Echocardiography and Ultrasound in the Intensive Care Unit

Central Venous Cannulation

There are numerous articles dealing with ultrasound guidance for central venous cannulation in the intensive care unit. The reader is encouraged to refer to the American Society of Echocardiography (ASE) and Society of Cardiovascular Anesthesiologists (SCA) joint guideline, published in 2011, for recommendations for vascular cannulation. For internal jugular vein cannulation, the guideline recommends that properly trained individuals use real-time ultrasound based on Level 1 evidence. For the subclavian vein, it states that the use of ultrasound for routine cannulation is not supported by literature, but for high-risk individuals, ultrasound to assess location and patency of the vein may be beneficial. For the femoral vein, the guideline states that the scientific evidence does not support routine use of ultrasound (Troianos et al., 2011).

As an aside, ultrasound techniques have been well described for femoral vein and internal jugular vein cannulation. Both static and real-time ultrasound guided cannulation techniques have also been described for the subclavian vein though they are more technically difficult. Fragou and colleagues reported on a comparison between real-time ultrasound guided cannulation and a landmark technique for subclavian vein and found the real-time technique to be superior in terms of complication rates. Their technique utilized the identification of the axillary vein between 1^st and 2^nd rib in the infraclavicular region in a long-axis (longitudinal) view, and watching the needle enter the vein (Fragou et al., 2011).

Arterial Cannulation

Though there are no Level 1 recommendations on the role of sonography in arterial cannulation, there are a fraction of patients in the cardiac ICU who have mechanical devices that reduce native arterial pulsatility. In this patient population, ultrasound is very useful in locating an arterial vessel and guiding cannulation.