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Topics in Practice Management

Ultrasound-Guided Internal Jugular

A Proposed Standardized Approach and
Implications for Training and Practice
David Feller-Kopman, MD, FCCP

In 2001, the Agency for Healthcare Research and Quality recommended the use of ultrasound for
the placement of central venous catheters (CVCs) as one of their 11 practices to improve patient
care. These recommendations were based on the results of several randomized clinical trials
showing significantly improved overall success as well as reductions in complications. This article
will describe the practical aspects of using ultrasound to guide placement of CVCs in the internal
jugular vein in a how I do it approach, as well as review the practice management and training
aspects related to incorporating ultrasound into daily practice.
(CHEST 2007; 132:302309)
Key words: central venous catheter; complications; internal jugular vein; outcomes; ultrasound
Abbreviations: CPT current procedural terminology; CVC central venous catheter; IJ internal jugular

than 5 million central venous catheters

M ore
(CVC) are placed each year in the United
States, with an associated complication rate of
15%.1,2 Mechanical complications such as arterial
puncture and pneumothorax are seen in up to 21%,
and up to 35% of insertion attempts are not successful.35 The risk of complications depends on several
factors, including (but not limited to) operator experience, urgency of placement, as well as patient
factors such as obesity, prior difficult cannulation,
and coagulopathy.4,6,7 Although the above-mentioned studies were performed in the 1970s through
the 1990s, there have been several more prospective/
randomized trials,8 16 as well as two metaanaly*From the Medical Procedure Service, Harvard Medical School,
Boston, MA.
The author has no conflict of interest to disclose.
Manuscript received November 7, 2006; revision accepted February 17, 2007.
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
Correspondence to: David Feller-Kopman, MD, FCCP, Interventional Pulmonology, Beth Israel Deaconess Medical Center, One
Deaconess Rd, Suite 201, Boston, MA 02215; e-mail:
DOI: 10.1378/chest.06-2711

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ses17,18 that suggest the use of ultrasound has been

associated with a reduction in complication rate and
an improved first-pass success when placing catheters in the internal jugular (IJ) vein. Although factors
other than the use of ultrasound may be responsible
for the improved outcomes, these data have led the
Agency for Healthcare Research and Quality to
recommend the use of ultrasound as one of their 11
practices to improve patient care in their landmark
2001 publication, Making Health Care Safer: a
Critical Analysis of Patient Safety Practices.19,20 The
National Institute of Clinical Excellence21 in the
United Kingdom has also fully supported the use of
ultrasound guidance for CVC placement.
Unfortunately, the incorporation of these recommendations into clinical practice has been met with
resistance. A survey of 250 anesthetists in the United
Kingdom found that 41% disagreed or strongly
disagreed with the recommendation that ultrasound
imaging should be the preferred method for insertion of a CVC into the IJ vein.22 Although 84% of
respondents believed that those using ultrasound
imaging should have appropriate training, 67% of
respondents believed the level of training provided
for ultrasound-guided CVC placement was inadeTopics in Practice Management

quate.22 Likewise, a study23 in the United States also

found that 15% of surgery, anesthesia, emergency
medicine, internal medicine, and family medicine
housestaff used ultrasound guidance for most CVC
This article will discuss the practical aspects of
performing ultrasound-guided CVC placement, and
address recommendations for training in ultrasoundguided CVC placement. The reader is referred to the
above-referenced studies for detailed discussions
concerning the improvement in success and reduction in complications with the use of ultrasound for
CVC placement. Additionally, as the data suggesting
ultrasound guidance for other sites, including the
subclavian, femoral, and axillary veins, are less robust, discussion will focus on the use of ultrasound
for IJ CVCs.

