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TECHNICAL INNOVATION

The Ultrasound-Only Central Venous

Catheter Placement and Confirmation
Procedure
Turandot Saul, MD, RDMS, RDCS, Michael Doctor, MD, Nicole L. Kaban, MD, Nicholas C. Avitabile, DO,
Sebastian D. Siadecki, MD, Resa E. Lewiss, MD

Videos online at www.jultrasoundmed.org

The placement of a central venous catheter remains an important intervention in the
care of critically ill patients in the emergency department. We propose an ultrasound-
first protocol for 3 aspects of central venous catheter placement above the diaphragm:
dynamic procedural guidance, evaluation for pneumothorax, and confirmation of the
catheter tip location.
Key Words—central venous access; central venous catheter placement; contrast-
enhanced ultrasound; emergency ultrasound; iatrogenic pneumothorax

T he placement of a central venous catheter remains an

Received September 22, 2014, from the Department
of Emergency Medicine, Division of Emergency
Ultrasound, Mount Sinai–St Luke’s Hospital,
Mount Sinai–Roosevelt Hospital, New York,
New York USA (T.S., M.D., N.L.K, N.C.A.,
S.D.S.); and Department of Emergency Medicine,
University of Colorado Hospital, Aurora,
Colorado USA (R.E.L.). Revision requested
October 9, 2014. Revised manuscript accepted
for publication October 24, 2014.
Address correspondence to Turandot
Saul, MD, RDMS, RDCS, Department of
Emergency Medicine, Mount Sinai–Roosevelt
Hospital, 1000 10th Ave, New York, NY
10019 USA.
E-mail: turan@joshsaul.com
doi:10.7863/ultra.34.7.1301
important intervention in the care of critically ill patients in
the emergency department. It is an essential procedural skill
for the emergency physician. Bedside ultrasound guidance for central
venous catheter placement is the standard of care, particularly at the
internal jugular vein site.1–6 Benefits of bedside ultrasound for central
venous catheter guidance include fewer complications (eg, arterial
puncture and pneumothorax),1,2 fewer cannulation attempts, and a
decreased procedure duration.3,4 More recently, bedside ultrasound
guidance has also been described for subclavian vein central venous
catheter placement.7,8
Once the central venous catheter procedure is completed, the
presence of iatrogenic pneumothorax should be excluded, and proper
placement of the catheter must be confirmed before it can be used
except in emergent situations (eg, insertion of a transvenous pace-
maker or use of a double-lumen hemodialysis catheter in a patient
requiring emergent hemodialysis). In many locations, postprocedure
chest radiography is performed to identify pneumothorax or hemo-
thorax and to confirm the location of the catheter tip.9,10 In a busy
emergency department, the limited availability of portable chest radi-
ography may incur a considerable time delay. The availability of chest
radiography may also be severely limited in resource-poor and austere
settings such as in the field or in the military/battle setting.
Bedside ultrasound is sensitive in its ability to evaluate the loss
of pleural line sliding as a marker of pneumothorax.11 It also has
promise in its ability to identify the location of the catheter tip.
Unlike chest radiography, bedside ultrasound imaging lacks ioniz-
ing radiation and may be performed in real time by the treating
physician. There is a minimal time delay, and the patient does not
need to be repositioned.

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Saul et al—Ultrasound-Only Central Venous Catheter Placement and Confirmation Procedure

Central venous access via the femoral vein will not be
discussed in this article. Ultrasound has been shown to be
valuable in the placement of central venous access catheters
in pediatric patients12; however, the literature on evaluat-
ing the tip location/placement in the pediatric population
is limited and will not be discussed in this article. Conse-
quently, we present a review and description of the literature
supporting the use of bedside ultrasound in adult patients.
We propose an ultrasound-first protocol for 3 aspects of
central venous catheter placement above the diaphragm:
dynamic procedural guidance, evaluation for pneumotho-
rax, and confirmation of the catheter tip location.
Sonographic Guidance of Central Venous
Catheter Placement in the Internal Jugular
Vein
The use of ultrasound-guided central venous catheter
placement in the internal jugular vein is well established
for its safety profile.1,2,5 Both the short-axis, out-of-plane
and long-axis, in-plane techniques require fewer attempts
and less time and result in fewer complications than the
landmark technique.1–5,13,14 Of note, there is also consid-
erable variation of the position of the internal jugular vein
in relation to the internal carotid artery, and ultrasound
guidance may help guide the operator away from inadver-
tent puncture of this arterial structure.15 In addition, an
oblique technique has been described, which uses the
strengths of the long-axis view while maintaining the short-
axis visualization of important structures.16
There are two sonographic approaches to the subcla-
vian vein: superior and inferior to the clavicle. The infra-
clavicular approach can be difficult due to shadowing from
the overlying clavicle. To avoid this effect, infraclavicular
subclavian vein visualization is performed via a lateral
approach to the vein (Figure 1).
The supraclavicular transducer placement carries some
benefits over the infraclavicular approach, including a
shorter distance from skin to vein, a larger target area,
a straighter path to the superior vena cava, and a greater
distance from the adjacent lung.21 The transducer is placed
transversely on the neck, visualizing the internal jugular
vein, which is followed proximally until it is seen at its con-
fluence with the subclavian vein (Figure 2).
Figure 1. The transducer is placed transversely and slightly obliquely,
following the long axis of the distal half of the clavicle. The axillary vein is
identified as it passes beneath it and becomes the subclavian vein at the
lateral border of the first rib.

