauge toallow passage of the guide wire (ie, from 18 to 21 gaugeto allow passage of 0.35 to 0.0018 in guidewires).31,32

The needle tip is highly echogenic, and is moreechogenic than the shaft.33 It is hypothesized that thesecharacteristics arise from the abrupt discontinuity in thehomogeneously reflecting shaft and that the needle tipechoes likely arise from reflection produced at the tipof the needle and proximal edge of the beveled open-ing.33 In general, the needle tip and shaft have a hyper-echoic sonographic image. Because ultrasound beams



Figure 1. Thick hyperechoic arterial vessel wall (arrowhead)and thin hypoechoic venous wall (arrow). Both vessels haveanechoic lumens.

may be scattered and not pass through the needle, ashadow or loss of signal (appearing grey or black) maysometimes be seen posterior to the needle image.34

More often, a sonographic artifact termed reverbera-tion, or ring-down, is seen posterior to the needle im-age; it appears as a linear formation of evenly spacedgrey or white echoes (Figure 2).35

Needle tip echogenicity and shaft visualization areinfluenced by needle gauge, the position of the needlebevel, and the angle of the needle in relation to thetransducer. Needle gauge has been shown to correlatepositively with a more prominent needle tip echo andability to visualize the needle.36,37 Using A-mode and B-mode ultrasonography, Bondestam and Kreula36

demonstrated a linear and exponential increase in theintensity of standard needle tip echoes (P < 0.001) withincreasing needle diameter. Studies have also shownthat greater tip visualization can be achieved by posi-tioning the bevel opening toward or away from thetransducer, and more intense needle shaft reverb-erations can be achieved with an angle of needle ap-proach between 30 and 60 degrees.36,37 Measuring vary-ing angles of standard needle rotation and angles ofneedle approach, Hopkins and Bradley37 confirmedthat positioning the bevel opening parallel to the ultra-sound signal significantly improved visibility (P = 0.01)and that a needle-to-transducer angle of 20 degrees orless diminished needle echo intensity (P = 0.0001).

Procedure needles may be echogenically enhancedto improve ultrasonographic visualization of the needleshaft and tip. Commercially available needles that arecoated, dimpled, or notched have been shown to haveincreased needle echogenicity compared with smoothstandard needles.38 Moreover, enhanced needles havethe advantage of maintaining adequate visibility when

smaller gauge needles are used and in circumstanceswhen a less than ideal needle-to-transducer angle mustbe used.37,38

Mechanical Guides

Mechanical guides are manufactured to help the ul-trasonographer position and advance the needle whenattempting vascular access under ultrasound guidance.There are 2 types of mechanical guides: (1) a built-inneedle slot located centrally or laterally on the ultra-sound transducer itself, and (2) an attachment fitted tothe transducer that contains a slot to assist with anglingthe needle. Guides are useful for the less experiencedoperator because they provide stability to the advanc-ing needle, provide a fixed, predictable, uniform tra-jectory in relation to the transducer, and direct theneedle in a plane in line with the focused ultrasoundbeam.21,23 Typically, they are built with a specific angula-tion such that the needle will intersect in the center ofthe ultrasound beam at a specific depth below thetransducer surface.

Mechanical guides have some notable disadvan-tages.39 They represent an additional expense, they addbulk to the transducer, and they restrict the needle to afixed presentation, thus preventing operator redirection.In addition, attachment mechanical guides are producedby companies that manufacture linear transducers, andmost are manufactured to attach only to a specific trans-ducer. When using a mechanical guide in associationwith the ultrasound machine, specific needle gauges ortypes may be required for proper use. Therefore, opera-tors should review the preferences recommended by thespecific mechanical guide manufacturer.39,40

ULTRASOUND-GUIDED TECHNIQUESVessel Visualization: Short-Axis Versus Long-Axis Views

