I think it is now considered standard practice in the majority of UK ICU's, to insert catheters under ultrasound guidance. There are pros and cons to this approach, but it is increasingly difficult to defend any compilations that may occur when not using ultrasound guidance.

Thank you Charlotte. Do you always do it under ultrasound guidance? In Croatia in most hospitals we still do it "the old way" mainly due to lack of equipment . We are slowly solving this problem but old habits slowly die

I learned to insert them using the landmark technique a long time ago, but as we always have ultrasound available, I cannot remember the last time I undertook central vein catheterisation without using it!

I learned land mark too, but now cannot imagine placing an IJ without an ultrasound. I have been lucky enough to always work in centres with good US access. NICE in the UK recommended US way back in the early 2000's. In my opinion if US is available, there are no good reason not to use it.

I insert the central catheter utilizing the land mark technique in all the insertions.Though literature is full of the benefit of ultrasound for CVC catheterization,in my place of work it is not available leading us to rely on the age old landmark technique.

I think now is a good practice to use ultrasound for the placement of central venous catheters and to identify the location, and for any partial thrombosis of the vessel in those who have already brought a CVC, and where there have been several attempts. However, I remain of the view that one must also know the anatomical landmarks to remedy any failure that may occur and the ultrasound does not always have a second instrument.

I personally still use anatomical landmarks, if I'm not sure of the procedure I use ultrasound to detect the blood vessel and in the most difficult cases using only ultrasound.

In the US it is becoming standard practice but I was trained to perform it without ultrasound. I think those physicians who were trained a while ago usually are not using it, but those that have just finished training are using it quite often. Obviously if after two attempts without ultrasound an ultrasound is a good idea to evaluate the venous system and guide placement of the catheter

I agree that USG is the method of choice and is especially preferred by the newer generation of anesthesiologist trained in its use.However old habits die hard or non-availability of USG are two indications of use of the time tested anatomical landmark technique.it should be taught to students so that they are not hindered in the event of non-availability of USG.

I would like to state two important principles in modern medicine (in my opinion). First: a low cost, useful and effective method like ultrasound should be usually present in hospital. Second: ultrasound is a method that should be used in any case your diagnostic procedure may take advantage in terms of time, safety and mistake reduction.

Please answer the following question for yourself: which method should be used for placement of a CVC at yourself? This should be the method for your patient.

Well ... it should be the standart. I work on two intensive cares in Brazil (one public and one private) and both of them didn't have the ultrasound available. All the insertions on the two sites (one of them is an academic center) are with the old fashion way. Few centers in Brazil have the ultrasound available, and that I know, not a single one of them use it in ALL insertions. If there are another brazilians in the discussion I'll be glad to know that someone are using what I suppose IS the choice for for ALL the insertions.

To contribute to this question, it is best to do cvc procedure with the aid of ultrasound. I know a lot of countries still do it with the old method of anatomic landmark but this is not error proof. In United States about 98% if not 100% do cvc with the use of ultrasound. This is the era where just checking placement of g-tube is no longer by gastric content but by x-ray so cvc being a more complicated procedure should receive better caution.

I am currently at a hospital that always has a portable ultrasound machine available. Though I was trained by anatomical technique for central line insertion it has come down to a risk/benefit analysis for me. It is recommended practice to use ultrasound so for the elective patients or semi-urgent cases I would definitely use the ultrasound technique. For the emergency patient if using the ultrasound would not delay life-sustaining therapy I would also use it. If I want inotropes pronto I tend to site a L. external jugular cannula until I can safely (infection control!) perform a central line.

Interestingly, does anyone do their central lines by fluoroscopy? It may seem like overkill, but I would just love to see the look on interventional radiologists faces if someone was to publish that that was the safest way to do elective central line placement and it became policy!

Sadly, many of the medical and surgical registrars only infrequently perform central line placement, so for patient safety all central lines are done by our anaesthetic department.

It is necessary to learn the landmarks and anatomy and never be oblivious to them; but I have seen that my complication rates are close to zero when using ultrasound. I am sure everyone has had some or the other complications when only using landmark technique. If an ultrasound is not available, obviously we have no choice and we fall back on to our landmark technique.

In our emergency medicine, South korea, we have educated ED resdients the CVC with USG as well as landmark technique. As you know, CVC with USG is very helpful for the patient with shock or variant anatomy, especially in emergency department. I believe that Always using real-time USG improves the success rate of CVC ,and safety of patient and reduces the infection rate and attempts

In Italy, in many institutions it is becoming standard of practice to place CVC with ultrasound aid also in adult patients. I was trained without the ultrasound help, but the deep knowledge of the anatomic landmark technique has helped me in many critical situations.

