There's a lot of work to do still. Ultrasound is not infallible in the hands of the untrained operator but it helps. I think the question is what's the best way to teach central lines are inserted as safely as possible. Ultrasound helps significantly but the technique still must be taught properly.

I completely agree with Daniel. The choice of technique should depend on the skills of the operator: I think it is best not to use ultrasound guidance if the operator is not experienced. The learning curve of any technique of placement of central venous lines is long, with or without ultrasound. I have put thousands of central venous catheters without ultrasound and without major accidents, now I also use the ultrasound technique, but I had to learn completely and now I'm pleased to have TWO beautiful and reliable skills in my professional luggage .

Daniel, I can see you are an enthusiastic researcher mainly regarding to the use of the ultrasound in the ER. Congratulations for your studies and papers published. We agree that US fail sometimes, but we also think that there should be some specific indications to US use and not using it indiscriminately. The reason for that is exactly what you said! How our residents will perform when they don't have a US available for placing a CVC? In our service we have seen a low rate of complications with a landmark cannulation, so we opted to teach them to use anatomic landmarks, and then, just like Paolo Narcisi pointed out, learn another different technique for difficult CVC's - this time with more experience with the US.

Thanks Daniel and Paolo for your input!

During my training, ultrasound became available about 18 years ago and I have used it for almost every line since, providing it was available. I am not sure about the training argument. One of the difficulties training people is they often have a poor mental image of what's going on below the skin. They tend to follow landmark rules without having an image of the anatomy, the variations in anatomy, the effects of disease, the behaviour of vessels as the needle approaches, the behaviour of vessels in different postures and different cardiovascular states. Ultrasound can demonstrate all of those things. Once the trainee has seen those things with their own eyes, it's my opinion that they will be *better* prepared if they find themselves placing a line when no ultrasound is available. If the technology is available then why poke around blindly? Sometimes the target vessel is not there or is empty or is tortuous or is blocked or has some other important structure between it and the landmark-defined insertion site. Using ultrasound, you can choose the most appropriate vessel, choose the safest approach, use extra manoeuvres to fill the vein if necessary (eg val salva). The only counter-arguement I've come across is that it's quite true that people with years of experience at the landmark technique sometimes have an increased rate of complications when they first adopt ultrasound (unless they have some proper training first .... which doesn't seem to always happen.)

This debate does not only apply to central lines. The cardiologists are providing a steady stream of work for the vascular surgeons - repairing femoral pseudo-aneurysms. It's probable that ultrasound guidance will become standard of care for femoral puncture too.

I think it is helpful to distinguish the use of static ultrasound (landmarking) and dynamic ultrasound (real-time visualization of the needle entering the vein). Using static ultrasound requires little training but improves success and minimizes complications. I agree with the other comments that the use of dynamic ultrasound requires much more teaching and training but ultimately is better. In the end dynamic is best, but static is better than landmark alone. If you have ultrasound it is essential to central line insertion at least using the static technique.

I think it has become the standard for IJ and femoral lines, however it is still not reliable for subclavian placement depending on your equipment, and the subclavian route is recommended by CDC due to decreased infectious risk. Also in trauma emergency setting not always practical.

During my medical education i was faced with a lot of different techniques using landmark aproach for placing CVC. Although i developed I a high level of succesful punctures without major complications, sometimes i was frustrated by small vessels or venous thrombosis occlusion especially in ICU patients needing repetitive central venous access. Nowadays i routinely do static US to exclude these problems. If I realize there may be a difficult puncture (small vessel, vein collapse ,hypovolaemia) I go on with dynamic US. It makes me feel more safe . Nevertheless I still teach young residents both techniques (landmark and US) because I think if you have the possibility to use US use it - if not you still must have the skills to place the line.

It is an eye to operator performing central venous puncture. Bedside availability is more important than experience. It does help in citing the vein and artery.

I do not think the arguments against using US when available have much substance, and the posts above outline the most important elements of the case in favour. The case for the use of good equipment following good training is pretty solid IMHO.

Nevertheless, I maintain that it remains important to be able to place lines withiout the assistance of US so one is prepared for those occasions where a machine is simply not available. I am already aware of one case of poor outcome when the decision not to place a central venous line was felt to have contributed significantly. The anaesthetist said no line could be placed because there was no US available. Dangerous thinking in my view.

