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Ultrasound-Guided Internal Jugular Access*: A Proposed Standardized Approach and Implications for Training and Practice FREE TO VIEW

David Feller-Kopman, MD, FCCP
Author and Funding Information

*From the Medical Procedure Service, Harvard Medical School, Boston, MA.

Correspondence to: David Feller-Kopman, MD, FCCP, Interventional Pulmonology, Beth Israel Deaconess Medical Center, One Deaconess Rd, Suite 201, Boston, MA 02215; e-mail: dfellerk@bidmc.harvard.edu



Chest. 2007;132(1):302-309. doi:10.1378/chest.06-2711
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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.

Figures in this Article

More than 5 million central venous catheters (CVC) are placed each year in the United States, with an associated complication rate of > 15%.12 Mechanical complications such as arterial puncture and pneumothorax are seen in up to 21%, and up to 35% of insertion attempts are not successful.35 The risk of complications depends on several factors, including (but not limited to) operator experience, urgency of placement, as well as patient factors such as obesity, prior difficult cannulation, and coagulopathy.4,67 Although the above-mentioned studies were performed in the 1970s through the 1990s, there have been several more prospective/randomized trials,816 as well as two metaanalyses1718 that suggest the use of ultrasound has been associated with a reduction in complication rate and an improved first-pass success when placing catheters in the internal jugular (IJ) vein. Although factors other than the use of ultrasound may be responsible for the improved outcomes, these data have led the Agency for Healthcare Research and Quality to recommend the use of ultrasound as one of their 11 practices to improve patient care in their landmark 2001 publication, “Making Health Care Safer: a Critical Analysis of Patient Safety Practices.”1920 The National Institute of Clinical Excellence21 in the United Kingdom has also fully supported the use of ultrasound guidance for CVC placement.

Unfortunately, the incorporation of these recommendations into clinical practice has been met with resistance. A survey of 250 anesthetists in the United Kingdom found that 41% disagreed or strongly disagreed with the recommendation that ultrasound imaging should be the preferred method for insertion of a CVC into the IJ vein.22 Although 84% of respondents believed that those using ultrasound imaging should have appropriate training, 67% of respondents believed the level of training provided for ultrasound-guided CVC placement was inadequate.22Likewise, a study23 in the United States also found that < 15% of surgery, anesthesia, emergency medicine, internal medicine, and family medicine housestaff used ultrasound guidance for most CVC placements.

This article will discuss the practical aspects of performing ultrasound-guided CVC placement, and address recommendations for training in ultrasound-guided CVC placement. The reader is referred to the above-referenced studies for detailed discussions concerning the improvement in success and reduction in complications with the use of ultrasound for CVC placement. Additionally, as the data suggesting ultrasound guidance for other sites, including the subclavian, femoral, and axillary veins, are less robust, discussion will focus on the use of ultrasound for IJ CVCs.

Two types of ultrasound guidance are available: Doppler and B-mode (also referred to as two-dimensional ultrasound). Doppler ultrasound transforms the sound waves reflected from a moving object (RBC in this case) into an amplified audio signal. The respirophasic venous waveform is distinctly different from arterial pulsations, and Doppler ultrasound is frequently used to assess arterial patency in the lower extremities and aid in arterial catheters. The data behind Doppler ultrasound for vascular access, however, is associated with a longer learning curve than B-mode ultrasound, longer insertion times, and higher costs.2426As such, IJ CVC catheter placement is performed with B-mode ultrasound; from here on, the generic reference to ultrasound will imply B-mode.

B-mode ultrasound converts the reflected sound waves into a real-time gray scale image. Fluid (ie, blood) is hypoechoic and appears dark on the screen, while tissue is more isoechoic and appears gray. The IJ vein is typically seen anterior and lateral to the artery; however, significant anatomic variation exists where the vein can overly the artery and even be medial to the artery.2728 The IJ vein and artery can be distinguished by the fact that the vein is compressible, nonpulsatile, and distensible by the Trendelenberg position or the Valsalva maneuver. The use of ultrasound is an excellent teaching tool to demonstrate the following: (1) excessive pressure during carotid palpation decreases IJ vein diameter (one cannot move the artery medially away from the vein as they lie in the same sheath); (2) extreme contralateral head rotation can decrease IJ vein diameter and increase overlap on the carotid artery; and (3) the Trendelenberg position and correct head positioning can significantly increase IJ vein diameter.2932

