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In 2001, the Agency for Healthcare Research and Quality recommended the use of ultrasound for
the placement of central venous catheters (CVCs) as one of their 11 practices to improve patient
care. These recommendations were based on the results of several randomized clinical trials
showing significantly improved overall success as well as reductions in complications. This article
will describe the practical aspects of using ultrasound to guide placement of CVCs in the internal
jugular vein in a how I do it approach, as well as review the practice management and training
aspects related to incorporating ultrasound into daily practice.
(CHEST 2007; 132:302309)
Key words: central venous catheter; complications; internal jugular vein; outcomes; ultrasound
Abbreviations: CPT current procedural terminology; CVC central venous catheter; IJ internal jugular
the Trendelenberg position and correct head positioning can significantly increase IJ vein diameter.29 32
I recommend that one perform an ultrasound
assessment of the anticipated side prior to creating a
sterile field in order to assess the degree of overlap of
the carotid artery by the IJ vein, the compressibility
of the vein, and the presence of internal echoes that
may signify clot. If there is significant overlap of the
carotid artery, the operator should try to reexamine
the neck with the head in the neutral position,
instead of with the head turned to the contralateral
side.31,32 If the vein is not compressible or a clot is
visualized, the other IJ vein should be examined.
Color power Doppler can also be used to visualize
the distinct arterial and venous pulsations, although
there have not been any studies ascribing specific
benefit to its use.
Once the appropriate vein is selected, the site is
sterilized and draped as per standard technique with
full barrier precautions33 and the ultrasound probe is
placed in a sterile sheath. This step generally requires an assistant to hold the probe vertically and
apply conducting gel to the uncovered probe. The
sterile operator can also drop sterile conducting gel
on the probe. The operator then inserts a hand into
the sheath, holds the probe, and then inverts the
sheath over the probe, making the probe and cable
sterile. Additional gel is then placed on the outside of
the sheath to ensure adequate coupling.
The two most commonly used methods for ultrasound guidance are the one-handed or the threehanded methods. In the one-handed method, the
operator controls the ultrasound probe with the
nondominant hand and the needle with the dominant hand. The three-handed method requires an
assistant (with full sterile barrier precautions) to hold
the probe while the operator controls the needle and
performs the procedure under real-time guidance.
The one-handed method is quite easy to learn,
improves first-pass success and overall success when
compared with the three-handed method,34 and is
the method we currently teach to our fellows. Using
the ultrasound to mark the skin and proceed without
real-time guidance is not recommended given the
significant increase in success rates for dynamic
guidance as compared with the X marks the spot
technique.34
Regardless of the method used, the IJ vein and
carotid artery are identified with ultrasound and
centered on the screen. The lidocaine needle is then
inserted through the skin directly anterior to the
vessel (in the center of the probe), and the wheal of
subcutaneous lidocaine is visualized with the ultrasound as an enlarging hypoechoic area. It is often
helpful to jiggle the lidocaine needle to improve
visualization of the hyperechoic needle. As the proCHEST / 132 / 1 / JULY, 2007
303
essential, this portability makes these smaller machines extremely well suited for the ICU environment, especially when procedures need to be performed in geographically separate units. Several
machines are available, each with their own pros and
cons. For vascular access, one should use a 7.5- to
10-MHz linear array transducer because this provides excellent resolution and sufficient penetration.
Some ultrasound units are specifically made for
vascular access, whereas other units allow the transducers to be interchanged, permitting the sonographer to use the same machine for pleural/chest,
cardiac (including transesophageal echocardiography),
and abdominal ultrasound. Although not necessary,
color power Doppler is a useful added feature to the
standard vascular ultrasound unit, and if one plans on
performing more advanced ultrasound/echocardiography, the availability of M-mode, computation software,
and videotape storage may be beneficial.