To get back to the original post, this becomes highly problematic when guidelines make the use of US mandatory. Perhaps 'should be used when available' would have been a judicious alternative?

Thanks Dr Bennet for your post. I guess you mentioned the core of the question! May be US is effective and safe but it looks like landmarks also are, in trained hands just as US. Dr Carl Shulman also made an important comment. The US is not always practical on the emergency setting or may be it is just not available in some centers

I guess it can not be mandatory unless ASA is asking everybody to be certified ultrasonographer. It will become a liability for those who placed the central line and use ultrasound, without being certified, for confirming appropriate placement. I have seen physician rescue a life in intensive care unit but got fired because of he was not "certified physician to do so". But, US does reduce exposure to radiation.

Use of US technology to place central lines is very good. I have inserted central lines by landmark technique for years (and would consider myself experienced in the technique). However, when I learned and started using US for line placement, I became aware of variations in anatomy and was pleasantly surprised (and thankful) that I had not pierced the arteries instead of veins many more times that I have! Having said that, I agree with the comments that landmark training is also essential and the excuse that a line cannot be plavced because US is not available is negligent. In the UK NICE guidelines suggest that US, when available, should be used.

All,

See attached the document in discussion. Special attention to the algorithm (Fig 1; 546)

Though I do not have much experience with USS for CV cannulation, I am of the opinion that a good knowledge of useful landmarks combined with the use of USS will only improve the safety of the technique.I know some of us with skill sufficient to do a CV cannulation 'even with our eyes closed' will wonder if the introduction of USS has any role to play at all.

It seems that the ready availability is the most limiting factor than the learning CV cannulation under USG. In my opinion it is an eye to see through skin.

US is recognized as the gold standard for vascular access placement. I can suggest new evidenced-based guidelines published in Intensive Care Medicine by me and a panel of mutidisciplinary specialist in which it is finally stated that US has to be used in every vascular access placement. I think that in every Hospital an US machine is available and should be used in every patient because variations from normal anatomy are common and it would be unsafe to use LM any more.

I agree regarding the learning curve in US vascular access placement. I've coauthored a new guideline regarding training that will be published in BJA in the next few weeks

anatomy can be different. I'd suggest to study more on US anatomy not leaving LM It seems an old case between old dogs and new tricks.

i can give scenario i faced . patient on heparin , severe AR in AF for valve replacement ., adult ASD in AF for ICR with L svc. its gold standard for IJV cannulation but beware of deskilling . one article there in JCVA oct 2009 pro and con may throw some light to the issue .

I'd suggest the use of US for IJV or brachicephalic vein cannulation. It has not been demonstrated when deskilling from US makes the procedure as unsafe as LM.

Nicola Parenti Intensive Care Unit Hospital of Imola, Italy

I think that we have not to discuss if it is necessary to use US for central vein cannulation, but we should discuss about which is the best way to make vein cannulation. In particular I think all the in-plane US access are more safe.

I am interested to know which evidence there is about this my opinion ?

How many studies have been conducted on the difference in safety between US in-plane and out-plane approach ?

Thank you for attention

The EBM consensus on USVA has found that adequate training is required for both approaches since IP require more training and OOP is better for setting small target vessels or when vital structures are in close prossimità to target vessels. At the moment there are only few articles clearly demonstrating that IP is better than OOP.

US use in all aspects ( for this purpose ) is cost effective. it prevents a lot of complication especially for residents and fellows undergoing training.

absolutely not; in our institution, we never use ultrasound to locate central venous; and the complicaiton is extremely rare! may be ultrasound is used for research purpose. I saw many publications in this field.

Did you count pneumothorax? You can't say you got fever if you don't measure it. Costs for a single pneumothorax can rise up to 2000 USD. Please be more precise when you say "many publications". Evidence is not currently supporting landmarks apart where US is not available.

Probably it may be due to the fact that ultrasound is not availible in our department; and each time when we order a ultrasound, it is time consuming. we have extremely large number of patients to treat, probably one physician have to deal with 24 critically ill patients one day. peumothorax is encountered last year in our institution, but the patient revocered after surgical treatment.