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.3132 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 “three-handed” 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 procedure is performed in real-time, a “finder” needle is not required, and the introducer needle is then inserted in the same location. The only caveat one needs to be aware of for the one-handed method is that the operator usually needs to put down the ultrasound probe in order to make the skin insertion site taught for easy passage of the introducer needle. Once the introducer needle is through the skin, the probe is picked up with the nondominant hand and used to guide the needle into the vessel. The introducer needle will indent the anterior IJ vein wall and, depending on the diameter of the vessel, may penetrate the posterior wall, resulting in a flash of venous blood on withdrawal of the needle. As such, orienting the patient’s neck as well as the ultrasound probe in such a way as to minimize arterial overlap is important. The primary advantage of ultrasound in this setting is that this can be visualized.

Passage of the introducer needle into the IJ vein can be performed either with a transverse (short axis) view or a longitudinal (long axis) view (Fig 1 ). Benefits of the transverse view are that it is generally associated with a shorter learning curve and it can be easier to visualize small vessels. The primary advantage of the longitudinal view is allows better visualization of the advancing needle tip, which may reduce perforation of the posterior vessel wall. It is for this reason that the longitudinal view is recommended by the American College of Emergency Physicians.35 If using the transverse view, it is crucial to follow the advancing needle tip with the ultrasound, making sure the plane of the ultrasound is not too proximal or distal. Some ultrasound units can provide simultaneous transverse and longitudinal views.

One can also use a needle guide to help with insertion of the introducer needle. This is a piece of plastic that angles the needle so it will intersect the center of the vessel. A randomized trial36 found that needle guides were associated with improved first-pass and second-pass success rates, but no difference in arterial sticks when compared to ultrasound-guided CVC placement without the use of a needle guide. This being said, the needle guides can be slightly cumbersome; and once experienced with ultrasound-guided CVC placement, additional benefit may not be present.

Once the IJ vein is entered with the introducer needle, the ultrasound probe is placed on the field and the typical modified Seldinger technique is used to place the CVC. A study37 suggested immediate use of the ultrasound after the procedure to confirm line placement and rule out pneumothorax. Obvious benefits include being able to use the line immediately, instead of waiting for a chest radiograph, minimizing radiation exposure, and the lack of need to reposition the patient.

Over the last several years, ultrasound machines have become quite small and portable. Although not 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.

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 Department’s 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 accordance with recommended training and education standards developed by each physician’s respective specialty.

It is therefore our responsibility to develop training guidelines and incorporate them into our daily practice as well as our fellowship programs.

The American College of Emergency Physicians and the American College of Surgeons have set the standard by developing policy statements addressing the scope of practice, training and proficiency recommendations, quality improvement, and documentation issues regarding the use of ultrasonography in the emergency setting.3940 Both of these documents strongly support the use of ultrasound by members of their societies and address ways to obtain and maintain competency, as well as ensuring quality control.

To gain the skills required to incorporate ultrasonography in clinical practice, the nonradiologist needs to become proficient in both cognitive and psychomotor skill sets. Training in image acquisition and interpretation needs to include didactic lectures, demonstrations and, most importantly, proctoring by a skill sonographer.

As compared to the broad use of ultrasound in the trauma setting, for example, two key factors allow for a much more rapid learning curve for ultrasound guidance for CVC placement. Firstly, ultrasound-guided CVC placement is not performed as a diagnostic test as is the focused abdominal sonography for trauma examination or echocardiography, and therefore the clinical implications that result from interpretation of the ultrasound image are significantly less. Secondly, if the CVC was going to be placed anyway, ultrasound imaging can only serve to improve outcome. That is to say, misinterpretation of ultrasound imaging may not adversely affect outcome when compared to placing a CVC with the landmark technique. For example, even if an intraluminal thrombus is missed and the line is attempted, it would have been attempted at that site without the aid of ultrasound. Nonetheless, there is always some element of diagnosis in all cases. For example, if a thrombus is seen in the right IJ, in addition to perhaps placing the catheter in the left IJ, appropriate evaluation and treatment of the right IJ thrombus is required.