Ultrasound-Guided IJ CVC Placement:

How I Do It
Two types of ultrasound guidance are available:
Doppler and B-mode (also referred to as twodimensional ultrasound). Doppler ultrasound transforms the sound waves reflected from a moving
object (RBC in this case) into an amplified audio
signal. The respirophasic venous waveform is distinctly different from arterial pulsations, and Doppler ultrasound is frequently used to assess arterial
patency in the lower extremities and aid in arterial
catheters. The data behind Doppler ultrasound for
vascular access, however, is associated with a longer
learning curve than B-mode ultrasound, longer insertion times, and higher costs.24 26As such, IJ CVC
catheter placement is performed with B-mode ultrasound; from here on, the generic reference to ultrasound will imply B-mode.
B-mode ultrasound converts the reflected sound
waves into a real-time gray scale image. Fluid (ie,
blood) is hypoechoic and appears dark on the screen,
while tissue is more isoechoic and appears gray. The
IJ vein is typically seen anterior and lateral to the
artery; however, significant anatomic variation exists
where the vein can overly the artery and even be
medial to the artery.27,28 The IJ vein and artery can
be distinguished by the fact that the vein is compressible, nonpulsatile, and distensible by the Trendelenberg position or the Valsalva maneuver. The
use of ultrasound is an excellent teaching tool to
demonstrate the following: (1) excessive pressure
during carotid palpation decreases IJ vein diameter
(one cannot move the artery medially away from the
vein as they lie in the same sheath); (2) extreme
contralateral head rotation can decrease IJ vein diameter and increase overlap on the carotid artery; and (3)

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the Trendelenberg position and correct head positioning can significantly increase IJ vein diameter.29 32
I recommend that one perform an ultrasound
assessment of the anticipated side prior to creating a
sterile field in order to assess the degree of overlap of
the carotid artery by the IJ vein, the compressibility
of the vein, and the presence of internal echoes that
may signify clot. If there is significant overlap of the
carotid artery, the operator should try to reexamine
the neck with the head in the neutral position,
instead of with the head turned to the contralateral
side.31,32 If the vein is not compressible or a clot is
visualized, the other IJ vein should be examined.
Color power Doppler can also be used to visualize
the distinct arterial and venous pulsations, although
there have not been any studies ascribing specific
benefit to its use.
Once the appropriate vein is selected, the site is
sterilized and draped as per standard technique with
full barrier precautions33 and the ultrasound probe is
placed in a sterile sheath. This step generally requires an assistant to hold the probe vertically and
apply conducting gel to the uncovered probe. The
sterile operator can also drop sterile conducting gel
on the probe. The operator then inserts a hand into
the sheath, holds the probe, and then inverts the
sheath over the probe, making the probe and cable
sterile. Additional gel is then placed on the outside of
the sheath to ensure adequate coupling.
The two most commonly used methods for ultrasound guidance are the one-handed or the threehanded methods. In the one-handed method, the
operator controls the ultrasound probe with the
nondominant hand and the needle with the dominant hand. The three-handed method requires an
assistant (with full sterile barrier precautions) to hold
the probe while the operator controls the needle and
performs the procedure under real-time guidance.
The one-handed method is quite easy to learn,
improves first-pass success and overall success when
compared with the three-handed method,34 and is
the method we currently teach to our fellows. Using
the ultrasound to mark the skin and proceed without
real-time guidance is not recommended given the
significant increase in success rates for dynamic
guidance as compared with the X marks the spot
Regardless of the method used, the IJ vein and
carotid artery are identified with ultrasound and
centered on the screen. The lidocaine needle is then
inserted through the skin directly anterior to the
vessel (in the center of the probe), and the wheal of
subcutaneous lidocaine is visualized with the ultrasound as an enlarging hypoechoic area. It is often
helpful to jiggle the lidocaine needle to improve
visualization of the hyperechoic needle. As the proCHEST / 132 / 1 / JULY, 2007