US is time and cost effective. See Dr Calvert study in BMJ 2003. If you have to deal with multiple trauma pts you could avoid chest x-rays to rule out PNX or use it for procedures (vascular devices placement, nerve blockage i.e.). Only if you use it as a gadget it is not time and cost effective but this is caused by a inappropriate learning curve. Costs of any US machine are cutting down. For this reason in many western Hospitals, US is becoming the stethoscope of the future.

Cost debate is immaterial frankly speaking if you have started using US guidance, you will stop fanning your pilot needle to locate IJV. Believe Me!!!

First of all, the majority of serious complications from CVL placement do not arise during placement. They are infection (which may be more likely with more "stuff" etc), thrombosis and late perforation and tamponade. It has been estimated that we would need about 20,000 patients to prove a 10% reduction in placement complications. Second of all, the NICE guidelines state that operators should be able to place lines using landmarks, and how can they do it if they never try? Third of all, no one is measuring the morbidity for people who cannot or will not place a line in an emergency in the absence of an u/s machine. The cost debate is crucial when there are large parts of the world who have NO resources, including lots of patients in India. I place CVLs in neonates on a regular basis and seldom (but not never) use US.

Landmarks should still be a part of Central venous Line placement teaching. I agree with the concept of CVL management as major complications are CLABSI as thrombosis caused by under-management of CVLs. In the next few weeks I'm publishing a new guideline regarding training in CVL management that includes also post-insertional complications management.

We have to face with the economical costs of complications every day and US is now considered a standard of care in order to reduce insertional complications. No way!

There are good ways of healthcare management and US could be embraced by every CVL placement Unit with a good budget plan.

I use systematically the ultrasound to place central venous lines , in the near future when all hospital structures will be equipped with ultrasound recommendations in france will be able to evolve

At places where is mandatory yes. I believe that is very useful to minimize risks during insertion, especially when the blind technique fails. I had put more than one hundred CVL subclavian access, two of those in childs, only one pneumotorax ( very little) and some very difficults, but I want learn to use US for this. Exist a lot of evidence about the benefits of US in critical area and training systems (WINFOCUS by example). I use the unique US machine ( old machine: HONDA 2000) of the emergency room for lung US and eFAST with good results (I´m not US specialist, I´m internist). If the machine is used to maximum the benefit exceed the cost. Here a brazilian publication about the matter. I agree that US is becoming the stethoscope of the future.

Ultrasound guidance certainly helps in minimizing the incidence of carotid artery puncture. I have done more than 2000 (two thousand) central venous lines (IJV); about 1500 using landmark technique and rest using ultrasound guidance (USG). I have encountered only two arterial punctures under USG while earlier I had more than 20. As far as subclavian lines (infraclavicular approach) is concerned I have not found any difference in the incidence of pneumothorax. It is 1.5% to 2%. My personal opinion is in the favor of using USG, whenever available, and must in short neck cases and in pediatrics. Professor of Anesthesiology, SGPGIMS, Lucknow, India

Pretty much standard in most ICU's in Australia to have US available for IV access. Obviously, complication rate with US is significantly reduced in comparison with the landmark or blind technique. Very useful in the obese, short neck, coagulopathic patient,...The anatomical variation between right and left IJ/Femoral is sometimes quite remarkable and easy identification of a thrombus in the chronic dialysis or oncology patient favors US use.

US device is essential in the OR suite and in the ICU. First of all this is for the prevention of medical error and improvement of patient safety. The complexity of medical care in the OR and ICU, the situation, the diversity and individual variations of patients, the former thrombembolic diseases and cannulations of CVs with the poor communication suggest, that this tool has great role in the visualisation of CVs, guiding wire and position of the central line. With this tool inadvertent carotid punction and other adverse effect of care can be preventable.

Ultrasound is a tool which is useful for central venous cannulation in cases which the surface and anatomical landmarks are inadequate for the operator to feel confident in performing the procedure. Personally we should learn both conventional (surface landmark) and ultrasound skills for placing central lines. At least we would still be able to insert the line when the machine suddenly stops working!

