CENTRAL VENOUS ACCESS is a procedure regularly performed in hospitalized patients. It involves the insertion of a catheter into a large vessel for the emergency administration of fluid, blood products, and medications. Additionally, it can be used to obtain invasive hemodynamic monitoring, and to provide hemodialysis in the emergency department and plasmaphoresis therapies in the future once admitted to the intensive care unit. Some estimates have more than 5 million central venous catheters (CVCs) placed each year in the United States (Thaut, Weymouth, Hunsaker, & Reschke, 2019). This is a procedure commonly performed in certain clinical scenarios using the assistance of ultrasound (US) guidance.
Many organizations and societies promote the use of US guidance during central venous access. Multiple research studies in areas such as emergency medicine, critical care, and anesthesia have reported significant reductions in cost, time to cannulation, and complication rates with the use of US technology (Criss, Gadepalli, Matusko, & Jarboe, 2018; Gurney, Paul, & Price, 2018; Lalu et al., 2015; Takeshita, Nishiyama, Fukumoto, & Shime, 2019). The Agency for Healthcare Research and Quality has listed the use of real-time US guidance during central line insertion to prevent complications as one of the most highly rated patient safety practices (Peabody & Mandavia, 2017). Their support for US in CVC placement is reflected in their national quality measures used for public reporting and reimbursement (Ablordeppey & Drewry, 2019).
Complication rates for central line insertion are reported to be from 3.1% to as high as 19% in the literature (Bell et al., 2018; Gurien et al., 2018; Hoffman et al., 2017; Lathey et al., 2017; Saugel, Schreen, & Teboul, 2017). To decrease risk for complications, providers must consider appropriate insertion sites, contraindications, and comorbidities. Some examples of comorbidities are coagulopathies and respiratory diseases. Confirmation of catheter placement before use is also vital to successful central line insertion. Ultrasound allows the operator to visualize the needle being advanced through the tissue and as it is inserted into the target blood vessel. Short- and long-axis views allow the clinician to see the guidewire enter and remain in the vessel. Ultrasound is highly valued in central line insertion because studies assessing the difference between using anatomical landmark technique and US technique show preferable outcomes using US (Hoffman et al., 2017).
INTRODUCTION TO ULTRASONOGRAPHY
Most ultrasonography uses piezoelectric crystals in the transducer to convert electricity coming from the US machine to vibration (Hoskins, 2010). This vibration is sent from the transducer and travels to and from structures multiple times forming a pulse echo. When returning to the transducer the waves are then turned back to electricity, and information is plugged into a screen in the form of a pixilated image using a grayscale (Hoskins, 2010). Images in the upper portion of the screen are considered superficial and in the lower part are deeper. The US waves travel at different velocities depending on the medium. Air has the lowest speed and bone is considered the highest (Hsu & Menaker, 2016). Additionally, different mediums produce various levels of returning echo. Mediums with lower capability of returning echo or echogenicity are plotted darker and mediums with high returning echo are plotted brighter (Hoskins, 2010). Fluid has no returning echo, so it is plotted black compared to tissue which has more returning echo and it is plotted brighter on the screen (Hsu & Menaker, 2016). It is also essential to have an understanding of the different anatomical planes used in US (González, Ortega, Crenshaw, & de Tantillo, 2019). Longitudinal planes include coronal and sagittal planes. These are known as long-axis planes. Transverse and cross-sectional planes are considered short axis (González et al., 2019). For a CVC placement, the emergency department nurse practitioner uses a high-frequency probe, which allows for visualization of the more superficial structures such as vasculature. An example of such a probe is the linear array probe with a frequency of 10–5 MHz (Hsu & Menaker, 2016).
ULTRASOUND VERSUS LANDMARK TECHNIQUE
Traditionally, CVCs were placed using anatomical landmarks; however, some patients have anomalous anatomy or landmarks difficult to discern, such as in obese patients. This has contributed to unsuccessful placement of the CVCs and complications associated with the procedure. The use of US allows the clinician to visualize patient anatomy before attempted insertion of the catheter and allows the operator to visualize the needle during the procedure as it enters the vessel.