Ultrasound is an implementation and I would consider it as a safe welcomed aid that should never let us forget the "old style" procedure that needs to remain in the basic ability of all of us young and less young

There is plenty of current supportive literature that clearly demonstrates that the use of ultrasound guidance in CVC (or any other vascular access device improves patient safety, increases the prodecuralists success at accessing the vessel on the first pass, therefore reducing trauma to the vessel( and surrounding structures if there are more than one attempt) and has much greater patient satisfaction in th eoverall procedure.

I have been placing CVADs for 20 years and using US for the last 10. I would most highly recommend the use of ultrasoun for CVAD insertion in any situation.

There is current literature on my ResearchGate page if you are interested, including our recent outcomes data published in CCM.

Armin Seibel posed the similar style question that I always ask as well - "would you rather be able to see what you are doing or not when placing a CVC?" When I teach doctors, I always ask them that question - in every instance they give me a YES.

So why do we still allow unsafe practice of blind insertion - not everyones anatomy is textbook - ultrasound proves that, because we see it's differences every day.

If high quality healthcare is what we are wanting to provide, cost should not be an influencing factor - POC ultrasound machines are relatively inexpensive in todays technological age and having a business case to support the purchase of such machines is easy to achieve.

Flouroscopy is an advantage, but in vascular access it is aimed at the catheter/vessel pathway and optimising tip location (and obviously other issues) - however, flouroscopy is often expensive to utilise.

There are a huge number of influencing factors also - coagualtion, airways disease, obesity that all increase the risk of inadvertent complications if ultrasound is not utilised from the beginning.

To the original poster of this question (Natasa Viskovic Filipcic), how many blind attempts do you consider as a fail? Why not aim high and achieve cannulation on the 1st pass, every time, but utilising ultrasound in your daily practice. Your patients will love it.. and so will you!

I am international Faculty for an ultrasound guided CVC program that is run in the USA - we are running a course at the upcoming AVA meeting in Washington DC in September. If you have clincians that need to upskill, this is a great program.

I am happy to provide more information if you need.

Article Central Venous Catheter Placement by Advanced Practice Nurse...

No, we are not using ultrasound routinely for central venous cannulation. Our patient's condition is the deciding factor to go ahead with blind or guided technique.

We should be aware of both the technique as guided procedure is very helpful in hematology patients.

"Our patient's condition is the deciding factor to go ahead with blind or guided technique" - May I ask why should any patient be disadvantaged based upon their condition? If US is available, the international recommendations (NICE, AVA, CDC, EPIC2, ESPEN, British Haematology Society, RCN and others) are to use it in every instance, as patient safety is paramount in invasive procedures that have serious complications.

If its available, I would strongly recommend its use in every situation.

Hi Timothy. While I agree that the ultrasound technique is highly recommended and believe that once it's available it would very difficult to defend using the landmark technique based on current evidence and recommendation, there are situations I myself may prefer to do the landmark technique.

As to Neha's comment, it may be useful to make the business case to the anaesthesiology department there. May I suggest inviting Dr. Spencer who should certainly enjoy a visit to your beautiful institution! If he's not interested I would not mind visiting (to conduct audit)!

Dear All

I suppose that it is a matter of time and all the CVC insertions will be US guided, I am 31 years old and I have inserted hundreds of CVCs in my crowded university hospital, since 2008 there was no US machine in our ICUs so all of my colleagues are very well trained on the landmark technique but since 2 years 2 portable US machines were available in our units and since then the preference of the US guidance is increasing , if you asked a 2005 registrar he will tell you that he prefers the landmark technique, on the other hand if you asked a 2010, 2011 resident he will tell you that he prefers the US guidance, for me , as I had the chance to take a training on the US guidance, I use US guidance in difficult cases only, but I am changing this these days and I am trying to use US guidance in all cases, I want to conclude that it is a matter of training not a matter of preference .

We rarely use ultrasound except in special situations such as high risk punction (due to coagulation disorders or low platelet count). However we do use ultrasound when punction based on anatomical landmarks fails. It´s probably not a good behaviour but we still have this "old school" hands practice.

Almost Always. There is a strong evidence basr that US guidance improves success at cvc plavement. What would you want if you were the patient?

Allan Walkey - you are absolutely correct. I always ask this of clincians when I am training them in US - "how would they feel about the use of US (or not using it) on themselves or a family member if they needed a CVC?"

Every reply is 'I would prefer US'.

This is pretty convincing support also..

So I pose the question..

Without US, how can you determine;

1) the vessels patency

2) the vessels pathway

3) respiratory variation/haemodynamic stability of the vessels

If you had a thrombosed R)IJ, then you would not know until you had already tried the procedure i.e punctured the vessel (on possibly more than 1 attempt, and had a likely failed guidewire feed).

US would allow the clinician to determine the vessels 'state of health' before even commencing the procedure, therefore reducing the risk of possible inadvertent thrombus dislodgement.

