Key Evidence-Based Recommendations for Ultrasound-Guided Vascular Access

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Ultrasound-guided vascular access has been in use for over three decades and is becoming more widely utilized due to its proven efficacy at reducing medical complications while increasing success rates during cannulation.??

An article published in Current Opinion in Anesthesiology in 2015 shows that ultrasound guidance enhances medical success in central venous catheterization, providing improved accuracy to subclavian and femoral routes. It also offers the power of detection for any malpositioning or complications arising from arterial accesses as well as difficult peripheral insertions.?

?Real-time ultrasound needle guidance is proven to increase the accuracy of vessel placement on initial pass, reducing the likelihood of complications. While it reflects ideal practice in medical settings, practicality may not always allow for its implementation.?

To create awareness around the use of ultrasound guidance for vascular access, we want to share with you some evidence-based recommendations published in Intensive Care Medicine.?

Recommended Technology and Technique for Ultrasound Vascular Access?

For ultrasound imaging during vascular cannulation, higher probe frequencies are best for imaging superficial vessels and enable visualization of nearby nerves and smaller arteries.?

Lower frequencies benefit deeper vessels, such as those in obese patients.??

Images may be saved informally to help with subsequent clinical management, though this is not a standard clinical practice yet.??

Additionally, in-plane techniques should be included in adequate training for ultrasound-guided central venous access as they may help prevent puncturing the posterior wall of the vein.?

Ultrasound-Guided Vascular Access for Neonates and Children?

Pediatric patients require more experience and skills with ultrasound management. The implementation of skin marking using ultrasound has shown an increased success rate and should be used as soon as operator experience with the device permits.?

Ultrasound visualization of the subclavian and brachiocephalic veins is possible, with two different approaches available: infra-clavicular and supra-clavicular. Infra-clavicular offers a longer view of the vein but requires more expertise due to acoustic shadowing from the clavicle, while supra-clavicular offers perfect in-plane needle visualization.??

It’s important to keep in mind adequate practices to properly visualize the brachial plexus and maintain balance between comfort and infection risks.?

Ultrasound visualization of femoral veins in infants is difficult and extra care should be taken with the puncture, near the inguinal ligament. Low abdominal compression may be used to increase visibility.?

Even though the use of ultrasound is an effective way of visualizing and cannulating superficial and deep veins, its use with superficial veins may be difficult due to compression from the probe. An alternative for this is the use of an acoustic standoff pad filled with gel or also known as "standoff device" gel. This solution is placed under the ultrasound transducer to increase the distance between the transducer and the skin, expanding its field of view.?

Ultrasound guidance should also be used for placing peripherally inserted central catheters if the arm vein is 3 mm or larger. In neonates and children, ultrasound-guided arterial catheterization should be routinely used as the peripheral arteries are smaller and more difficult to detect than in adults.?

Pediatric central venous cannulation is a delicate and potentially dangerous procedure which should be performed using ultrasound guidance. It is recommended to have ultrasound equipment available soon after the procedure for early detection of complications.??

Furthermore, pre-procedural ultrasound evaluation can allow for a rational choice of the most appropriate patent vessel. For risk reduction, it is suggested that the external diameter of the catheter should not exceed 1/3 of the internal diameter of the vein, and care must be taken to prevent J-wire guides larger than the vessel from being used.??

Ultrasound-Guided Vascular Access for Adults?

Ultrasound-guided venipuncture can greatly improve the accuracy and overall success of vascular access procedures. While research has primarily focused on internal jugular, subclavian, and femoral veins, increasing clinical experience suggests that ultrasound can be used effectively for all venous access sites.?

Ultrasound-guided venipuncture has been proven to be beneficial in both short-term and long-term central venous access procedures, as visualization and puncture of the veins can be done accurately. Ultimately, ultrasound guidance leads to better outcomes, reducing the risk of catheter contamination and thrombosis.?

Ultrasound guidance has become increasingly popular when positioning peripherally inserted central catheters (PICC) in the last decade, as it allows placement in the majority of patients even if there are no obvious superficial veins.??

Insertion at mid-arm leads to better security and dressing, patient comfort, low risk of contamination, and a significantly lower risk of infection compared to standard central venous catheters. This effect may be due to the location being further away from airway secretions or because PICCs are selected for less intensive treatment regimens.?

Ultrasound-guided arterial puncture is less documented in the literature than venous cannulation, but meta-analysis and expert consensus suggest it is more efficient and faster than landmark-based cannulation, especially when the pulsation of the artery is not visible or the artery is small.??

Ultrasound examination of the pleura has several advantages as a method for checking for immediate post-procedural lung complications, such as being bedside, easy to learn and can be performed with the same probe used for cannulation.??

Trans-thoracic echocardiography is a valid procedure for detecting the tip of the catheter in the right atrium; however, it has limitations such as not providing precise information when the tip is in the superior vena cava, usually requiring a different probe than ultrasound-guided cannulation and needing both specific training and injection of echo-contrast medium.?

How Cost-Effective Is the Use of Ultrasound-Guided Vascular Access??

Cost-effectiveness analysis can be used to compare different test modalities and look for ways to decrease costs and/or improve outcomes.??

There is a growing body of evidence that ultrasound-assisted vascular access has both clinical and economic value, as demonstrated by improved success rates, reduced procedure time and lower complications.??

Ultrasound assistance could be especially useful for patients undergoing repeated access procedures and expanded resources could potentially provide significant cost savings.?

Decision and sensitivity analyses can be used to measure the cost-effectiveness of ultrasound for vascular access, with meta-analysis and guidelines demonstrating that it is cost-effective in reducing major complications and access time. This cost was not considered in most evaluations but is important when emergency central vascular access is needed or surgeries are delayed due to failed/multiple attempts.?

Infection Prevention Practices During Ultrasound-Guided Vascular Access Procedures?

Aseptic technique is essential to prevent catheter-related bloodstream infections? (CRBSIs). Current CDC guidelines recommend maximal barrier precautions during catheter insertion to ensure asepsis, which are very effective in reducing the risk of CRBSIs. These precautions include:?

• The use of sterile covers for the probe and cable to prevent contamination?
• The use of sterile gel inside and outside the cover?

Overall, ultrasound-guided vascular access provides a reliable, safe, and evidence-based method for accessing the veins of neonates, children, and adults. By using the correct technology and techniques when performing vascular access procedures, it is possible to effectively manage patient risk while improving comfort and providing an optimal outcome.?

By following infection prevention practices according to medical guidelines, practitioners can reduce the potential for postoperative complications due to microbial contaminants. With this knowledge in mind, clinicians should feel empowered to confidently offer this form of invasive vascular procedure for their patients.?

Lamperti, Massimo et al. “International evidence-based recommendations on ultrasound-guided vascular access” Intensive Care Medicine?volume?38,?pages1105–1117 (2012)?

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