For a single application, the American College of Emergency Physicians suggests 3 to 4 h of didactics, 2 to 4 h of laboratory training, and 25 proctored examinations.39 Didactics should include lectures on the basic physics and principles of ultrasound, “knobology” (how to actually work the ultrasound machine), image acquisition, identification and interpretation of ultrasound artifacts, identification of the relevant anatomy, and knowledge of anatomic variation. From the trauma literature, an 8-h course including 4 h of didactic and 4 h of proctored examinations on 15 normal patients, followed by 50 trauma examinations proctored by credentialed sonographer or verified by standard diagnostic evaluations was shown to be sufficient to produce well-trained trauma surgeon sonographers.41Others42 suggest 8 h of didactics, 10 normal proctored examinations, and 10 proctored, focused abdominal sonography for trauma examinations may be adequate, depending on the prevalence of the disease being sought (hemoperitoneum in this study).

Clearly there is some aspect of gaining a procedural skill that is numbers based. For CVC insertion, the only data available relating experience to complications come from the preultrasound era, and suggest that operators who have performed > 50 insertions have half the complication rate of operators who have performed < 50 insertions.4 The Royal College of Radiology recommends 25 line insertions but also acknowledges that “different trainees will acquire the necessary skills at different rates and the end point of the training program should be judged by an assessment of competencies.”43For bronchoscopy and other interventional pulmonary procedures, the numbers published by the American College of Chest Physicians44 are generally less, in the range of 10 to 20 line insertions.

Given the rapid learning curve for US guidance of CVCs, especially for the physician who is already experienced in the landmark method of CVC placement, I would suggest approximately 2 h of didactics, 2 h of laboratory training, and 5 to 10 proctored examinations. It should be pointed out that these numbers are based on the above suggestions as well our experience with a medical procedure service. Clearly, these suggestions should be prospectively validated with trials comparing a group who receives formal education/simulation training to a group educated through other means such as mentorship. Laboratory training should include exposure to a variety of ultrasound units to ensure familiarity with knobology, examination of normal vascular anatomy on healthy volunteers, as well as hands-on simulation with vascular access models. Available models range in sophistication from Jell-O (Kraft Foods; Northfield, IL)/Metamucil (Proctor & Gamble; Cincinnati, OH)/Penrose (Sherwood-Davis & Geck; St. Louis, MO) drains, to the Blue Phantom (www.bluephantom.org) [Blue Phantom LLC; Kirkland, WA] to CentralLineMan (http://www.simulab.com/CentraLineMan.htm) [Simulab Corporation; Seattle, WA]. Ideally, some of the laboratory training would include visualization of abnormal anatomy (ie, the obese patient, intraluminal thrombus, or significant overlay of the carotid artery by the IJ vein). The 5 to 10 proctored examinations should be broken down into 3 to 5 ultrasound examinations of normal anatomy/vascular access models, followed by 5 to 7 proctored procedures on vascular access models/simulators. For the physician who is already an expert at CVC placement, I recommend two proctored examinations on real patients followed by review of the next five ultrasound-guided CVCs. This would include reviewing the stored static picture/videotape as well as outcome (success, complications, number of needle passes), and discussion about factors that may have influenced the outcome. Additionally, I recommend a postinstruction assessment of the basics covered in the didactic and hands-on session. This can include static images and videotape, asking the operator to identify anatomy, as well as questions relating to the use of the ultrasound unit. These numbers are clearly subjective, as are other procedural recommendations based on number,44 and the main determinant in determining competence should be the evaluation of the proctor.

Additional cognitive instruction can be provided via textbooks, continuing medical education courses/syllabi, digital video disk, and Web-based curricula. Continuous quality improvement measures need to be in place such that all complications are reviewed in addition to several random cases during the learning period. Skill maintenance is also crucial, and at least 10 ultrasound-guided CVCs should be performed each year in order to maintain proficiency.

All of these issues have clear implications on credentialing. As stated above, privileging is a local hospital issue. Credentialing committees will need to review their policy and likely incorporate some formal training to ensure quality. Most likely, the process will be department specific (ie, the Department of Medicine signing off on members of the Pulmonary and Critical Care Division). The issue of “grandfathering” also needs to be addressed because there are clearly physicians who have been using ultrasound for CVC placement for some time. It may be sufficient for this group to just take a quick quiz documenting their knowledge, or even just verify they have performed “X” number of ultrasound-guided CVC placements without incident.