cedure is performed in real-time, a finder needle is

not required, and the introducer needle is then
inserted in the same location. The only caveat one
needs to be aware of for the one-handed method is
that the operator usually needs to put down the
ultrasound probe in order to make the skin insertion
site taught for easy passage of the introducer needle.
Once the introducer needle is through the skin, the
probe is picked up with the nondominant hand and
used to guide the needle into the vessel. The introducer needle will indent the anterior IJ vein wall
and, depending on the diameter of the vessel, may
penetrate the posterior wall, resulting in a flash of
venous blood on withdrawal of the needle. As such,
orienting the patients neck as well as the ultrasound
probe in such a way as to minimize arterial overlap is
important. The primary advantage of ultrasound in
this setting is that this can be visualized.
Passage of the introducer needle into the IJ vein
can be performed either with a transverse (short axis)
view or a longitudinal (long axis) view (Fig 1).
Benefits of the transverse view are that it is generally
associated with a shorter learning curve and it can be
easier to visualize small vessels. The primary advantage of the longitudinal view is allows better visualization of the advancing needle tip, which may
reduce perforation of the posterior vessel wall. It is
for this reason that the longitudinal view is recommended by the American College of Emergency
Physicians.35 If using the transverse view, it is crucial
to follow the advancing needle tip with the ultrasound, making sure the plane of the ultrasound is not
too proximal or distal. Some ultrasound units can
provide simultaneous transverse and longitudinal
One can also use a needle guide to help with
insertion of the introducer needle. This is a piece of
plastic that angles the needle so it will intersect the
center of the vessel. A randomized trial36 found that
needle guides were associated with improved firstpass and second-pass success rates, but no difference
in arterial sticks when compared to ultrasoundguided CVC placement without the use of a needle
guide. This being said, the needle guides can be
slightly cumbersome; and once experienced with
ultrasound-guided CVC placement, additional benefit may not be present.
Once the IJ vein is entered with the introducer
needle, the ultrasound probe is placed on the field
and the typical modified Seldinger technique is used
to place the CVC. A study37 suggested immediate
use of the ultrasound after the procedure to confirm
line placement and rule out pneumothorax. Obvious
benefits include being able to use the line immedi304

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Figure 1. Top, A: Transverse view showing the IJ vein anterior

and lateral to the carotid artery. Note the significant overlap of
the artery. Center, B: Same image as seen in top with less
contralateral head rotation producing less overlap of the artery.
Bottom, C: Longitudinal view of the IJ vein.

ately, instead of waiting for a chest radiograph,

minimizing radiation exposure, and the lack of need
to reposition the patient.
Ultrasound Machine Requirements
Over the last several years, ultrasound machines
have become quite small and portable. Although not
Topics in Practice Management

essential, this portability makes these smaller machines extremely well suited for the ICU environment, especially when procedures need to be performed in geographically separate units. Several
machines are available, each with their own pros and
cons. For vascular access, one should use a 7.5- to
10-MHz linear array transducer because this provides excellent resolution and sufficient penetration.
Some ultrasound units are specifically made for
vascular access, whereas other units allow the transducers to be interchanged, permitting the sonographer to use the same machine for pleural/chest,
cardiac (including transesophageal echocardiography),
and abdominal ultrasound. Although not necessary,
color power Doppler is a useful added feature to the
standard vascular ultrasound unit, and if one plans on
performing more advanced ultrasound/echocardiography, the availability of M-mode, computation software,
and videotape storage may be beneficial.
In addition to the ultrasound unit and transducer,
one will need to invest in the sterile sheaths and
sterile ultrasound gel. Peripherals such as larger
monitors, docking stations, needle guides, and a
printer may be nice to have but are not essential. As
discussed below, in order to properly bill for ultrasound-guided CVC placement, documentation of the
ultrasound image with patient identifiers is required.
This can be either electronic or on paper, and
therefore one will need either a printer to place an
image in the medical record, or a method of transferring the ultrasound images to a computer. Clearly,
image storage requires disk space, with each image
being approximately 902 kilobytes. Over a 1-year
period, we archived 1.7 gigabytes for our chest and
vascular images. Many hospitals now have picture
archiving and communication systems, and integration with these systems is certainly possible. Additionally, images can be burned onto inexpensive
compact discs for permanent storage as well.
Implications for Training
The use of ultrasound is not limited to radiologists.
The American Medical Association policy on privileging for ultrasound imaging states the following38:
Ultrasound imaging is within the scope of practice of appropriately trained physicians. . . broad and diverse use and
application of ultrasound imaging technologies exist in medical practice. . . privileging of the physician to perform ultrasound imaging procedures in a hospital setting should be a
function of hospital medical staffs and should be specifically
delineated on the Departments Delineation of Privileges
form. . . each hospital medical staff should review and approve criteria for granting ultrasound privileges based on
background and training for the use of ultrasound technology
and strongly recommends that these criteria are in

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dance with recommended training and education standards

developed by each physicians respective specialty.