Guidelines are very useful in front of the court. A well defined anatomical landmark could hide a thrombosed vein and the risk for multiple attempts without success. No guideline suggest to teach US-guided technique only and both technique should be learned in case US stops working (this should be the case of a sudden electricity blackout). Remote or rural areas are still not provided with US machines that could help doing multiple procedure that we usually perform using the blind technique (i.e. nerve blocks, thoracentesis). This is not any more ethically acceptable in the so called "developed world" where US is available and physicians should be confident with this technology.

Most of the foregoing discussion ignores the fact that many IJ / femoral CVCs are placed in the emergency department, as this is the situation where much of the resuscitation has to be done. Most people are familiar with the various studies and bundles around sepsis for instance where the most effective (and simple) initial therapies need to be given as early as possible, and waiting to get the patient to ICU, (which often doesn't exist in the smaller hospital necessitating medical retrieval with all its inherent delays) before placing essential monitoring such as a CVC, would lead to poorer patient outcomes from the initial pathology. It misses the point that probably in about 50% or more of small hospitals in urban or rural areas of Australia for instance, US technology is just not available, and few physicians are trained in its use. The placement of CVCs etc by LM is often the only alternative. Discussions such as these have to acknowledge the real world not just the more advanced institutions, usually urban and tertiary.

This discussion started to establish is US is an essential tool for placing CVCs. I agree that the real world is different from the ideal world but US could be more useful and cost effective in rural areas where it is a real diagnostic tool (i.e. IVC measurement, lung consolidation, cardiac failure and TaKastubo syndrome). There are lots of papers demonstrating that even in emergency patients US is more effective than LM in terms of safety and efficacy. This evidence should guide physicians and administrators to have more US machines avaiable not only in tertiary well organized centres but also in the desert or in rural areas where a CT scan is not available but an US portable machine could save lot of lives.

Undoubtedly; however what the real world means, at least in Australia, is that the medical workforce is often junior, inexperienced or transient, and often all three. US machines, however useful and potentially life saving they are (and I think we all agree on this) will potentially never be purchased in some hospitals (many EDs even in larger hospitals wait until they can find charitable funds or similar) an if they were there is often no-one appropriate to train in their use. My point was that MANDATING US in CVC placement helps no-one in places such as rural Australia other than to give more ammunition for criticism and potential litigation. Describing a standard of care is different.

I agree with most of you that US is very useful tool in insertion of CV lines ; however making is MANDATORY is totally unjust as per me. As pointed out by some, availability and training in US is essential for US guided CV cannulation. Unless it is ensured that each and every centre has US availability and US training is part of curriculum like measuring of BP or pulse, making it mandatory will give no better results. Moreover, it would lead to loss of touch with the landmark technique which may be very helpful in certain situations like machine malfunction or electrical problems. It would be fair that the guidelines state that US guided CV should be preferred technique whenever possible (machine and skill available ) rather than mandatory. ASA guidelines may be appropriate for USA but need to be modified from every state and country depending on 2 essentials available --machine with appropriate probe and skilled experienced physician. The guidelines should be realistic and easily abidable rather than being idealistic . I guess every country's Anaesthesiologist Society should write to ASA regarding this , since in legal instances available guidelines are what the non -medical guys use as defense.

I agree with most of you that ultrasound is very useful tool in insertion of central lines, however making is mandatory is totally unjust as per me because central lines should be placed in the emergency department during initial resuscitation without any delays. In many small hospitals ultrasound is just not available or a few physicians are trained to its use. Guidelines are very useful in front of the court but we should learn both conventional (surface landmark) and ultrasound skills for placing central lines. Availability and training in ultrasound is essential for ultrasound guided placing central lines.

There is still a debate on training in Central venous access and which approach should be used. Guidelines are a usefull tool not only in front of the Court but mainly for patients' Safety. I agree that Ultrasounds are still not present in every ER and small Hospitals but evidence should guide governments to buy more portable ultrasounds than CT scans.

Guidelines should also convince physicians to what is now the standard of care or when it could be obtained. Zeroing complications is possible only using Technology and our mind. Achieving a difficult IV access in Emergency with a pulseless patient is possible only if you can visualize vessels and you use Ultrasounds in your daily practice.

