The Oblique View: An Alternative Approach for Ultrasound-Guided Central Line Placement

Abstract

Background: Numerous studies have shown significant benefits of using real-time ultrasonography for central line intravenous access. Traditionally, the ultrasound probe is placed along the short axis of the vein to visualize and direct needle placement. This view has some limitations, particularly being able to visualize the needle tip. Some practitioners place the ultrasound probe in the long axis of the vessel to direct needle placement, allowing better visualization of the needle entering the vein, but this does not allow visualization of relevant anatomic structures. Objectives: We describe an alternative means to obtain ultrasound-guided vascular access using an oblique axis rather than the traditional short-axis approach. Discussion: This view allows better visualization of the needle shaft and tip but also offers the safety of being able to visualize all relevant anatomically significant structures at the same time and in the same plane. This orientation is halfway between the short and long axis of the vessel, allowing visualization of the needle as it enters the vessel. This capitalizes on the strengths of the long axis while optimizing short-axis visualization of important structures during intravenous line placement. Conclusion: Ultrasound-guided vascular access can be obtained in a variety of ways. We describe a technique that is used by some experienced ultrasound users but that has never been fully described in the literature. This technique for obtaining ultrasound-guided vascular access offers another option for attempting ultrasound-guided vascular access that has the potential to improve success rates and minimize complications associated with intravenous access.

Introduction

Obtaining vascular access is a vital component of patient care. When peripheral intravenous access is unable to be obtained, an intravenous catheter may be blindly placed percutaneously into the internal jugular vein using surface landmarks for guidance. Unfortunately, the performance of a landmark-guided procedure can be associated with significant complications, particularly in the obese, hypotensive, or anticoagulated patient, and in those with traumatic or congenital abnormalities.

Ultrasound-assisted vascular access can provide a safer and more efficient means of obtaining both peripheral and central venous access, reducing morbidity and the time required to place the catheter (1, 2, 3, 4). Meta-analyses have reported that ultrasound guidance significantly increases the probability of successful cannulation while reducing both the number of attempts and the complication rate (5, 6). The Agency for Healthcare Quality Research has recommended that ultrasound guidance be used for central line placement due to an improved margin of patient safety (7). Likewise, some authors suggest using ultrasound-guided vascular access in all central line attempts, and recommend that it should become the standard of practice for central line placement (8, 9).

Several techniques for the performance of internal jugular vein central line placement have been described. These include the central, anterior, and posterior approaches (10). All are performed blindly, guided only by anatomic landmark of the sternocleidomastoid muscle where it overlies the internal jugular vein in the neck, and do not consider anatomic variation or abnormality.

Our purpose was to describe the use of an oblique view for direct visualization of the vein and artery during placement of ultrasound-guided venous catheter.