Good points, Timothy. All well thought out and hard to argue with. Makes you quite a salesperson!

Interesting comments. In our institute too, USG guidance is asked for in special situations. But I feel, guided procedure should be performed more frequently than not. By guided, I mean to say combined USG and floroscopic procedure, in cases it is feasible. In other situation, USG guidance alone should be resorted too.

In recent discussion with clinical residents, I learnt that there is a fairly high number of initial arterial punctures

John Hewitt - it's not really the 'salesperson' in me - its the 'patient safety factor' in me..

I prefer using ultrasound for central line insertion

And we are routinely using it for such this procedures

I trained in the pre ultrasound guided era. If I were the patient I would prefer a doctor who is skilled in their chosed method of insertion than someone producing an ultrasound machine that they cannot work or interpret the images.

I'm sure in time we will all be doing it but we need to know how to use the ultrasound and how to interpret the images.

Pretty soon we will surely have the first case of ultrasound guided insertion of milk and two sugars foor the morning coffee and who knows what this will lead to!

Is better see what no see.

I agree that in ideal situation cv cath should be done by experienced clinician using ultrasound. But some of us work in not nearly ideal conditions with only one (if we're lucky) US machine and multiple OR starting at the same time. So unless hard placement is anticipated we start the procedure using landmarks and if problems are encountered we involve ultrasound.

Also there has been an issue about arterial cannulation using ultrasound mostly because of fear of pseudoaneurysm formation. To my knowledge and big experience of my older colleagues we did not see that complication although we almost never used US for this procedure

What factors would you use to predict hard/difficult placement? Some seem evident like previous difficulty, Hx of head/neck Sx involving vessels, neck radioTx. Others are difficult to know without US as mentioned by Dr. Spencer - patency, anatomical variation/course, hypovolaemia leading to a collapsing vein during the respiratory cycle. Do you also use any factors during anatomical placement to decide when to abandon the procedure - number of attempt, failing to advance guidewire?

As to the possibility of arterial cannulation/pseudoaneurysm formation I have definitely had less arterial punctures since using ultrasound. Most of my collegues use the short-axis (SAX) view with the linear probe angled to the needle tip. The needle path can be predicted with the artery well away. A 'bouncing' motion of the needle can be used to see the filled vein tent downward on puncture and after Seldinger wire insertion tent upward. The long-axis (LAX) view can then be used to confirm a tented vein with the wire through skin, subcutaneous tissue into vessel lumen. While using the long-axis view from the start should allow needle tip visualization without angling the probe hand, I feel more secure having a view with the artery in it thus 'seeing' I'm well away from it.

I've attached a study that may be worth repeating at your centre comparing anatomical vs ultrasound (SAX and LAX) for IJ catheterization in ITU patients.

I always use a scanner. It is amazing how often the anatomy doesn't follow the text books. Often the artery is below the vein, or even on the "wrong" side.

You wouldn't do archery with your eyes closed, even if you know where the target "should" be. Why would you put a needle deep in to an anatomically important part of the body without knowing where you are going?

We should use US to guide the catheterization. We know how sometimes complications of every procedures could finish.

Now, the different trainings should provide the courses to be trained during the residency.

If I am a patient, i will require the use of US to have my central line ;)

we started use US more frecuently in our ICU in tha last 2 years

There are ASA Guidelines published in 2012 in anesthesiology.

so we should use static USG fo VJI ant it can be used for VSCL and FV

and we should use it in real time for VJI. in elective patients.

Of course if available. So if You don't do it after 1-2 unsuccessful attempt you should may be call your lawyer.

I systematically perform a preliminary echographic examination before any attempt in order to select the site of puncture, i.e: where the puncture will be the easiest. I examine each site ( sub-clavian and internal jugular left and right). Then, according to the result ( depth under the skin, anatomical position, venous diameter), I make my choice and  select the site. After that, I do not alw 

If you use landmark technique to start with and use US after several failed attempts, you may have the problem of havin hit the vessel before and there may be some hematoma which would make it more difficult to identify the structures and may cause more complications. I trained in pre ultrasound era but now I do not do it without US. As pointed out in other comments, a pre scan would help you in identifying the anatomy and patency of the vessel specially in cancer patients who have had multiple long dwelling CVCs and may have thrombosed vessels. 

It just seems common sense for practitioners to adapt their insertion practice to include the US. Learning new and improved techniques don't come without a learning curve, but the benefit of the learning curve is improved patient outcomes. Hand washing protects patients. Treatment of disease processes follow evidence-based research to ensure patient safety. Open heart surgery has evolved over time. All these things are improvements on how we used to do things. US guided cannulization should follow suite: 

By using US technique you are avoiding major problems, such as pneumothorax, and carotid artery stick which can lead to major hematoma formation that can further compromise your attempts at successful cannulation. In short, set yourself for success right from the get go!