Short-axis and long-axis views are most useful in tar-geting and cannulating a prospective vessel. The short-axis view provides visualization of the vessel in thetransverse plane and is produced by placing the longaxis of the transducer perpendicular to the long axis ofthe vessel. When this view is obtained correctly, thevein with its corresponding artery should appear circu-lar or oval in shape (Figure 3). When the transducer iscentered over the target vein, the midpoint of thetransducer becomes a reference point for introductionof the access needle. Transducers often have a markerthat designates this reference point, facilitating local-ization of a puncture site and approach.23,32

The long-axis view provides visualization of the pro-spective vessel in the longitudinal plane. This view is ob-tained by placing the transducer over the vessel so that



Figure 2. Hyperechoic needle tip (arrowhead) with ring-down artifact (arrow).

the long axis of the transducer is parallel to the long axisof the vessel, producing a sonographic image of the ves-sel along its length. The transducer is then oriented toview the vessel at its greatest anterior-posterior diameter(Figure 4).41 Unlike the short-axis view, the long-axisview allows only a single vessel to be maintained in thefield of view and cannot be used to define the anatomicrelationship between the vessels. Therefore, when usingthis view, confirmation of vessel type prior to cannula-tion is particularly essential because slight changes in theangle of the transducer may inappropriately target theaccompanying artery.

General Approaches to Ultrasound-Guided VascularAccess

This section reviews the standard access techniquesthat are applicable to a real-time ultrasound-guided cen-tral venous access procedure irrespective of access site.

Short-axis approach. Preparation for sterile techniqueincludes placing the transducer into a sterile sheath con-taining conducting medium at its tip and rolling the ster-ile sheath back over the transducer and cable. The trans-ducer is then positioned to obtain short-axis views of theprospective vein and plan the approach. The skin entrysite and angle of needle presentation should be chosento maximize the chances that, as the needle tip touchesthe vessel wall, it will intersect the scan plane of the trans-ducer. Abboud et al41 recommend that the operatorpierce the skin with the needle placed at an angle of atleast 45 degrees to the transducer. Nemcek42 agrees withthis angulation and recommends piercing the skin sur-face at a distance from the transducer that is equal to thedistance between the vessel and the transducer. Forexample, if the vessel is 1 cm deep, he recommendsentering the skin surface at a 45 degree angle 1 cm awayfrom the transducer (Figure 5).

Once adequate local anesthesia is injected overlyingthe access site, skin puncture utilizing a sterile needlemay commence. Upon puncturing the skin, the opera-tor should identify the hyperechoic needle image onthe monitor. In this approach, the needle is perpendic-ular to the ultrasound signal. Because the ultrasoundsignal only interacts with a cross-section of the needle,the needle tip or shaft will appear as a hypoechoic(grey) or hyperechoic (white) point in the field of view(Figure 6). As noted earlier, the needle tip echo willoften have greater intensity than the shaft.33

The needle is advanced toward the target vessel and,ideally, the operator should directly visualize entrance ofthe needle into the vessel. Fine adjustments should bemade continually in both the direction of advancementof the needle and in the transducer’s angle and field ofview. When the needle comes into contact with the ante-rior wall of the vessel, the operator may see a “tenting” ofthe vessel wall (Figure 7). The vein collapses slightly just



Figure 3. Short-axis image of internal jugular vein (arrows). Figure 4. Long-axis image of internal jugular vein (arrow-heads).