In addition to the ultrasound unit and transducer,
one will need to invest in the sterile sheaths and
sterile ultrasound gel. Peripherals such as larger
monitors, docking stations, needle guides, and a
printer may be nice to have but are not essential. As
discussed below, in order to properly bill for ultrasound-guided CVC placement, documentation of the
ultrasound image with patient identifiers is required.
This can be either electronic or on paper, and
therefore one will need either a printer to place an
image in the medical record, or a method of transferring the ultrasound images to a computer. Clearly,
image storage requires disk space, with each image
being approximately 902 kilobytes. Over a 1-year
period, we archived 1.7 gigabytes for our chest and
vascular images. Many hospitals now have picture
archiving and communication systems, and integration with these systems is certainly possible. Additionally, images can be burned onto inexpensive
compact discs for permanent storage as well.
Implications for Training
The use of ultrasound is not limited to radiologists.
The American Medical Association policy on privileging for ultrasound imaging states the following38:
Ultrasound imaging is within the scope of practice of appropriately trained physicians. . . broad and diverse use and
application of ultrasound imaging technologies exist in medical practice. . . privileging of the physician to perform ultrasound imaging procedures in a hospital setting should be a
function of hospital medical staffs and should be specifically
delineated on the Departments Delineation of Privileges
form. . . each hospital medical staff should review and approve criteria for granting ultrasound privileges based on
background and training for the use of ultrasound technology
and strongly recommends that these criteria are in accorwww.chestjournal.org
305
Limitations to Ultrasonography
There are some realities one needs to face, however, prior to embracing ultrasound for all IJ CVCs.
First, there are no blinded randomized trials proving
improved outcome with infection (catheter-related
blood stream infection), ICU/hospital length of stay,
or mortality as end points. For the time being, we
therefore need to rely on the current evidence
showing improvements in success and arterial injury.
Clearly, experienced physicians can perform IJ
CVC placement safely without ultrasound guidance.
At this time, each of the relevant risks and benefits of
performing IJ CVC placement with or without ultrasound guidance need to be assessed on a case by case
basis. Given the recommendations by Agency for
Healthcare Research and Quality and National Institute of Clinical Excellence, ultrasound guidance
for IJ CVC placement will almost certainly become
standard of care. We may soon find ourselves in the
position of needing to explain why an IJ CVC was
placed without ultrasound guidance.
Secondly, there are numerous ultrasound machines available, each with their own advantages and
disadvantages, and although bells and whistles may
be nice to have, they are not required, and simple/
older machines can be adequate for most needs. The
initial financial investment can be quite significant
(approximately $25,000 to $40,000), although new
and used equipment can even be found on Internet
sites such as ebay.com for significantly less money.
Additionally, maintenance costs and costs of additional supplies such as sterile sheaths and a printer
need to be budgeted for. Unfortunately, the data
regarding cost/benefit analysis for ultrasound guidance is extremely small. Calvert et al21,45 performed
a decision analysis with estimations of net benefits
and costs. With relatively conservative assumptions,
they found a significant cost savings associated with
the use of ultrasound of 2,000 for every 1,000
patients treated. Clearly, this is a model, and real
cost/benefit analyses are required that will include
the number of ultrasound machines per hospital or
specific unit. Thirdly, and perhaps most importantly,
quality assurance for both the ultrasound unit as well
as the physicians performing and interpreting the
ultrasound needs to be high on all of our priorities.
CHEST / 132 / 1 / JULY, 2007
307
Summary
Ultrasonography is an easily learned procedure
that not only enhances the physical examination but
has the distinct advantages of being a portable tool
that can provide real-time guidance for IJ CVC
placement with significant improvements in firstpass success, overall success, and arterial injury. As
chest physicians/intensivists, we need to embrace the
broad clinical applications of ultrasound, not only for
IJ CVC placement, but in our patients with pleural
disease, ascites, shock, and who have sustained
trauma. It is crucial that we take the lead in advocating that ultrasound become part of our daily
practice, create educational opportunities for members of our societies, and incorporate ultrasound
training in our fellowship programs.
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