How to choose the most appropriate ultrasound-guided approach for central line insertion: Introducing the rapid central venous assessment protocol

Overview

Standard central venous access performed with the “blind” technique was historically based on the puncture of two central veins (the subclavian vein and the internal jugular vein), but ultrasound (US) guidance has expanded the spectrum to at least four sites: the internal jugular vein, the brachiocephalic (or “innominate”) vein, the subclavian vein, and the axillary vein. In many patients, two additional, centrally located venous segments can be cannulated: the external jugular vein (in its final tract close to the junction of the subclavian vein) and the cephalic vein (in its final, infraclavicular tract close to the junction of the axillary vein).

The list just presented is limited to the veins available for placement of central venous catheters (CVCs) in the neck/thoracic area . However, other peripheral veins can be used for US-guided cannulation and placement of a peripherally inserted central catheter in the upper part of the arm (the cephalic vein, the brachial veins, the basilic vein, and the axillary vein in its distal tract). Other peripheral veins located in the groin area (the femoral and saphenous veins) can be accessed for placing “central” venous catheters.

The shift from a “heads-or-tails” choice (subclavian vs. jugular) to a wide spectrum of choices (internal jugular, brachiocephalic, subclavian, axillary, etc.) is the real “Copernican” revolution of the US era. Whereas in the last century the physician was bound to choose between the subclavian and jugular sites on the basis of personal preference, instinct, or experience, selection of the most appropriate vein to cannulate can be determined today on a rational basis by means of US technology.