Yes

Ultrasound has become an essential tool for Central Venous Cannulation

It adds safety in IJV and femoral insertions, but useless in Subclavian as vessels are behind the clavicle. It could be used for a more lateral Brachial approach though.

OK. Lets be a bit controversial. Train in both techniques - no issue. In developing countries the technology is a barrier. In developed countries there is NO excuse. Rural v teaching is irrelevant. US machines for line placement are available at very reasonable prices, and if your hospital can afford to run an OR and an ED it can afford ultrasound. If they tell you otherwise go and check the costs of some of the surgical or radiology equipment in comparison to a basic US for lines. Is it necessary - not is you are good at landmark. But trainees coming through now will accumulate much less experience and work in a much less tolerant environment when it comes to adverse events. These are less common with US, and it has the added advantage of allowing selection of the most appropriate site and location on the vein, and as importantly avoiding damage to surrounding structures which landmark does NOT help with consistently. I use both. But ultrasound is fun!

The most important tool for placing central venous lines is experience. Those who are responsible for trainees with variable experience will be very enthusiastic about mandating ultrasound for placement in all situations. As this discussion reveals, ultrasound machines are not universally available when a central line needs to be placed. With experience, careful attention to patient positioning, and avoidance of repeated unsuccessful attempts at placement the incidence of serious complications should be very low. Would universal use of ultrasound make it lower? Probably so. Should this be mandated as the best use of limited resources? That is not so clear, in my opinion.

I agree with Harold V. Gaskill III and I think the most important tool for placing central venous lines is experience. However, undoubtedly it is advisable to use of ultrasound when possible, but I think that emergency physicians need to know cannulate a central vein also without the use of ultrasound in emergency situations.

What does it mean experience? In the history of ships there was a very experienced captain who wrecked during one of his transatlantic trips (Titanic's wreck). In order to assess experience and outcome a physician should deal with numbers not personal opinions. Evidence and metanalysis demonstrate that the use of US enhances safety in terms of reduction of major and minor complications. US is not useful for subclavian vein puncture because it is really impossible to achieve a good imaging of the vein and surrounding structures.

If you have an US machine around you it will be better for your patient if you use it on a routine base in order to be more proficient. Experience means that the target is achieved not only when you have to puncture the vein but also to avoid late complications as infections.

If someone really wants to demonstrate that LM are superiore to US, I'll invite him to place a Line in 1kg baby using a RCT. Any Ethics commitee will

accept it any more.

We have to face with the real World where US are still not available and LM are the only solution BUT if you have an US with you the best care is to start performing US guided CVC placements and beeing an expert practicioner.

Experience with central line placement would mean more than 100 cases - keeping in mind that patients who are obese or have other challenging anatomical characteristics will require equal experience for those particular situations.

I am not opposed to US placement. However, as people become more experienced placing central lines their complication rate becomes very small. In that situation the advantages of US become smaller as well. Thus, a mandate for US use in every case by every practitioner is probably not appropriate.

One of the disadvantages of meta-analysis is that the conclusions can be rather robust for the population but the population is made up of more diverse elements and applicability of the conclusions to any particular element becomes tenuous.

Here is a very good paper offering a differing opinion:

http://icvts.oxfordjournals.org/content/3/3/523.full.pdf+html

I do not remember any paper demonstrating a learning curve during Central Line placement when using LMs. The only published evidence on learning curves is on US vascular placement.

Any technique could be unsafe if the physician is not really trained and proficient. Our recent data on more than 1400 pts demonstrated that zeroing major complications is possible.

Regarding the metanalysis published in 2004, there are some methodological errors that do not support their results. I've previously published some similar conclusions regarding a paper on a metanalysis on Central Line placement in children.

I'd be very happy if someone could convince me with numbers more than with personal opinions.

I agree that, in order to assess the experience and results to the physician should deal with a number of patients treated. However, it is not a personal opinion that a cannulation of a central vein may be required in out-hospital emergency care where do not have US and where, I agree with Massimo Lamperti, US can be of little use and is not useful for the subclavian puncture. For these cases the physician should be able without US. However, the use of US certainly increases the safety in terms of reduction of major and minor complications and facilitates in difficult cases.