Figure 5. Needle orientation in short-axis approach.

before puncture and then reexpands after entry of theneedle into the vessel. A concurrent flash of bloodshould be noted in the syringe upon aspiration. Visuali-zation of the needle tip echo within the vessel lumen mayprovide final confirmation of needle entry (Figure 8).However, the needle tip may not always be clearly visual-ized, and vessel tenting, or distortion, may be the onlyindication of location. Once the vessel has been accessed,the transducer may be released and standard asepticcatheter introduction can proceed.15,23,30

Long-axis approach. In this approach, the vein to becatheterized is identified and the access site and trans-ducer are prepared for sterile technique as describedearlier. The transducer is then positioned to obtain an

appropriate long-axis view of the vessel. When utilizingthe long-axis approach, Abboud et al41 recommendpiercing the skin just outside one of the edges of thetransducer and inserting the needle at a 30 degree angle(Figure 9) to the skin surface. As they are introduced,the needle tip and shaft will be visualized along theircourse due to the wider sonographic view provided bythe long-axis view (Figure 10).24,42 The needle is ad-vanced in a plane aligned with the long axis of the trans-ducer, which as mentioned previously should centerover the vessel in its longitudinal axis. Imaging the nee-dle puncture and aspiration of venous blood confirmaccess to the vessel (Figure 11). As noted earlier, the veinwill undergo mild deformation as the needle contactsthe vessel wall just prior to needle penetration. Catheter-ization then proceeds and is completed.

The long-axis approach presents certain disadvan-tages. Body contour changes, such as at the neck orgroin in protuberant patients, may make it challengingto place the transducer longitudinally and still enterthe vessel with the advancing needle in a satisfactoryposition. Furthermore, in some cases the presentingneedle may actually push the vessel away or slip off ofthe vessel. Some operators find that a short-axis ap-proach allows easier real-time needle position andpressure adjustment to better address these concerns.42

Blaivas et al43 compared the 2 approaches in an inani-mate model and found that novice emergency medi-cine resident operators could perform cannulationmore quickly using the short-axis approach (short-axismean time, 2.36 min; long-axis mean time, 5.02 min; P = 0.03). However, there were no statistical differencesfound in respect to mean difficulty, number of at-tempts, and mean number of needle redirections inthis study.



Figure 6. Short-axis view: hyperechoic needle tip (arrow)above vessel.

Figure 7. Short-axis view: needle tip deforming vessel wall(arrow).

Figure 8. Short-axis view: hyperechoic needle within vessellumen (arrow).

Techniques for Accessing Specific Vessels

The following sections describe technical aspectsspecific to ultrasound-guided venous access of the IJV,subclavian vein, and femoral vein, including position-ing of the patient and placement of the transducer.These specific techniques are rooted in the generaltechniques described above.

IJV. Typically, the IJV lies anterior and slightly lateralto the carotid artery (CA). However, anatomic varia-tions that make blind insertion techniques more com-plicated have been reported to occur in up to 5.5% ofpatients.23 A sonographic study of the vessels of theneck found that the IJV overlays the CA in 54% ofcases,22 an anatomic orientation that predisposes to CApuncture if the cannulating needle traverses the IJV.44

Preparation for IJV catheterization entails positioningthe patient in the Trendelenburg position with a 30-degree head rotation, thereby distending the prospec-tive vein and reducing the risk of air embolism. Thetransducer should be placed just cephalad to the clavicleat the insertion of the 2 heads of the sternocleidomastoidmuscle. The long axis of the transducer may be placedparallel and superior to the clavicle, thereby producing ashort-axis view of the blood vessel. Skolnick24 noted thatwhen ultrasound guidance is used the IJV can be punc-tured at a site farther cephalad on the neck than whenthe landmark technique is used.

Femoral vein. The approximate position of the fem-oral vein can be determined by dividing the distancebetween the anterior superior iliac spine and the pubictubercle into thirds. In most patients, the femoral arterylies at the midpoint of the middle third, and the fem-oral vein lies just medial to the femoral artery.45 As withthe IJV, there are variations in anatomic positioning

and alignment, with a recent study reviewing computedtomography scans of the pelvis in 100 patients showingthat a portion of the femoral vein and the femoralartery overlap in an anteroposterior plane 65% of thetime.46

In preparing for CVC placement, the patient shouldbe placed in a supine position with the ipsilateral hipin a slight to fully externally rotated position.45 Thetransducer is placed a few centimeters distal to theinguinal ligament. Often, the long axis of the transduc-er is oriented parallel to the inguinal ligament toachieve a short-axis view of the femoral vessels. Oncethe arterial and venous structures are identified anddifferentiated, the transducer should be centered onthe target vein for needle guidance.20

Subclavian vein. The subclavian vein typically lies



Figure 9. Needle orientation in long-axis approach.Figure 10. Long-axis view: needle deforming vessel wall(arrow).

