Ultrasound-Guided Cannulation: Time to Bring Subclavian Central Lines Back

Echogenic needles versus non-echogenic needles for in-plane ultrasound-guided infraclavicular axillary vein cannulation, a randomized controlled trial

Echogenic needles improve the reflection of the ultrasound beam. The aim of the study was to compare needle performance during ultrasound-guided cannulation of the infraclavicular axillary vein with an in-plane needle approach, using echogenic needles or non-echogenic standard needles. One hundred adult patients undergoing surgical procedures that required a central venous catheter were randomized for either echogenic or non-echogenic needles. The primary outcome was access time. Secondary outcomes encompassed total procedure time, success in first attempt, number of attempts, number of skin punctures, change of site for vascular access, catheter placement, subjective experience with needle visualization and needle procedure, and adverse events. Median (IQR) [range] venous access time was 21 (15-56) [6-440] in echogenic needle group and 26 (14-91) [6-925] in the non-echogenic needle group (p = 0.40). No statistically significant differences were found in the secondary outcome measures. One patient (non-echogenic needle group) experienced pneumothorax. In three patients in each group (6%) arterial puncture occurred. Echogenic needles did not significantly improve needle control or safety when used for infraclavicular axillary vein cannulation with an in-plane needle approach. The results indicate that standard needles are appropriate for ultrasound guided subclavian vascular access in a perioperative situation.

Efficacy and safety of supraclavicular versus infraclavicular approach for subclavian vein catheterisation: An updated systematic review and meta-analysis of randomised controlled trials

Background and Aims

Subclavian vein catheterisation (SVC) is more effective than internal jugular or femoral catheterisation and is linked to a lesser incidence of infection and patient discomfort. Whether the supraclavicular (SC) or infraclavicular (IC) approach is more effective for SVC is unclear in the previous systematic review. This updated review is designed to search the efficacy and safety of both approaches adopting the Grading of Recommendations Assessment, Development and Evaluation approach.

Methods

In May 2022, we explored the databases of Embase, MEDLINE, CENTRAL, ClinicalTrials.gov and WHO-ICTRP for randomised controlled trials to compare the two approaches.

Results

Seventeen trials (2482 cases) were included. In the primary outcomes, the SC approach likely reduces the failure proportion (relative risk [RR], 0.63; 95% confidence interval [CI], 0.47-0.86; I² = 5%) and the incidence of malposition (RR, 0.23; 95% CI, 0.13-0.39; I² = 0%) with moderate evidence and may slightly reduce the incidence of arterial puncture and pneumothorax (RR, 0.59; 95% CI, 0.29-1.22; I² = 0%) with low evidence. In the secondary outcomes, the SC approach may decrease the access time and may increase the first-attempt success proportion.

Conclusion

The SC approach for SVC should be selected after considering the clinician's expertise.

Smart Bio-Impedance-Based Sensor for Guiding Standard Needle Insertion

A venipuncture is the most common non-invasive medical procedure, and is frequently used with patients; however, a high probability of post-injection complications accompanies intravenous injection. The most common complication is a hematoma, which is associated with puncture of the uppermost and lowermost walls. To simplify and reduce complications of the venipuncture procedure, and as well as automation of this process, a device that can provide information of the needle tip position into patient’s tissues needs to be developed. This paper presents a peripheral vascular puncture control system based on electrical impedance measurements. A special electrode system was designed to achieve the maximum sensitivity for puncture identification using a traditional needle, which is usually used in clinical practice. An experimental study on subjects showed that the electrical impedance signal changed significantly once the standard needle entered the blood vessel. On basis of theoretical and experimental studies, a decision rule of puncture identification based on the analysis of amplitude-time parameters of experimental signals was proposed. The proposed method was tested on 15 test and 9 control samples, with the results showing that 97% accuracy was obtained.