Massimo, maybe that is why we appear to disagree more than we do. My experience is about 70% placement of subclavian lines in acute trauma where US is not as useful and the time factor is much more urgent. We can also manage any complications expeditiously and have a rationale for accepting them in the context of the entire clinical situation.

In a acute setting, it has been demonstrated that IJV as femoral can be achieved in less than 5sec after appropriate US training (25 Cannulations) . Yes, we disagree but you could convince me with an RCT or more numbers. When I started my career I could not imagine that US could really be more effective than LM. Now, It's hard to demonstrate that in experienced operators US is less effective than LM.

Again, subclavian vein cannot be accesses using US but axillary vein access is even faster when using US.

In ER an US machine can really save time in PNX detection and FAST procedures. Then it could be usefull for CVC placement.

Yes

Clinical skills and technology should go hand in hand but cannot replace each other completely. While I agree that using ultrasound in settings where it is available would definitely help the trainees in committing fewer mistakes, the skill of putting a subclavian or internal jugular line cannot be mastered if one were to use the equipment right from the start.

Instead trainees should initially be made to insert lines in older children (without any evidence of DIC or bleeding disorder) with large veins so that they are acquainted with the landmarks. Once they are confident in inserting lines in less than 2 pricks they may be allowed to insert lines in younger stable children.

In all cases if ultrasound machine is available it may be used to confirm line placement once the line has been inserted. This will boost their confidence and will also help in ruling out immediate complications such as pneumo or hemothorax. In very young children (infants) it would be advisable to use the ultrasound machine if available in all cases as there is little scope for mistake here owing to their vulnerability. However if the machine is not available a trainee with enough experience and confidence (as assessed by the trainer) should be allowed to use landmarks to insert the same in this age group as well and the procedure should be supervised for the initial few patients.

Trainees should be routinely trained to detect any immediate complications such as pneumothorax and hemothorax using clinical skills and x ray or ultrasound whichever is available and intervene immediately on finding the same. In sicker children arrangement should be made for blood transfusion and chest tube drainage before undertaking all such procedures so that the complications could be easily managed in settings where USG is not available. Even in settings where ultrasound is available the arrangements should be made for all sick children as complications with ultrasound placement although low is not uncommon. Research has shown that 1 out of every 5 lines placed by USG may land up in complications (Theodore D, 2010; Acad Emerg Med). A recent systematic review by Mehta N published in Emerg Med Journal in 2012 showed that use of ultrasound resulted in successful line insertion in only 93% of the cases and the rate of complications was nearly 5%.

Thus a step wise approach to training the new comers under supervision and use of ultrasound to confirm or place lines in situations as mentioned above would help in passing the skill over to the next generations while taking utmost care to safeguard the life of patients may be the way forward.

I'll download in my web space an evidence based guideline on Central vascular a access placement as soon as BJA will give me back the proofs. There is still some confusion in which is the best choice for the patient and if we have to defend the LMs again. Next generations will probably have more US machines than now and they should have not to forget the LMs just in case of electricity blackout.

Some of the studies cited in Mehta metanalysis did not mentioned the learning curve of their practicioners. We have always to check the validity of such studies.

I recommend placing central venous line at ultrasound control, especially in VJI.

I use ultrasound at placing central venous line in VJI always.

The complications are rare.

Found another indication for using US placing lines. Have you ever tried to place a line in patient with severe heart failure who is on ECMO or LVAD ? If you do not have pulsatile flow landmark technique is like driving in a tunnel with no lights on.

Ingo, I think that is a real tip! And I like the analogy of driving in a tunnel without lights.

Yes

Once you start using it routinely, at some point you start wondering how it could possibly have gone right so often without US (and you start understanding the occasional times you seem to be unable to find the vein where it was supposed to be).

If you have an ultrasound and ultrasound experience can not be considered otherwise. of course yes!

What about emergency situations where seconds are important. We face these kinds of situation in our daily practice of cardiac anesthesia. US is of course useful if available, but skilled hands should not be forgotten by equipment. To say, we don't have US right now.