It is therefore our responsibility to develop training

guidelines and incorporate them into our daily practice as well as our fellowship programs.
The American College of Emergency Physicians
and the American College of Surgeons have set the
standard by developing policy statements addressing
the scope of practice, training and proficiency recommendations, quality improvement, and documentation issues regarding the use of ultrasonography in
the emergency setting.39,40 Both of these documents
strongly support the use of ultrasound by members
of their societies and address ways to obtain and
maintain competency, as well as ensuring quality
To gain the skills required to incorporate ultrasonography in clinical practice, the nonradiologist
needs to become proficient in both cognitive and
psychomotor skill sets. Training in image acquisition
and interpretation needs to include didactic lectures,
demonstrations and, most importantly, proctoring by
a skill sonographer.
As compared to the broad use of ultrasound in the
trauma setting, for example, two key factors allow for
a much more rapid learning curve for ultrasound
guidance for CVC placement. Firstly, ultrasoundguided CVC placement is not performed as a diagnostic test as is the focused abdominal sonography
for trauma examination or echocardiography, and
therefore the clinical implications that result from
interpretation of the ultrasound image are significantly less. Secondly, if the CVC was going to be
placed anyway, ultrasound imaging can only serve to
improve outcome. That is to say, misinterpretation of
ultrasound imaging may not adversely affect outcome when compared to placing a CVC with the
landmark technique. For example, even if an intraluminal thrombus is missed and the line is attempted,
it would have been attempted at that site without the
aid of ultrasound. Nonetheless, there is always some
element of diagnosis in all cases. For example, if a
thrombus is seen in the right IJ, in addition to
perhaps placing the catheter in the left IJ, appropriate evaluation and treatment of the right IJ thrombus
is required.
For a single application, the American College of
Emergency Physicians suggests 3 to 4 h of didactics,
2 to 4 h of laboratory training, and 25 proctored
examinations.39 Didactics should include lectures on
the basic physics and principles of ultrasound,
knobology (how to actually work the ultrasound
machine), image acquisition, identification and interpretation of ultrasound artifacts, identification of the
relevant anatomy, and knowledge of anatomic variaCHEST / 132 / 1 / JULY, 2007


tion. From the trauma literature, an 8-h course

including 4 h of didactic and 4 h of proctored
examinations on 15 normal patients, followed by 50
trauma examinations proctored by credentialed
sonographer or verified by standard diagnostic evaluations was shown to be sufficient to produce welltrained trauma surgeon sonographers.41 Others42
suggest 8 h of didactics, 10 normal proctored examinations, and 10 proctored, focused abdominal
sonography for trauma examinations may be adequate, depending on the prevalence of the disease
being sought (hemoperitoneum in this study).
Clearly there is some aspect of gaining a procedural skill that is numbers based. For CVC insertion,
the only data available relating experience to complications come from the preultrasound era, and
suggest that operators who have performed 50
insertions have half the complication rate of operators who have performed 50 insertions.4 The
Royal College of Radiology recommends 25 line
insertions but also acknowledges that different
trainees will acquire the necessary skills at different
rates and the end point of the training program
should be judged by an assessment of competencies.43 For bronchoscopy and other interventional
pulmonary procedures, the numbers published by
the American College of Chest Physicians44 are
generally less, in the range of 10 to 20 line insertions.
Given the rapid learning curve for US guidance of
CVCs, especially for the physician who is already
experienced in the landmark method of CVC placement, I would suggest approximately 2 h of didactics,
2 h of laboratory training, and 5 to 10 proctored
examinations. It should be pointed out that these
numbers are based on the above suggestions as well our
experience with a medical procedure service. Clearly,
these suggestions should be prospectively validated
with trials comparing a group who receives formal
education/simulation training to a group educated
through other means such as mentorship. Laboratory
training should include exposure to a variety of ultrasound units to ensure familiarity with knobology, examination of normal vascular anatomy on healthy volunteers, as well as hands-on simulation with vascular
access models. Available models range in sophistication
from Jell-O (Kraft Foods; Northfield, IL)/Metamucil
(Proctor & Gamble; Cincinnati, OH)/Penrose (Sherwood-Davis & Geck; St. Louis, MO) drains, to the Blue
Phantom ( [Blue Phantom
LLC; Kirkland, WA] to CentralLineMan (http://www. [Simulab Corporation; Seattle, WA]. Ideally, some of the laboratory
training would include visualization of abnormal anatomy (ie, the obese patient, intraluminal thrombus, or
significant overlay of the carotid artery by the IJ vein).