Brass et al. completed two Cochrane Database systematic reviews and meta-analyses summarizing evidence for whether there was a difference in the rate of complications when using US guidance versus anatomic landmark technique for CVC placement (Brass, Hellmich, Kolodziej, Schick, & Smith, 2015a). The first review examined complication rates for US guidance versus anatomic landmarks for internal jugular vein (IJV) catheterization. The second review examined complication rates for US guidance versus utilizing anatomic landmarks for both subclavian vein (SCV) and femoral vein (FV) catheterization. The studies compared total rate of complications and overall success between US-guided line placement and anatomic landmark technique.
In the IJV site, the meta-analysis reviewed 35 trials with a total of 5,108 patients. The researchers found a reduced rate of total complications in the US group of 71% (14 trials, 2,406 participants, risk ratio (RR) 0.29, 95% confidence interval (CI) 0.17–0.52; p value < 0.0001, I2 = 57%) (Brass et al., 2015a). They also found that overall success rates were increased in the groups studied by 12% (23 trials, 4,340 participants, RR 1.12, 95% CI 1.08–1.17; p value < 0.00001, I2 = 85%) (Brass et al., 2015a).
In another review, Brass et al. analyzed SCV and FV insertions, which included nine studies with 2,030 patients. For SCV insertion using US, they found a decreased rate of complications in the US group versus those using landmark group with respect to arterial puncture (three trials, 498 participants, RR 0.21, 95% CI 0.06–0.82; p value 0.02, I2 = 0%) and hematoma formation (three trials, 498 participants, RR 0.26, 95% CI 0.09–0.76; p value 0.01, I2 = 0%) (Brass, Hellmich, Kolodziej, Schick, & Smith, 2015b). There were no statistically significant differences, for overall success of SCV cannulation using US guidance versus landmark technique (Brass et al., 2015b). In accessing the FV for CVC insertion using US guidance over landmark technique, Brass et al. found no difference in complication rates (Brass et al., 2015b). They also found using US for FV CVC versus landmark was shown to have a small increase in success overall (Brass et al., 2015b). Ultrasound-assisted central venous cannulation is generally supported for the IJV site, however not for the SCV and FV based on the lack of evidence from clinical studies.
INDICATIONS AND CONTRAINDICATIONS
The placement of a central line is not without risk, even when using US guidance. Indications and contraindications to line placement should be carefully considered when determining if and where central venous access should be placed. Central venous catheter insertion in emergency departments is indicated when (1) there is an inability to obtain peripheral access, (2) the patient needs to be aggressively resuscitated with fluids and/or blood and blood products, (3) certain medications are caustic or act as irritants to peripheral blood vessels, (4) the patient may need to receive in the future specific therapies such as hemodialysis, plasmapheresis, or parenteral nutrition, (5) the patient may need long-term venous access, and (6) hemodynamic monitoring and determining treatment strategies by obtaining central venous pressures and other valuable information from the cardiovascular system is necessary (Gurney et al., 2018).
Contraindications for central venous access are also considered prior to performing the procedure. Infection at the insertion site, thrombosis of the target vessel, and coagulopathy as well as anatomic variation of the patient's anatomy are all considered contraindications for central venous access (Pires, Rodriguez, Machado, & Cruz, 2017). After inspecting the surface area of the intended site, US can be used to identify appropriate anatomy and, confirm vessel patency to exclude thrombosis. It is also advised to screen for abnormal blood clotting using a coagulation panel prior to CVC insertion.
Preparation is significant to the success of any procedure. This includes appropriate site selection. The most common sites for central venous access are the IJV, SCV, and FV. An important aspect of safe central line insertion includes choosing the appropriate site for the patient as opposed to solely the site preferred by the clinician performing the procedure. Each site has a benefit as well as a potential for complications. This should be taken into account as well as any comorbidities the patient may have, for example respiratory disease or being in a hypocoagulable state.