Figure 11. Long-axis view: hyperechoic needle within vessellumen (arrow).

adjacent to the subclavian artery in an inferior andanterior position. It originates from the axillary vein atthe site of the first rib and extends to its junction withthe internal jugular vein. Anatomically, it lies close toimportant structures, such as the lung, pleura, subcla-vian artery, and brachial plexus.47,48 Two approaches toultrasound-guided subclavian vein access have beendescribed: the supraclavicular approach and the infra-clavicular axillary approach. The supraclavicular ap-proach requires holding the transducer just superior tothe clavicle with sufficient pressure to provide adequateimages. Patients often describe this procedure as un-comfortable due to the constant pressure over the clav-icle. In addition, there is limited anatomic space forconcurrent placement of the transducer and introduc-tion of the needle.41

The ultrasound-guided infraclavicular techniqueutilizes a more lateral approach. Cannulation may oc-cur at the level of the axillary vein to provide access tothe subclavian vein. The patient is placed in a supineposition in 15 degrees Trendelenburg, with the ipsilat-eral arm abducted 45 degrees from the trunk.47 The lit-erature describing this technique is fairly limited. Arandomized controlled study compared the landmarktechnique and ultrasound-guided technique for infra-clavicular subclavian vein catheter placement.21 Thesite was imaged to view the axillary vessels just caudal tothe lateral aspect of the clavicle. The artery tended tobe more cephalad than the vein. Once the vein wasidentified in short axis, it was imaged along its course 2 cm more medially to ensure that normal anatomywas present up to the point of the prospective needleinsertion site. A mechanical guide was used to guidethe needle. Due to the more distal insertion site andlonger trajectory to the central circulation, a catheter20 to 25 cm long was used and is recommended.21

CONCLUSION

Central venous catheter placement under ultra-sound guidance is widely supported in current medicalpractice. This technique has been shown to ensure safeand timely catheter placement and to reduce many ofthe potential complications associated with anatomiclandmark methods. Through adherence to basic prin-ciples of ultrasonography, clinicians may readily incor-porate the techniques presented in this review andenhance venous access performance. HP

REFERENCES1. Greitz T. Sven-Ivar Seldinger. AJNR Am J Neuroradiol

1999;20:1180–1.2. Mermel LA, Farr BM, Sherertz RJ, et al. Guidelines for the

management of intravascular catheter-related infections.Infectious Diseases Society of America, American Collegeof Critical Care Medicine, Society for Healthcare Epidem-iology of America. Clin Infect Dis 2001;32:1249–72.

3. Vincent JL, Bihari DJ, Suter PM, et al. The prevalence ofnosocomial infection in intensive care units in Europe.Results of the European Prevalence of Infection in In-tensive Care (EPIC) Study. EPIC International AdvisoryCommittee. JAMA 1995;274:639–44.

4. Etheridge SP, Berry JM, Krabill KA, Braunlin EA. Echo-cardiographic-guided internal jugular venous cannula-tion in children with heart disease. Arch Pediatr AdolescMed 1995;149:77–80.

5. Verghese ST, McGill WA, Patel RI, et al. Ultrasound-guided internal jugular venous cannulation in infants: aprospective comparison with the traditional palpationmethod. Anesthesiology 1999;91:71–7.

6. Alderson PJ, Burrows FA, Stemp LI, Holtby HM. Use ofultrasound to evaluate internal jugular vein anatomyand to facilitate central venous cannulation in paediatricpatients. Br J Anaesth 1993;70:145–8.