Ultrasound Localization of Nitinol Wire of Sub-Wavelength Dimension

Goal: To enhance endovascular navigation using surgical guidewires and the use of ionizing radiation, we demonstrate a method for ultrasonic localization of wires with diameters less than the wavelength of ultrasound in the medium. Methods: Nitinol wires with diameters ranging from 50 μm to 250 μm were imaged ultrasonically in a 0.25-in-diameter water-filled tube in a gelatin medium. Imaging frequencies were 5 MHz, 7.5 MHZ, and 10 MHz. Results: For the full range of diameters traversing the phantom, the wires were localized successfully via visual inspection of both regular and difference ultrasound images. Similarly, two convolutional neural networks were trained, and both achieved an accuracy of over 95%. Conclusions: Wires with diameters as small as 50 μm were localized successfully in a water-based gelatin phantom, indicating the potential use of ultrasound to enhance endovascular navigation and surgical treatment.

Inadvertent arterial puncture involving the subclavian artery and the aorta during central venous catheterization: a case report

Background

This case report describes a subclavian vein cannulation that inadvertently led to an arterial puncture with the catheter tip radiologically seen at the level of the aorta. This case emphasizes the importance of postprocedural imaging and the disadvantages of not using ultrasound guidance in central venous catheterization.

Case presentation

A 24-year-old Caucasian man with diabetes mellitus type 1 presented himself to the emergency department due to abdominal pain accompanied by nausea and vomiting. The patient’s vital signs revealed blood pressure of 84/53 mmHg, heart rate of 103 beats per minute, respiratory rate of 18 breaths per minute, and temperature of 98.2 °F (36.7 °C). On physical examination, he was found to have dry oral mucosa with poor skin turgor, with diagnostics showing that he was in diabetic ketoacidosis after running out of insulin for 2 days. The patient was transferred to the intensive care unit to receive a higher level of care. Unfortunately, due to difficulty of peripheral line placement, only a gauge-22 cannula was secured at the left dorsum of the hand. Efforts to replace the current peripheral line were unsuccessful, and a decision to perform a central vein cannulation via the internal jugular vein was made. This was futile as well due to volume depletion, prompting a subsequent right subclavian vein route attempt. The procedure inadvertently punctured the arterial circulation, leading to the catheter tip being visible at the level of the aorta on postprocedure X-ray. The subclavian line was immediately removed with no adverse consequences for the patient. A right femoral line was successfully placed, and continuous management of the diabetic ketoacidosis ensued until normalization of the high anion gap was achieved.

Conclusion

Utilization of real-time ultrasound guidance via the subclavian approach could have allowed for direct visualization of needle insertion to the anatomical structures, guidewire location, and directionality, all of which can lead to decreased complications and improved cannulation success compared with the landmark technique. A leftward direction of the catheter seen on postprocedural X-rays should raise high suspicion of inadvertent catheter placement and immediate correction. This complication should have been prevented if ultrasound guidance had been used.

Inadvertent direct pulmonary artery catheterization complicating the effort for subclavian venous cannulation and central venous catheter placement: A case report and review of the literature

Subclavian access is commonly used in the intensive care unit (ICU) for central venous catheterization. Many complications have been reported during the placement of central venous catheters including pneumothorax, hemothorax, hematoma, and bleeding. The direct, through the thoracic wall, catheterization of pulmonary artery is a very rare one with only three previous reports in the literature. We report a patient who was catheterized for subclavian venous catheter placement, but the imaging techniques (chest X-ray and computed tomography with reconstruction of the images) revealed the direct positioning of the catheter into the pulmonary trunk, fortunately without other adverse events for the patient. Our case report in accordance with recent review of the literature strongly emphasizes the benefits of performing ultrasound-guided interventions in ICU.

Static Ultrasound Guidance VS. Anatomical Landmarks for Subclavian Vein Puncture in the Intensive Care Unit: A Pilot Randomized Controlled Study

BACKGROUND

Subclavian vein puncture is commonly used in the intensive care unit (ICU) but is associated with complications.

OBJECTIVE

Our aim was to compare the efficacy and safety of static ultrasound-guided subclavian vein puncture with traditional anatomical landmark-guided subclavian vein puncture in critically ill patients in the ICU.