When considering the internal jugular as a potential site, the benefits include an easily compressible vessel in the event of bleeding as in the case of carotid puncture. There is also a decreased rate of pneumothorax using the IJV site when compared to the SCV. The disadvantage of IJV cannulation includes higher risk of infection, when compared to SCV. When considering the SCV as a potential site, the benefits include a lower risk of bloodstream infection and a lower risk of symptomatic thrombosis (Parienti et al., 2015) when compared to the IJV. The disadvantage to the SCV site is the higher risk of pneumothorax and a decreased ability to directly compress a bleeding vessel in the event of an arterial puncture or laceration. The FV is yet another potential site for central line insertion with its own set of advantages and disadvantages. It has a high rate of success, and it is a compressible vessel as long as the insertion site is below the inguinal ligament. There is zero risk of pneumothorax; however, disadvantages include infection and thrombosis rates higher than IJV and SCV (see Table 1).
Table 1. -
Advantages and disadvantages by site
|Internal jugular vein (IJV)
Easy to compress if bleeding occurs
Lower risk of pneumothorax
Higher risk of infection when compared to SCV
Higher risk of thrombosis when compared to SCV
|Subclavian vein (SCV)
Lower risk of infection when compared to IJV
Lower risk of symptomatic thrombosis
Higher risk of pneumothorax when compared to IJV
Noncompressible site if bleeding occurs
|Femoral vein (FV)
Higher rate of success
Compressible when inserted below the inguinal ligament
Zero risk of pneumothorax
Higher infection rates when compared to other sites
Higher thrombosis rate when compared to other sites
Place the patient in the Trendelenburg position with the head turned to the contralateral side if attempting to cannulate either the IJV or SCV. Position the head and confirm the target vein is seen on US anterior and lateral to the carotid artery (Dietrich et al., 2016) to decrease the risk of carotid puncture. The Trendelenburg position has the effect of increasing volume to the heart, thereby increasing the filling pressure and the cross-sectional lumen of the IJV (Saugel et al., 2017). In contrast, when cannulating the FV, the patient can be placed in the reverse Trendelenburg with the leg externally rotated, to increase the lumen of the FV.
In the nondominant hand, use the high-frequency linear transducer with a sterile cover, to visualize the vessel in either short or long axis. In the short-axis view, the probe is placed transverse to the vessel showing a cross-sectional image of the vessel. In the long-axis view, the probe is placed parallel to the vessel showing a longitudinal image of the vessel.
Using the standard landmarks for finding the IJV, the triangle formed by the two heads of the sternocleidomastoid muscle and the clavicle is found. Here, the probe is placed and the carotid artery and IJV are visualized. The IJV is seen anterior and lateral to the carotid artery. The carotid artery is pulsatile and not easily compressed, whereas the IJV is nonpulsatile and more easily compressed than the carotid. The right IJV is a little larger and straighter than the left. This makes the right IJV a bit easier to cannulate when compared to the left (Hoffman et al., 2017).
The SCV and subclavian artery run alongside of each other and are separated by the anterior scalene muscle. The subclavian artery lies posterior to this muscle whereas the SCV lies anterior to it. The SCV can be cannulated using the infraclavicular or supraclavicular approach. Using the supraclavicular approach, the vein is seen more superficial than inferior to the clavicle (Hoffman et al., 2016). There is a large venous space for access just before the SCV merges with the IJV. Visualizing the SCV using the infraclavicular approach may be difficult due to shadowing from the clavicle. In an attempt to avoid this, the SCV can be approached more laterally (Saul et al., 2015).