7. Hind D, Calvert N, McWilliams R, et al. Ultrasonic locat-ing devices for central venous cannulation: meta-analysis.BMJ 2003;327:361.

8. Hatfield A, Bodenham A. Portable ultrasound for diffi-cult central venous access. Br J Anaesth 1999;82:822–6.

9. Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ul-trasound guidance for placement of central venouscatheters: a meta-analysis of the literature. Crit CareMed 1996;24:2053–8.

10. Kwon TH, Kim YL, Cho DK. Ultrasound-guided cannu-lation of the femoral vein for acute haemodialysis access.Nephrol Dial Transplant 1997;12:1009–12.

11. Mansfield PF, Hohn DC, Fornage BD, et al. Complicationsand failures of subclavian-vein catheterization. N Engl JMed 1994;331:1735–38.

12. Sznajder JI, Zveibil FR, Bitterman H, et al. Central veincatheterization. Failure and complication rates by threepercutaneous approaches. Arch Intern Med 1986;146:259–61.

13. Bernard RW, Stahl WM. Suclavian vein catheterizations:a prospective study. I. Noninfectious complications. AnnSurg 1971;173:184–90.

14. Morton PG. Arterial puncture during central venouscatheter insertion. Crit Care Med 1999;27:878–9.

15. Hrics P, Wilber S, Blanda MP, Gallo U. Ultrasound-assistedinternal jugular vein catheterization in the ED. Am JEmerg Med 1998;16:401–3.

16. Mallory DL, McGee WT, Shawker TH, et al. Ultrasoundguidance improves the success rate of internal jugularvein cannulation. A prospective, randomized trial. Chest1990;98:157–60.

17. Slama M, Novara A, Safavian A, et al. Improvement of



Test your knowledge and comprehension of this article with the

Clinical Review Quiz on page 32.

internal jugular vein cannulation using an ultrasound-guided technique. Intensive Care Med 1997;23:916–19.

18. Rothschild JM. Ultrasound guidance of central vein cath-eterization. Agency for Healthcare Research and Quality.Available at www.ahrq.gov/clinic/ptsafety/pdf/chap21.pdf. Accessed 18 Jan 2006.

19. National Institute for Clinical Excellence, NationalHealth Service. Final appraisal determination: ultrasoundlocating devices for placing central venous catheters.Available at www.nice.org.uk/page.aspx?o=35419. Ac-cessed 18 Jan 2006.

20. Hilty WM, Hudson PA, Levitt MA, Hall JB. Real-timeultrasound-guided femoral vein catheterization duringcardiopulmonary resuscitation. Ann Emerg Med 1997;29:331–7.

21. Gualtieri E, Deppe SA, Sipperly ME, Thompson DR.Subclavian venous catheterization: greater success ratefor less experienced operators using ultrasound guid-ance. Crit Care Med 1995;23:692–7.

22. Troianos CA, Jobes DR, Ellison N. Ultrasound-guidedcannulation of the internal jugular vein. A prospective,randomized study. Anesth Analg 1991;72:823–6.

23. Denys BG, Uretsky BF. Anatomical variations of internaljugular vein location: impact on central venous access.Crit Care Med 1991;19:1516–9.

24. Skolnick ML. The role of sonography in the placementand management of jugular and subclavian centralvenous catheters. AJR Am J Roentgenol 1994;163:291–5.

25. Fry WR, Clagett GC, O’Rourke PT. Ultrasound-guidedcentral venous access. Arch Surg 1999;134:738–41.

26. Rose SC, Nelson TR. Ultrasonographic modalities toassess vascular anatomy and disease. J Vasc Interv Radiol2004;15(1 Pt 1):25–38.

27. Nielsen TJ, Lambert MJ. Physics and instrumentation.In: Ma JO, Mateer JR, editors. Emergency ultrasound.New York: McGraw-Hill; 2003:45–54.