Ultrasound should be available, especially in an emergency. I use the ultrasound to look for pneumothorax, do a brief echo, and a FAST scan (where clinically indicated) in an unstable patient. Having said that, I will often do a subclavian (without ultrasound) in an emergency, I find it is generally faster.

Depending of the patients and the kind of the operations. You can't do mistake for a Cardiothoracic patient. You have to be sure were is your vein. Especially the Internal IJV which has high variability in her position

I use ultrasound for placing central veinous access. It can be difficult in neonate or little children . Actually it's a good practice to use it because there is less puncture and you can make the diagnosis of thrombus before the puncture...

Though we all can put IJV with blind eyes but if i am not blind would always like to put a probe to see where to poke especially in children. For subclavian through infraclavicular approach i use ultrasound only as rescue. I always like to trace the guide wire with ultrasound for correct location of catheter tip.

I think after careful evaluation of your patient you may find out if you definitely need ultrasound assistance or if you could manage without it, however, even for the second category you may end up with using it in about 5% of your patients

In some settings where US is not easily accessible nor available, a knowledge of anatomy is crutial. Of course, accessing the patient and when we have medical students and other registrars to teach, using the blind technique and the US assistance can be very helpful. In saying so, I myself have never had to use US (as it is not available) but normal CXR has always assisted, after the procedure, before turning the line on.

I use ultrasound for placing central veinous access. Especialy in scoliosis surgery we are routinely using it. It is good practice to use it because there is less puncture of arter.

one can place a cv access even without US guidance but once in a while i think we all will find a case in which anatomical marks are not enough to get the job done. so US is an essential part of training and practice because if one is not used to with it to try and do it in a difficult case will be very tough. for IJV lines US are absolutely essential according to me and as far as subclavians are concerned its a matter of choice.

but anyone doing work in intensive care must know the use of US to put central venous access.

We routinely check small arteries around the IJV especially in children such as the vertebral artery (1-3) and the transverse cervical artery (3,4) with ultrasound color images and ultrasound images of guidewires in-plane during pediatric central venous catheterization (5).

References

1. Kayashima K, Habe K. A case report of an accidental vertebral arterial puncture videotaped during central venous catheterization in a child undergoing a ventricular septal defect repair. Pediatric Anesthesia 2012 (3) ; 22 : 311–12.

2. Kayashima K, Ueki M, Kinoshita Y. Ultrasonic analysis of the anatomical relationships between vertebral arteries and internal jugular veins in children. Pediatric Anesthesia 2012; 22: 854–858.

3. Kayashima K. The artery behind the internal jugular vein: the vertebral artery or transverse cervical artery? Intensive care medicine ; in press.

4. Kayashima K, Imai K, Sozen R. Two case reports of the transverse cervical artery description under and below internal jugular veins in securing pediatric central venous catheters by ultrasound echo images. Pediatric Anesthesia 2012 (3) ; 22 : 309–10.

5. Kayashima K, Imai K, Sozen R. Ultrasound detection of guidewires in-plane during pediatric central venous catheterization. Pediatric Anesthesia 2013 (1) ; 23 : 79-83.

I used to perform catheterisation of central veins for about 15 years in neonates. Since I started tu use US, im not going to go back to blind catheterisation of IJV or femoral vein any more. Just for an advantage of the patient. When you have US somewhere around inside the department it is fast enough even in emergency situations.

I do not use it for subclavian punctures routinely, only as rescue and extremely seldom.

No, it is not essential in routine simple cases. once you are addicted to US guided centeal line insertion, you can not do with out it

I did not mention before about confirming vessels at first without US. We confirm the vessels before using US to touch the common carotid artery, the internal jugular vein (IJV), and the existence of small arteries behind the IJV. We can sometimes find the existence of the vertebral artery behind the IJV by touching and check the course of the VA with US in children (1). It may be difficult to find the transverse cervical artery behind the IJV even in adults (2) and of course in children (3). We can puncture the IJV without US; however, the safety level must be down. We cannot go back to the technique 10–20 years ago.

References

1. Kayashima K, Ueki M, Kinoshita Y. Ultrasonic analysis of the anatomical relationships between vertebral arteries and internal jugular veins in children. Pediatric Anesthesia 2012; 22: 854–858.

