Improved results using ultrasound guidance for central venous access

Central venous cannulation is an essential part of patient management in a variety of clinical settings. The complications of cannulation may be as high as 10 per cent and include arterial puncture, pneumothorax, hemothorax, cardiac tamponade, hematoma, malposition of catheter, nerve injury, and death. Standard technique for placement of central venous catheters is by use of a blinded, external landmark-guided technique. Success rates and complication rates vary according to the technique employed. Ultrasound use in general surgery has gained popularity and is now readily available in most operating suites. A prospective study was conducted to evaluate the feasibility of ultrasound-guided placement of central venous access devices. Ultrasound guidance was used to place central venous ports for chemotherapy in 29 patients. Catheters were placed using a handheld ultrasound (7.5 MHz, linear probe, Aloka, Wallingford, CT) with the Seldinger technique. The internal jugular vein was used as the primary site. Accurate placement within the superior vena cava was confirmed with fluoroscopy. All procedures were performed under local anesthesia with intravenous sedation. The data analyzed included length of procedure, complications, and success rates. The right internal jugular vein was used in all but 4 of our patients. In 2 of those patients, the left internal jugular was chosen initially. In the other 2, anatomical variants were discovered requiring a modification of technique to cannulate the right internal jugular vein. Overall, ultrasound led to a change in management in 14 per cent of patients. The average time for placement was 30 minutes (range, 22-42 minutes). There were no failures in placement or misplacement of the catheters. Detection of anatomy prior to venipuncture and direct real-time visualization are the keys to success with ultrasound guidance. This study shows that placement of central venous catheters, using ultrasound guidance, may be done in a timely manner while minimizing risks and maximizing success.