It remains crucial that operators still receive training and become proficient in the standard/landmark method of CVC insertion.21 Although one can make the argument that learning the ultrasound-guided technique first will make operators dependant on technology, it has been our experience that the anatomic knowledge gained by using ultrasound makes one a better operator when the ultrasound is not available, such as may be the case during a cardiac arrest.

The American Medical Association also supports reimbursement for “appropriately trained physicians.” It is the physicians’ responsibility to review the current procedural terminology (CPT) codes with their local billing expert as well as their local third-party payers as reimbursements vary between regions, and even within a state. The codes most commonly used codes for ultrasound-guided CVC placement include 36556 and 76937. Though the reimbursements vary regionally, CPT codes are created through the American Medical Association and are the same throughout the United States. Code 36556 describes “insertion of nontunneled centrally inserted central venous catheter; age 5 years or older” and has an associated Medicare payment of approximately $132–140 (facility, in Massachusetts, Greater Boston area) [https://catalog.ama-assn.org/Catalog/cpt/cpt_search.jsp?_requestid = 244532; http://www.cms.hhs.gov/apps/pfslookup/]. Code 76937 describes “ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real-time ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure)” and has an associated Medicare payment of approximately $35–40 (facility, in Massachusetts, Greater Boston area) [see above Web sites]. It should be noted, however, that 76937 includes the technical component associated with the procedure (supplies, technical staff). The professional component is billed by using the “-26” modifier. In metropolitan Boston, the reimbursement for code 76937 is $39.94 ($22.26 technical, $17.68 professional component) [http://www.cms.hhs.gov/apps/pfslookup/].

As with all billing practices, it is the physician’s responsibility to ensure proper billing and documentation, and the reader is urged to review local requirements with their insurance companies and billing experts. It is also crucial to discuss reimbursement with ones third-party payers as they may wish to have a letter from the chief of radiology at your institution stating you have achieved competency. This is yet another reason why our societies need to take an active role in advocating for our own ability to determine competency.

In addition to using the proper CPT codes, adequate documentation is a must. For ultrasound, either a hard copy or electronic copy of the pertinent images need to be saved in the medical record. This needs to be done in accordance with the Health Insurance Portability and Accountability Act guidelines, and all patient identifiers need to be safeguarded if the images are to be stored electronically. Documentation for procedural billing that utilizes imaging techniques includes a formal report that describes the sonographic findings in the procedure note including location, adequate compressibility of the vessel, and the fact that the ultrasound was used for real-time guidance of the needle insertion.

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.

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 first-pass 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.

Abbreviations: CPT = current procedural terminology; CVC = central venous catheter; IJ = internal jugular

The author has no conflict of interest to disclose.

Figure Jump LinkFigure 1. Top, A: Transverse view showing the IJ vein anterior and lateral to the carotid artery. Note the significant overlap of the artery. Center, B: Same image as seen in top with less contralateral head rotation producing less overlap of the artery. Bottom, C: Longitudinal view of the IJ vein.Grahic Jump Location
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Board of the Faculty of Clinical Radiology, The Royal College of Radiologists. Ultrasound training recommendations for medical and surgical specialties. 2004. Available at: http://www.rcr.ac.uk/docs/radiology/pdf/ultrasound.pdf. Accessed June 4, 2007.
 
Ernst, A, Silvestri, GA, Johnstone, D Interventional pulmonary procedures: guidelines from the American College of Chest Physicians.Chest2003;123,1693. [PubMed]
 
Calvert, N, Hind, D, McWilliams, R, et al Ultrasound for central venous cannulation: economic evaluation of cost-effectiveness.Anaesthesia2004;59,1116-1120. [PubMed]
 

Figures

Figure Jump LinkFigure 1. Top, A: Transverse view showing the IJ vein anterior and lateral to the carotid artery. Note the significant overlap of the artery. Center, B: Same image as seen in top with less contralateral head rotation producing less overlap of the artery. Bottom, C: Longitudinal view of the IJ vein.Grahic Jump Location

Tables

References

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