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The 5 to 10 proctored examinations should be broken

down into 3 to 5 ultrasound examinations of normal
anatomy/vascular access models, followed by 5 to 7
proctored procedures on vascular access models/simulators. For the physician who is already an expert at
CVC placement, I recommend two proctored examinations on real patients followed by review of the next
five ultrasound-guided CVCs. This would include reviewing the stored static picture/videotape as well as
outcome (success, complications, number of needle
passes), and discussion about factors that may have
influenced the outcome. Additionally, I recommend a
postinstruction assessment of the basics covered in the
didactic and hands-on session. This can include static
images and videotape, asking the operator to identify
anatomy, as well as questions relating to the use of the
ultrasound unit. These numbers are clearly subjective,
as are other procedural recommendations based on
number,44 and the main determinant in determining
competence should be the evaluation of the proctor.
Additional cognitive instruction can be provided
via textbooks, continuing medical education courses/
syllabi, digital video disk, and Web-based curricula.
Continuous quality improvement measures need to
be in place such that all complications are reviewed
in addition to several random cases during the
learning period. Skill maintenance is also crucial, and
at least 10 ultrasound-guided CVCs should be performed each year in order to maintain proficiency.
All of these issues have clear implications on
credentialing. As stated above, privileging is a local
hospital issue. Credentialing committees will need to
review their policy and likely incorporate some formal training to ensure quality. Most likely, the
process will be department specific (ie, the Department of Medicine signing off on members of the
Pulmonary and Critical Care Division). The issue of
grandfathering also needs to be addressed because
there are clearly physicians who have been using
ultrasound for CVC placement for some time. It may
be sufficient for this group to just take a quick quiz
documenting their knowledge, or even just verify
they have performed X number of ultrasoundguided CVC placements without incident.
It remains crucial that operators still receive training and become proficient in the standard/landmark
method of CVC insertion.21 Although one can make
the argument that learning the ultrasound-guided
technique first will make operators dependant on
technology, it has been our experience that the
anatomic knowledge gained by using ultrasound
makes one a better operator when the ultrasound is
not available, such as may be the case during a
cardiac arrest.
Topics in Practice Management