28. Cosgrove DO. Ultrasonic transducers. In: Grainger RG,Allison D, Dixon AK, editors. Grainger & Allison’s diag-nostic radiology: a textbook of medical imaging. 4th ed.New York: Churchill Livingstone; 2001:44.

29. Smith RS, Fry WR. Ultrasound instrumentation. SurgClin North Am 2004;84:953–71, v.

30. Hudson PA, Rose JS. Real-time ultrasound-guided inter-nal jugular vein catheterization in the emergency de-partment. Am J Emerg Med 1997;15:79–82.

31. Simpson ET, Aitchison JM. Percutaneous infraclavicularsubclavian vein catheterization in shocked patients: aprospective study in 172 patients. J Trauma 1982;22:781–4.

32. Hull JE, Hunter CS, Luiken GA. The Groshong cath-

eter: initial experience and early results of imaging-guided placement. Radiology 1992;185:803–7.

33. Bondestam S. The needle tip echo. J Ultrasound Med1992;11:253–6.

34. Matalon TA, Silver B. US guidance of interventionalprocedures. Radiology 1990;174:43–7.

35. Rose JS, Bair AE. Vascular access. In: Ma JO, Mateer JR,editors. Emergency ultrasound. New York: McGraw-Hill;2003:59–60, 353.

36. Bondestam S, Kreula J. Needle tip echogenicity: a studywith real time ultrasound. Invest Radiol 1989;24:555–60.

37. Hopkins RE, Bradley M. In-vitro visualization of biopsyneedles with ultrasound: a comparative study of stan-dard and echogenic needles using an ultrasound phan-tom. Clin Radiol 2001;56:499–502.

38. Culp WC, McCowan TC, Goertzen TC, et al. Relative ul-trasonographic echogenicity of standard, dimpled, andpolymeric-coated needles. J Vasc Interv Radiol 2000;11:351–8.

39. Matalon TA, Silver B. US guidance of interventionalprocedures. Radiology 1990;174:43–7.

40. Parker SH, Stavros AT, Dennis MA. Needle biopsy tech-niques. Radiol Clin North Am 1995;33:1171–86.

41. Abboud PA, Kendall JL. Ultrasound guidance for vascu-lar access. Emerg Med Clin North Am 2004;22:749–73.

42. Nemcek AA Jr. The use of ultrasound as an adjunct tothe performance of vascular procedures. J Vasc IntervRadiol 1996:7:869–75.

43. Blaivas M, Brannam L, Fernandez E. Short-axis versuslong-axis approaches for teaching ultrasound-guidedvascular access on a new inanimate model. Acad EmergMed 2003;10:1307–11.

44. Todd MR, Barone JE. Recognition of accidental arterialcannulation after attempted central venipuncture. CritCare Med 1991;19:1081–3.

45. Berk WA, Sutariya B. Vascular access. In: Tintinalli JE,Kelen GD, Stapczynski JS, editors. Emergency medicine: acomprehensive study guide. 6th ed. New York: McGraw-Hill; 2004:128–9.

46. Baum PA, Matsumoto AH, Teitelbaum GP, et al. Ana-tomic relationship between the common femoral arteryand vein: CT evaluation and clinical significance. Radi-ology 1989;173:775–7.

47. Nickalls RW. A new percutaneous infraclavicular ap-proach to the axillary vein. Anaesthesia 1987;42:151–4.

48. Galloway S, Bodenham A. Ultrasound imaging of theaxillary vein—anatomical basis for central venous access.Br J Anaesth 2003;90:589–95.



Copyright 2006 by Turner White Communications Inc., Wayne, PA. All rights reserved.

Documents

Ultrasound Guidance for Central Venous Catheter Placement · phy. The Seldinger technique for central venous cath-eter (CVC) placement is ubiquitous in medical prac-tice and the procedure