METHODS

This pilot randomized controlled trial enrolled patients admitted to the ICU and requiring subclavian vein puncture between November 2017 and September 2018. The patients were randomized to ultrasound-guided puncture or anatomical landmark-guided puncture. The primary outcome measure was the puncture success rate. The secondary outcome measures included the number of punctures, rate of success at the first attempt, puncture time (i.e., procedure duration) and incidence of complications.

RESULTS

A total of 194 patients were included in the analyses. Compared with the anatomical landmarks group, the ultrasound group had a higher puncture success rate (91.7% vs. 77.6%; p = 0.007), lower rate of complications (7.3% vs. 20.4%; p = 0.008), and lower incidence of mispuncture of an artery (2.1% vs. 14.3%; p = 0.002). There were no significant differences in the number of punctures and puncture time between the two groups (both, p > 0.05).

CONCLUSIONS

Static ultrasound-guided subclavian vein puncture is superior to the traditional landmark-guided approach for critically ill patients in the ICU. It is suggested that static ultrasound-guided puncture techniques should be considered for subclavian vein puncture in the ICU.

TRIAL REGISTRATION

ChiCTR1900024051.

Supraclavicular or infraclavicular subclavian vein: Which way to go- A prospective randomized controlled trial comparing catheterization dynamics using ultrasound guidance

Background and Aims:

Subclavian vein (SCV) catheterization via the supraclavicular (SSV) or infraclavicular (ISV) approaches under real time ultrasonographic (USG) guidance is being performed routinely in critically ill patients in ICU.The aim of this study is comparative evaluation of SSV and ISV approaches in terms of success rate, time taken and incidence of complications.

Settings and Design:

In this prospective study, 110 critically ill patients were randomly divided into two groups of 55 each. Right SCV catheterization was performed using real time USG by single experienced operator.

Methods:

Success rate, first attempt success rate, time taken for venous visualization, puncture, catheterization, total procedure, incidence of mechanical, and infectious complications were variables used for comparison among groups.

Statistical Analysis Used:

Normality tests were performed using the Kolmogorov-Smirnov test. All data are expressed as the mean (SD), number (%), or median [interquartile range (IQR)] as indicated. Data were compared using the χ² test, the Mann–Whitney U-test, Fisher's exact test and Student's t-test as appropriate.

Results:

Total procedural time was significantly lesser in SSV group than ISV group (P < 0.0001). Time for visualization, puncture and catheterization were significantly higher in ISV group (P < 0.001). Success rate was 100% in both groups. First attempt success rate was more in SSV (P = 0.171).Two incidence of malposition was found in ISV group. Infectious complications were comparable in both groups.

Conclusions:

Real time USG-guided supraclavicular subclavian approach is a viable and preferable alternative with significantly lesser total procedural time, similar success rate, fewer attempts, faster and lesser complication rates as compared with infraclavicular approach.

'Stop sign' position for subclavian ultrasound: a single-blinded observational study of subclavian vein dimensions

OBJECTIVE

Right subclavian vein (SCV) dimensions were evaluated on ultrasound and whether these change when the right upper limb is in a neutral position compared with the 'stop sign' position (shoulder abducted and externally rotated to 90°, elbow flexed to 90°), and when patients were positioned 30° head-up compared with lying supine.

METHODS

Images of transverse and longitudinal views of the right SCV in patients ≥18 years, presenting with a range of conditions to a Regional Hospital Emergency Department, were recorded by two physicians in a randomly assigned, nonsequential order and measured blinded. Data were analysed with paired Student's t tests. N = 62.

RESULTS

Primary outcome: cross-sectional area (CSA) of the right SCV in transverse images.

SECONDARY OUTCOMES

depth of SCV to skin and diameter of SCV on longitudinal images. There was no significant difference in CSA of the SCV in supine patients when the arm was in the stop sign position compared with neutral (mean CSA: 1.20 ± 0.42 and 1.15 ± 0.39 cm, respectively; P = 0.3). In patients positioned 30° head-up, the stop sign position significantly increased CSA from 0.65 ± 0.33 to 1.00 ± 0.38 cm (P < 0.0001).

CONCLUSIONS

Utilizing the stop sign position does not change SVC dimensions when patients are supine, however, may improve dimensions when lying supine is contraindicated.

