Ultrasound has become increasingly available in clinical settings due to the miniaturization of probes and technology. Machines no larger than laptop computers are both portable and versatile for use in both physicians’ offices and throughout the hospital. This increased availability should prompt us to consider other uses of ultrasound technology beyond diagnostic imaging of the heart and great vessels to improve patient care, make health care safer, and reduce costs associated with complications. Central venous catheter placement is inherently associated with risks related to injury of surrounding structures in close proximity to the intended vascular target, such as arteries, nervous tissue, pleural structures, and thoracic duct (left neck). The time has come for echocardiographers to advocate for the routine use of real-time ultrasound during the placement of catheters into the central venous system.
In their 2001 publication “Making Health Care Safer: A Critical Analysis of Patient Safety Practices, ” the United States Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) lauded real-time ultrasound guidance during central line placement as one of 11 patient safety practices with the greatest strength of supporting evidence to improve patient care. The following year, the National Institute for Health and Clinical Excellence (NICE) authority established by the United Kingdom’s National Health Service also recommended ultrasound guidance for elective central venous cannulation. These recommendations were based upon a systematic review and economic evaluation. A meta-analysis that calculated relative risk reductions (RRR) associated with internal jugular vein cannulation found several important outcomes regarding ultrasound guidance: (1) 86% RRR for failed catheter placements; (2) 57% RRR of complications with catheter placement; and (3) 41% RRR of failure on first attempt. Fewer overall attempts were required to successfully cannulate the vessel, using significantly less time. Monetary savings was estimated to be approximately £2000 ($3200) for every 1000 procedures performed using ultrasound guidance. The most favorable improvement in outcome appears to be associated with ultrasound guidance use by novice and inexperienced operators. Despite the heterogeneity among various subgroups, ultrasound increases the successful placement of internal jugular vein catheters and decreases complications most significantly among less experienced operators.
The long-standing obstacles to widespread implementation of ultrasound guidance for vascular access guidance have been the purchase cost of the equipment, availability, and the time and expense needed to train clinicians. With increased availability of ultrasound equipment in today’s healthcare settings, the current limitation appears to be physician bias. Many clinicians willingly use ultrasound as a “rescue” device only after several failed attempts with a landmark-guided method. Nearly 41% of 1494 cardiac anesthesiologists responded that ultrasound was always or almost always available for use during central venous catheter placement, yet only 15% always/almost always used the technology in a recent survey. Of the 67% who never/almost never use ultrasound guidance, 45.7% cited “no apparent need” as the most common reason. This perception is directly “at odds with the aim of patient safety,” especially in light of the Institute of Medicine and the AHRQ’s call for patient safety initiatives.
The availability of echocardiography and ultrasound equipment makes routine use of ultrasound for central venous access feasible and effective. Equipment purchased for transthoracic echocardiography, transesophageal echocardiography, or other ultrasound uses can be used for ultrasound guided vascular access. It is important for those who routinely use ultrasound or echocardiography in their daily practices to become advocates for ultrasound-guided vascular access, create educational opportunities for members of our society, and incorporate ultrasound training into our residency and fellowship programs.