2. Kayashima K. The artery behind the internal jugular vein: the vertebral artery or transverse cervical artery? Intensive care medicine ; in press.

3. Kayashima K, Imai K, Sozen R. Two case reports of the transverse cervical artery description under and below internal jugular veins in securing pediatric central venous catheters by ultrasound echo images. Pediatric Anesthesia 2012 (3) ; 22 : 309–10.

It is definitely useful, however, doctors should now how to insert it blindly to remember the anatomy and landmarks

Every doctor must know how to place a central line using anatomic landmarks but if available, central venous canalization must be done guided by ultrasound to avoid complications. I work in pediatric anaesthesia and I think that in this field it has to be absolutely mandatory.

Certainly the uses of USG decreases the incidence of complications. If available one should use it if not through t he entire procedure, atleast for location of puncture site.

Just added BJA paper on Central venous line training. Please note the US section.

If we agree that the goal of the exercise is to place a central venous catheter (CVC) in the appropriate position while mitigating iatrogenesis, then a consideration is the technique is largely up to the proceduralist. Folks with little to no training/experience using ultrasound guidance (USG) may perform worse than they would utilizing the traditional landmarks. With that said, most surgical/critical care folks these days are being trained using USG and there is little debate that visualization of the vessel can be beneficial.(1,2) Personally, I utilize USG on all CVC placements with the occasional exception of the subclavian route. I find my ability to manage the probe, visualize the vessel, and insert the "seeker" needle in that anatomical postion is sometimes limited and I resort to the landmark methodology.

In answering the question asked...I feel that being facile with the ultrasound is a mandatory skill for all providers placing CVCs-(as is an appreciation for the landmark methodology)...acknowledging that utilization is operator, patient, and situation dependent thus not a mandatory component of successful placement (although highly recommended) and USG should be utilized when available/appropriate...

1. R. D. Ball, N. E. Scouras, S. Orebaugh, J. Wilde, and T. Sakai

Randomized, prospective, observational simulation study comparing residents' needle-guided vs free-hand ultrasound techniques for central venous catheter access

Br. J. Anaesth. (2012) 108(1): 72-79 first published online November 14, 2011 doi:10.1093/bja/aer329

2. Rana K. Latif, Alexander F. Bautista, Saima B. Memon, Elizabeth A. Smith, Chenxi Wang, Anupama Wadhwa, Mary B. Carter, and Ozan Akca

Teaching Aseptic Technique for Central Venous Access Under Ultrasound Guidance: A Randomized Trial Comparing Didactic Training Alone to Didactic Plus Simulation-Based Training

Anesth Analg March 2012 114:626-633; published ahead of print December 20, 2011, doi:10.1213/ANE.0b013e3182405eb3

I agree with Dr.Antonio Pèrez-Ferrer ,every doctor should be able to place a central line using anatomical landmarks, it is necessary, if you can use ultrasound to perform central venous catheterization to avoid complications. Especially in pediatric anesthesia, I think it should be absolutely mandatory.

I agree with Dr. Antonio Pérez-Ferrer. In my opinion, central line placement using anatomical landmarks is one of the basic ICU/anestesiology skills; it's like intubation.

Hello,

I think it is mandatory to place CV lines under ultrasound guidness even though it is important to know anatomical landmarks. Those who are acquainted to ultrasound use can notice multiple anatomical variations and positioning of large vessels which could not be detected with blind insertion. Furthermore patients with hemodynamic problems may present collapsed veins where ultrasound is very helpfull. I think that blind insertion should be used exceptionnally. In answer to Dr Moore I suppose that your difficulty to locate the subclavian veine is because your search is placed very close to the medial end of the clavicle , I suggest to start search laterally at the jonction of the 1st and 2nd thirds of the clavicle. Best regards

I forgot to say once you locate the veine you can use a second person to keep the proble in the right position or buy an ultrsound probe holder. Regards

Ultrasound guided placement of central venous lines should be considered to be mandatory - not only in pediatric cardiac anesthesia. I work in cardiac anesthesia - as well pediatrics and adults - I don`t want to miss my ultrasound machine anymore. Access is quicker and I feel more comfortable when using large bore catheters just because I can visualize the way my guidewire and dilatator takes...