When cannulating the FV, the triangle formed by the inguinal ligament, sartorius muscle, and the adductor longus muscle is found. Once the probe is placed in this triangle, the FV is seen medial to the femoral artery. The femoral artery is pulsatile and not easily compressed, whereas the FV is nonpulsatile and more easily compressed than the femoral artery. It is very important to remember that the insertion site of the needle must be below the inguinal ligament and not above. If the insertion site is above the inguinal ligament, manual compression, in the event of bleeding, will be difficult (Wiles, Childs, & Roberts., 2017) (see Figures 1 and 2).
Using the dominant hand, advance the needle into the vessel with guidance from the US. The short-axis probe orientation has the benefit of allowing the clinician to visualize both the vein and the artery on the US screen together. This benefit can assist in avoiding accidental arterial puncture when cannulating the vessel. However, the short-axis view limits the ability to see the entire needle advance into the vein. In this view, the needle (and not necessarily the tip) is seen as an echogenic point. This may make it difficult to see the needle in relation to the posterior wall of the vessel. Conversely, the long-axis view does allow the clinician to see the entire needle, as it is advanced into the vessel. The needle tip and shaft can be visualized the entire time resulting in a decreased risk of posterior vessel wall puncture (Takeshita et al., 2019) (see Figures 3 and 4).
After using real-time US to advance the needle into the vessel, the emergency nurse practitioner then confirms the needle tip is located in the central portion of the vein. Next, the US is released, and the clinician withdraws venous blood easily while pulling back on the plunger of the syringe. The syringe is removed while the needle is held securely in place. Next, the guidewire is advanced through the needle approximately 18 cm (Andrews, Bova, & Venbrux, 2000) and the needle is removed over the wire. Placement of the wire in the vein is confirmed using US in both the short- and long-axis views. A reverberation artifact will be seen when the wire is in the vessel. Next, make a small incision in the skin at the wire insertion site and use the dilator(s) over the wire to create a tract from the skin to the vessel. Once removed, pressure is held at the site while the clinician prepares the catheter to be advanced over the guidewire and into the vessel at the appropriate centimeter marking. The wire is then withdrawn from the catheter and blood is aspirated from each port of the catheter. The ports are then flushed with saline to ensure catheter is in the vessel and to confirm the functionality of the catheter (Williamson & Cattlin, 2018).
Traditionally, chest x-ray is obtained to confirm placement of the catheter tip in the superior vena cava–right atrial junction immediately after the procedure and before being able to use the catheter. The accuracy of x-ray however is limited due to the inability to directly visualize the superior vena cava–right atrial junction (Chui et al., 2018). Further, in addition to delaying the use of the newly placed CVC, there are increased use of labor and costs associated with x-ray, and radiation exposure to the patient and staff (Chui et al., 2018). Ultrasound has been offered as a diagnostic modality used to detect CVC misplacement (Smit et al., 2018).
Immediately after placement of the catheter, the emergency nurse practitioner injects agitated saline into one of the ports of the catheter and while using US visualizes microbubbles in either the vascular or cardiac views (Schmidt et al., 2019). An analysis conducted by Smit et al. reviewed 25 studies with a total of 2,548 patients and 2,602 CVC placements (Smit et al., 2018). They concluded that US examination of CVC placement was feasible in 96.8% of the cases. The prevalence of CVC malposition was 6.8%. The time to confirm placement using US was 2.83 min whereas the time to chest x-ray performance was 34.7 min (Smit et al., 2018).
Complications are a known risk of CVC insertion occurring either immediately or in a delayed manner after the insertion. An example of a delayed complication is catheter or vessel thrombosis. Potential complications occurring immediately after insertion manifest as vascular, cardiac, and/or pulmonary issues. Catheter misplacement is also considered an immediate complication. The use of US has decreased immediate complications from 11.8% to between 4% and 7% as the number of overall attempts has decreased with the use of US (Kornbau, Lee, Hughes, & Firstenberg, 2015).