Hemothorax: A Review of the Literature

Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.^1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.

Sonographic visualization and cannulation of the axillary vein in two arm positions during mechanical ventilation: A randomized trial

BACKGROUND

Abduction of the arm has been used for ultrasound-guided infraclavicular axillary vein cannulation. We evaluated the influence of arm position on sonographic visualization and cannulation of the axillary vein in patients receiving mechanical ventilation.

METHODS

Sixty patients scheduled to undergo surgery under general anaesthesia with controlled mechanical ventilation were included in this prospective randomized study. The depth, size and distance of axillary vein to the pleura were recorded at three points: Point A, the most proximal part of the axillary vein visualized with adduction; Point A', Point A in abduction; and Point B, the most proximal part of axillary vein visualized in abduction. Cephalic movement of the clavicle at Point A' and the distance between Point A and Point B were noted. In Group A, cannulation was performed at Point A in the adducted arm and at Point B with the abducted arm in Group B after randomization.

RESULTS

Abduction moved the clavicle cephalad by 2.2 ± 0.6 cm and increased sonographic visualization of the axillary vein by 2.2 ± 0.5 cm in length, when compared with adduction. The distance from the vein to pleura was higher in Point A' (p < 0.001). No differences were found during cannulation in terms of first-pass success rate or number of attempts.

CONCLUSION

Abducted position moved the clavicle cephalad and allowed sonographic visualization of infraclavicular axillary vein approximately 2 cm more proximally than with the adducted arm, with a comparable rate of cannulation success.

Ultrasound- versus landmark-guided subclavian vein catheterization: a prospective observational study from a tertiary referral hospital

This was a single-center, observational, prospective study designed to compare the effectiveness of a real-time, ultrasound- with landmark-guided technique for subclavian vein cannulation. Two groups of 74 consecutive patients each underwent subclavian vein catheterization. One group included patients from intensive care unit, studied by using an ultrasound-guided technique. The other group included patients from surgery or emergency units, studied by using a landmark technique. The primary outcome for comparison between techniques was the success rate of catheterization. Secondary outcomes were the number of attempts, cannulation failure, and mechanical complications. Although there was no difference in total success rate between ultrasound-guided and landmark groups (71 vs. 68, p = 0.464), the ultrasound-guided technique was more frequently successful at first attempt (64 vs. 30, p < 0.001) and required less attempts (1 to 2 vs. 1 to 6, p < 0.001) than landmark technique. Moreover, the ultrasound-guided technique was associated with less complications (2 vs. 13, p < 0.001), interruptions of mechanical ventilation (1 vs. 57, p < 0.001), and post-procedure chest X-ray (43 vs. 62, p = 0.001). In comparison with landmark-guided technique, the use of an ultrasound-guided technique for subclavian catheterization offers advantages in terms of reduced number of attempts and complications.

Application of Lung Ultrasound in Critical Care Setting: A Review

This article reviews the use of thoracic ultrasound in the intensive care unit (ICU). The focus of this article is to review the basic terminology and clinical applications of thoracic ultrasound. The diagnostic approach to a breathless patient, the blue protocol, is presented in a simplified flow chart. The diagnostic application of thoracic ultrasound in lung parenchymal and pleural diseases, role in bedside procedures, diaphragmatic assessment, and lung recruitment are described. Recent updates discussed in this review help support its increasingly indispensable role in the emergent and critical care setting.

Point-of-Care Ultrasound in the Intensive Care Unit

Spreading beyond the realm of tertiary academic medical centers, point-of-care ultrasound in the intensive care unit is an important diagnostic tool. The real-time feedback garnered can lead to critical and clinically relevant changes in management and decrease potential complications. Bedside ultrasound evaluation in the intensive care setting with a small, portable equipment is well-suited for placement of central lines, lumbar puncture, thoracentesis or other bedside ICU procedures and in the evaluation of cardiac activity, pleural and abdominal cavity and the overall fluid volume. Formalized curriculums centering on point-of-care ultrasound are emerging that will enhance its applicability and relevance.