Billing and Documentation

The American Medical Association also supports
reimbursement for appropriately trained physicians.
It is the physicians responsibility to review the current
procedural terminology (CPT) codes with their local
billing expert as well as their local third-party payers as
reimbursements vary between regions, and even within
a state. The codes most commonly used codes for
ultrasound-guided CVC placement include 36556 and
76937. Though the reimbursements vary regionally,
CPT codes are created through the American Medical
Association and are the same throughout the United
States. Code 36556 describes insertion of nontunneled
centrally inserted central venous catheter; age 5 years
or older and has an associated Medicare payment of
approximately $132140 (facility, in Massachusetts,
Greater Boston area) [
244532;]. Code 76937
describes ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites,
documentation of selected vessel patency, concurrent
real-time ultrasound visualization of vascular needle
entry, with permanent recording and reporting (List
separately in addition to code for primary procedure)
and has an associated Medicare payment of approximately $35 40 (facility, in Massachusetts, Greater Boston area) [see above Web sites]. It should be noted,
however, that 76937 includes the technical component
associated with the procedure (supplies, technical
staff). The professional component is billed by using
the -26 modifier. In metropolitan Boston, the reimbursement for code 76937 is $39.94 ($22.26 technical,
As with all billing practices, it is the physicians
responsibility to ensure proper billing and documentation, and the reader is urged to review local
requirements with their insurance companies and
billing experts. It is also crucial to discuss reimbursement with ones third-party payers as they may wish
to have a letter from the chief of radiology at your
institution stating you have achieved competency.
This is yet another reason why our societies need to
take an active role in advocating for our own ability
to determine competency.
In addition to using the proper CPT codes, adequate documentation is a must. For ultrasound,
either a hard copy or electronic copy of the pertinent
images need to be saved in the medical record. This
needs to be done in accordance with the Health
Insurance Portability and Accountability Act guidelines, and all patient identifiers need to be safeguarded if the images are to be stored electronically.
Documentation for procedural billing that utilizes

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imaging techniques includes a formal report that

describes the sonographic findings in the procedure
note including location, adequate compressibility of
the vessel, and the fact that the ultrasound was used
for real-time guidance of the needle insertion.

Limitations to Ultrasonography
There are some realities one needs to face, however, prior to embracing ultrasound for all IJ CVCs.
First, there are no blinded randomized trials proving
improved outcome with infection (catheter-related
blood stream infection), ICU/hospital length of stay,
or mortality as end points. For the time being, we
therefore need to rely on the current evidence
showing improvements in success and arterial injury.
Clearly, experienced physicians can perform IJ
CVC placement safely without ultrasound guidance.
At this time, each of the relevant risks and benefits of
performing IJ CVC placement with or without ultrasound guidance need to be assessed on a case by case
basis. Given the recommendations by Agency for
Healthcare Research and Quality and National Institute of Clinical Excellence, ultrasound guidance
for IJ CVC placement will almost certainly become
standard of care. We may soon find ourselves in the
position of needing to explain why an IJ CVC was
placed without ultrasound guidance.
Secondly, there are numerous ultrasound machines available, each with their own advantages and
disadvantages, and although bells and whistles may
be nice to have, they are not required, and simple/
older machines can be adequate for most needs. The
initial financial investment can be quite significant
(approximately $25,000 to $40,000), although new
and used equipment can even be found on Internet
sites such as for significantly less money.
Additionally, maintenance costs and costs of additional supplies such as sterile sheaths and a printer
need to be budgeted for. Unfortunately, the data
regarding cost/benefit analysis for ultrasound guidance is extremely small. Calvert et al21,45 performed
a decision analysis with estimations of net benefits
and costs. With relatively conservative assumptions,
they found a significant cost savings associated with
the use of ultrasound of 2,000 for every 1,000
patients treated. Clearly, this is a model, and real
cost/benefit analyses are required that will include
the number of ultrasound machines per hospital or
specific unit. Thirdly, and perhaps most importantly,
quality assurance for both the ultrasound unit as well
as the physicians performing and interpreting the
ultrasound needs to be high on all of our priorities.
CHEST / 132 / 1 / JULY, 2007


Ultrasonography is an easily learned procedure
that not only enhances the physical examination but
has the distinct advantages of being a portable tool
that can provide real-time guidance for IJ CVC
placement with significant improvements in firstpass success, overall success, and arterial injury. As
chest physicians/intensivists, we need to embrace the
broad clinical applications of ultrasound, not only for
IJ CVC placement, but in our patients with pleural
disease, ascites, shock, and who have sustained
trauma. It is crucial that we take the lead in advocating that ultrasound become part of our daily
practice, create educational opportunities for members of our societies, and incorporate ultrasound
training in our fellowship programs.




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