Vessel injury/laceration, hemorrhage, and hematoma are all examples of vascular complications of CVC insertion. US guidance lowers the incidence of these complications at each of the three common sites of insertion (Kornbau et al., 2015). Kornbau et al. also state hematoma formation is reported in up to 4.7% of CVC placements (Kornbau et al., 2015). The mediastinum and pleural space are both potential spaces where hemorrhage and hematoma formation may occur. US can be used at the bedside to investigate the mediastinum and pleural space for free fluid.
US can also be used to investigate the pleural space for free air as in the case of pneumothorax. Bedside US allows the emergency nurse practitioner to evaluate the patient for pneumothorax post-CVC placement by determining whether there is a loss of pleural line sliding (Saul et al., 2015). The practitioner places a high-frequency US probe at the level of the fourth to fifth intercostal spaces in the mid-axillary line. On the brightness mode (or B-mode) there should be movement of the pleural line, which can be described as a shimmering line seen between the ribs (Rose, Siadecki, Tansek, Baranchuk, & Saul, 2017). In the case of pneumothorax pleural sliding or shimmering of the line is not observed, instead what is seen is a static bright line. To confirm, the practitioner could also put the US into the motion mode (or M-mode), which provides an image of the lung tissue over a short period (Rose et al., 2017). In the normal lung, parallel lines at the top of the image represent motionless tissue, whereas the lower part of the image on the screen looks very granular, which represents the moving lung. This is called the seashore line. In the case of pneumothorax, parallel lines are seen in the entire image, which looks like a “barcode” due to the lack of movement of the lung, and this is called the barcode or stratosphere sign (Rose et al., 2017).
Infection and thrombosis are examples of delayed complication resulting from CVC insertion. To decrease catheter-related bloodstream infections, certain practices should be adhered to. This includes performing hand hygiene, using appropriate skin preparations, and allowing it to dry before catheter insertion. Chlorhexidine gluconate is one such preparation, which may decrease catheter-related blood-stream infections and skin colonization when compared to povidone iodine (Hina & McDowell, 2017). Maximum sterile barriers are also recommended when inserting a CVC. This includes utilizing sterile gloves, sterile gown, cap, facemask, sterile US probe cover, and using a large sterile drape, which covers the patient's entire body (Kornbau et al., 2015).
Thrombosis is a potential complication occurring with the use of CVCs, particularly with long-term use. Symptoms seen include extremity edema, erythema, and paresthesia. This may lead to dysfunction of the catheter, increased risk of infection, and stenosis of the thrombosed vessel. The SCV has the lowest rate of thrombosis whereas the FV has the highest (Kornbau et al., 2015).
Central venous access techniques have evolved over the years. The use of ultrasonography for CVC insertion is recognized as the standard of care when inserting CVCs, as there are several studies showing improved success and fewer complications with its use. Increased first-attempt success and decreased complications when compared to landmark techniques make US a technology that provides safer health care, reduced costs, and improved patient outcomes. As the advanced practice provider role continues to grow in the emergency setting, the opportunity for CVC placement in this setting by nurse practitioners also grows. It is essential nurse practitioners not only feel comfortable performing these procedures, but are also proficient with the use of US technology. Standards for training and competency in CVC insertion vary throughout societies as well as the literature (American College of Emergency Physicians, 2016). Metrics and direct observation have been used to demonstrate venous catheterization competency (Gottlieb, Sundaram, Holladay, & Nakitende, 2017; Leibowitz, Oren-Grinberg, & Matyal, 2020). Still, there is a paucity in the literature regarding the number of insertions needed for competency (Moureau et al., 2013). Nurse practitioners' routine use of US will facilitate decreased complications and improved patient outcomes, which are part of best practices now tied to hospital reimbursements. Ultrasound guidance is also acknowledged as an acceptable method for nurse practitioners to rule out complications and verify placement. Ultrasound is becoming commonplace in acute settings such as the emergency department and the nurse practitioner's expertise with this modality will benefit patients in need of these specialized skills.
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