Supraclavicular approach for subclavian vein catheterization in pediatric anesthesia: The reborn of an ancient technique with the ultrasound's assistance

The insertion of a central venous catheter is a procedure frequently performed in paediatric anaesthesia. The most frequent approach for this procedure is the internal jugular vein. However, some specific factors in children, such as the short neck and the easy collapse of this vein, which is accentuated in situations such as hypovolaemia and changes in the respiratory pattern, can lead to greater difficulty. The supraclavicular approach of the subclavian vein was described more than 50 years ago. However, it is not often considered nowadays, even after the introduction of ultrasound, and despite the obvious advantages with respect to the internal jugular approach due to the lower incidence of thrombosis and infection. This document reviews the considerations of the supraclavicular approach according to the available evidence in paediatric anaesthesia, discusses the feasibility and safety of the procedure, and finally describes the technique of ultrasound--guided puncture.

Point-of-Care Ultrasound in Established Settings

The original and most widely accepted applications for point-of-care ultrasound (POCUS) are in the settings of trauma, shock, and bedside procedures. Trauma was the original setting for the introduction of POCUS and has been standardized under the four-plus view examination called the Focused Assessment with Sonography in Trauma (FAST). This examination was found to be especially practice changing for achieving rapid diagnoses in critically ill patients who are too unstable for the delays and transportation inherent in more advanced imaging with computed tomography. This application was broadened from the critically ill trauma patient to any critically ill patient, particularly the patient in undifferentiated shock. Although the Focused Assessment with Sonography in Trauma examination originally focused on sources of hemorrhage causing hypovolemic shock, POCUS also can quickly differentiate cardiogenic, obstructive, and distributive shock and help identify the more specific etiology such as massive pulmonary emboli, pericardial tamponade, and pneumothoraces. By expediting diagnosis, POCUS facilitates faster definitive treatment of life-threatening conditions. In pursuing treatment, US continues to serve a role in the form of visually guiding many procedures that were previously done blindly. US guidance of procedures has improved the safety of central line insertion, thoracentesis, and paracentesis, and has an emerging role in lumbar puncture. Experience in bedside US is becoming a vital tool in the clinician's bedside assessment and management, filling a void between the stethoscope and the more advanced studies and interventions available through radiology. Understanding the strengths and limitations of US enables clinicians to identify the appropriate situations in which they can apply this tool confidently.

Aortic regurgitation after chemoport catheter insertion: Diagnostic dilemma

Catheter insertion in central vein can potentially cause accidental arterial injury. However it is very unusual to see such catheter in aorta causing aortic regurgitation. Pressure monitoring and Ultrasound guidance can reliably prevent accidental arterial puncture.

Chest wall-parallel vs. conventional subclavian venous catheterization in cancer chemotherapy: A comparison of complication rates

The incidence of complications such as pneumothorax and hematoma between the chest wall-parallel and conventional subclavian venous catheterization in cancer chemotherapy was compared. From December 2011 to March 2016, a total of 314 patients undergoing chemotherapy for cancer in the Guizhou Provincial People's Hospital were assigned to either the Chest Wall-parallel (n=155) or the conventional subclavian venous catheterization group (n=159) in order to observe the primary success rate for catheterization and to assess the incidence of complications such as pneumothorax, hemothorax, hematoma, and internal jugular venous injury. The primary success rates for catheterization were not significantly different between the conventional and chest wall-parallel subclavian venous catheterization groups (94.3% vs. 96.8%, P>0.05), with a total catheterization success rate of 100% in both groups. However, the incidence of pneumothorax was significantly different between the groups (6.29% in conventional vs. 0% in chest wall-parallel subclavian venous catheterization group, P<0.05). Therefore, compared to conventional subclavian venous catheterization, the chest wall-parallel approach could reduce the risk of or even totally prevent pneumothorax and other venipunctures and is, thus, a relatively safe and effective technique that could have wide applications in clinical settings.

