Ultrasound guidance for placement of central venous catheters is becoming the standard of care across medical disciplines. Doppler localization of vascular structures has been used for many years, and the literature has slowly come to prove the utility of ultrasound. Newer portable equipment has made ultrasound useful and practical at the bedside. The widespread use of ultrasound has been slower to occur than might be anticipated. The success rate for internal jugular cannulation by the landmark technique is impressive at 95% to 99%. Many clinicians with skilled hands do not feel that they need assistance in localizing a central vein because they have had such dramatic success with the landmark method. However, in reviewing the studies that document such widespread success for internal jugular cannulation, we find that they often require multiple attempts and have a significant complication rate. A review of the literature demonstrates that two-dimensional ultrasound guidance for central venous access improves the success rate, reduces the complication rate, and reduces the number of attempts when compared to landmark techniques.

Ultrasound guidance improves cannulation success rates. For the internal jugular vein there is a relative risk reduction of 86% for failed cannulation in adults, and risk reduction of 85% in infants. For the subclavian vein, data demonstrate a relative risk reduction of 86% for failed cannulation. For the femoral vein, there is a relative risk reduction of 73%. These data are compiled from meta-analysis of large randomized controlled trials and are statistically significant.

Ultrasound guidance also reduces the likelihood of complication during central venous cannulation. There is a relative risk reduction of 57%. With a complication rate of 5% in experienced hands and 11% in inexperienced hands, these findings stand to improve patient safety and outcome dramatically.

Ultrasound guidance reduces the number of attempts for venous cannulation. The relative risk reduction for successful cannulation on the first attempt is 41%. Ultrasound also decreases the time to successful cannulation.
Some clinicians believe that ultrasound guidance adds time and burden to their procedures, but the evidence demonstrates fewer attempts and shorter times to successful venous cannulation.

The data presented above demonstrate a favored approach for ultrasound over landmark methods for central venous cannulation. Other metaanalyses have pooled data that include Doppler localization into the ultrasound group and could not demonstrate results as favorable. The Hind study demonstrates that Doppler localization (as opposed to two-dimensional ultrasound) is less successful and more time-consuming than even landmark methods. These data, therefore, support the use of two-dimensional ultrasound over Doppler localization and the landmark method.