Real-time ultrasound-guided axillary vein cannulation in children: a randomised controlled trial

The axillary vein is a good site for ultrasound-guided central venous cannulation in terms of infection rate, patient comfort and its anatomical relationship with the clavicle and lungs. We compared real-time ultrasound-guided axillary vein cannulation with conventional infraclavicular landmark-guided subclavian vein cannulation in children. A total of 132 paediatric patients were randomly allocated to either ultrasound-guided axillary vein (axillary group) or landmark-guided subclavian vein (landmark group). The outcomes measured were success rate after two attempts, first-attempt success rate, time to cannulation and complication rate. The success rate after two attempts was 83% in the axillary group compared with 63% in the landmark group (odds ratio 2.85, 95%CI 1.25-6.48, p = 0.010). The first-attempt success rate was 46% for the axillary group and 40% for the landmark group (p = 0.274) and median time to cannulation was 156 s for the axillary group and 180 s for the landmark group (p = 0.286). There were no differences in complication rates between the two groups, although three episodes of subclavian artery puncture occurred in the landmark group (p = 0.08). We conclude that axillary vein cannulation using a real-time ultrasound-guided in-plane technique is useful and effective in paediatric patients.

A randomized clinical trial of ultrasound-guided infra-clavicular cannulation of the subclavian vein in cardiac surgical patients: short-axis versus long-axis approach

PURPOSE

The aim of this study was to compare the success rate and safety of short-axis versus long-axis approaches to ultrasound-guided subclavian vein cannulation.

METHODS

A total of 190 patients requiring central venous cannulation following cardiac surgery were randomized to either short-axis or long-axis ultrasound-guided cannulation of the subclavian vein. Each cannulation was performed by anesthesiologists with at least 3 years' experience of ultrasound-guided central vein cannulation (>150 procedures/year, 50% short-axis and 50% long-axis). Success rate, insertion time, number of needle redirections, number of separate skin or vessel punctures, rate of mechanical complications, catheter misplacements, and incidence of central line-associated bloodstream infection were documented for each procedure.

RESULTS

The subclavian vein was successfully cannulated in all 190 patients. The mean insertion time was significantly shorter (p = 0.040) in the short-axis group (69 ± 74 s) than in the long-axis group (98 ± 103 s). The short-axis group was also associated with a higher overall success rate (96 vs. 78%, p < 0.001), first-puncture success rate (86 vs. 67%, p = 0.003), and first-puncture single-pass success rate (72 vs. 48%, p = 0.002), and with fewer needle redirections (0.39 ± 0.88 vs. 0.88 ± 1.15, p = 0.001), skin punctures (1.12 ± 0.38 vs. 1.28 ± 0.54, p = 0.019), and complications (3 vs. 13%, p = 0.028).

CONCLUSIONS

The short-axis procedure for ultrasound-guided subclavian cannulation offers advantages over the long-axis approach in cardiac surgery patients.

Supraclavicular Approach to Ultrasound-Guided Brachiocephalic Vein Cannulation in Children and Neonates

The correct choice of intra vascular access in critically ill neonates should be individualized depending on the type and duration of therapy, gestational and chronological age, weight and/or size, diagnosis, clinical status, and venous system patency. Accordingly, there is an ongoing demand for optimization of catheterization. Recently, the use of ultrasound (US)-guided cannulation of the subclavian vein (SCV) has been described in children and neonates. This article gives an overview of the current use of US for achieving central venous catheter placement in the SCV or the brachiocephalic vein (BCV) in neonates. More than 1,250 catheters have been reported inserted in children and neonates for a cumulated success rate of 98.4% and the complication rate is reported to be low. The technical aspects of various approaches are discussed, and we offer our recommendation of an US-guided technique for SCV and BCV cannulation based on our experience in a large NICU setting. Although the cannulation the SCV or BCV does not substitute the use of peripherally inserted central catheters or umbilical venous central catheters in neonates, it is a feasible route in very small children who are in need of a large caliber central venous access.

Ultrasound-guided vascular cannulation in critical care patients: A practical review

Vascular cannulation is common practice in critical care, and is traditionally performed using the landmark technique - though failures and complications are not uncommon. In this regard, ultrasound guided vascular cannulation (USGVC) has been shown to improve the procedure success rate and reduce its associated complications. This review addresses the fundamental aspects of USGVC and discusses some training issues related to this technique which is currently regarded as essential for intensivists.