Sonographic Guidance of Central Venous

Catheter Placement in the Subclavian Vein
Figure 2. The transducer is placed transversely, visualizing the internal
jugular vein at the level of the clavicular head. The internal jugular vein is
Most previous central venous catheter studies focus on followed proximally until it is seen at its confluence with the subclavian
internal jugular vein and femoral vein cannulation vein in its longitudinal axis, forming the innominate vein proximally.
because the anatomic location of the subclavian vein
makes it more technically challenging to identify sono-
graphically. There are recognized benefits of central
venous catheter placement in the subclavian vein com-
pared to the internal jugular vein. These include a more
accessible location for patients with spinal immobiliza-
tion, since repositioning is not required, and the ability
to remain patent even in the setting of hypovolemic
shock, due to support from the surrounding anatomic
structure of the fascia adhering to the ligaments and
periosteum of the clavicle.17,18 There is a growing vol-
ume of literature supporting the use of ultrasound guid-
ance and proposing various techniques for this newer
application.19,20

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Saul et al—Ultrasound-Only Central Venous Catheter Placement and Confirmation Procedure
An endocavitary probe approach to supraclavicular
subclavian vein access has been described. The shape and
smaller footprint of this probe allow it to fit easily into the
supraclavicular fossa, just lateral to the clavicular head of
the sternocleidomastoid muscle. Direct visualization of the
subclavian vein in the longitudinal axis results.7
In a randomized study of 52 subclavian vein cannula-
tions in the intensive care unit by postgraduate year 1 and
2 residents, the group that used ultrasound guidance (infra-
clavicular visualization) had a higher success rate (92% ver-
sus 44%) and a lower complication rate (4% versus 41%)
than the landmark-guided group.22 Another study in
mechanically ventilated patients showed a statistically sig-
nificant success rate (100% versus 87.5%) in the ultrasound-
guided group compared to the landmark-guided group.23
A third study evaluated subclavian vein visualization by a
supraclavicular versus infraclavicular technique. The authors
reported better visualization using a supraclavicular approach,
suggesting that it may be a technically easier option.24
Sonographic Evaluation for Pneumothorax
After Central Venous Catheter Placement
After placement of the central venous catheter in either the
internal jugular vein or the subclavian vein, an assessment
for pneumothorax should be performed. Lung sliding
essentially rules out pneumothorax; however, its absence
does not confirm it, with specificity of 91%.25 Conditions
such as massive atelectasis, right main stem intubation, pul-
monary contusions, adult respiratory distress syndrome,
and pleural adhesions can also cause a motionless pleural
line.11,26 A false-positive result may be avoided by knowing
the “state” of the pleural line before central venous catheter
placement, and prior assessment should be performed
before cannulation whenever possible. Visualization of a
single B-line rules out pneumothorax, with a true-negative
rate of 100%25 in patients with the absence of pleural dis-
ease. In complex patients with potentially abnormal pleura,
unusual sonographic findings such as the double lung point,
the septate pneumothorax, and the hydro point may be
present, and the operator should be aware of these diag-
nostic entities.27 Furthermore, a lung point can confirm
pneumothorax with 100% specificity28 and can be used to
estimate the size of the pneumothorax.29,30 However, the
sensitivity of a lung point is low in large pneumothoraces,
which cause complete retraction of the lung.28
Many studies have shown that lung ultrasound imaging
is more sensitive than supine anteroposterior chest radiogra-
phy for detecting pneumothorax in the setting of traumatic
injuries,31–34 as well as with iatrogenic causes such as transtho-
J Ultrasound Med 2015; 34:1301–1306
racic needle biopsy,35–38 chest tube placement,39 and as a
complication of central venous catheter placement. When
compared to the reference standard of computed tomogra-
phy, ultrasound has similar sensitivity for this diagnosis.40
Central Venous Catheter Placement in the
Internal Jugular Vein Versus the Subclavian
Vein
When comparing cannulation of the internal jugular vein
to the subclavian vein for central venous catheter place-
ment, in a meta-analysis by Ruesch et al,41 rates of pneumo-
thorax were shown to be similar. Furthermore, data varied
widely across studies regarding the success of the catheter
position between the two approaches and the experience
of the operators.
Sonographic Evaluation for the Position of
Central Venous Catheter Placement
Chest radiography has traditionally been performed to
evaluate the catheter tip’s location. However, its accuracy
is limited, as the superior vena cava–right atrial border
cannot be directly visualized.42,43 Instead, the tip position
is estimated by using anatomic landmarks with varying
success.9,10,43 Most guidelines recommend that the
catheter tip should sit in the inferior third of the superior
vena cava at the junction of the right atrium; however, the
safest location for the tip is still a topic of debate.9,42,43
In addition, changing the patient position from supine to
upright lengthens the distance from the insertion site
to the right atrium and can shift the catheter tip position.43
These changes may occur during patient positing for chest
radiography.
Unlike chest radiography, bedside ultrasound imaging
may be performed in real time, and the patient does not
need to be repositioned. Several studies advocate sono-
graphic evaluation of both internal jugular veins, both sub-
clavian veins, and the inferior vena cava, assessing for
incorrectly placed catheters, followed by cardiac ultrasound
imaging to observe catheter tips with an intracardiac loca-
tion. The superior vena cava is difficult to visualize sono-
graphically but may be attempted from the suprasternal
view or the right supraclavicular view with varying success.
For this reason, this technique requires the assumption that
if the catheter tip is not visualized in these other locations,
then it must be in the superior vena cava.44,45
To perform this scan protocol, the patient is placed in
a supine position, and a high-frequency transducer is
placed transversely on the neck at the apex of the triangle
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Saul et al—Ultrasound-Only Central Venous Catheter Placement and Confirmation Procedure

formed by the two heads of the sternoclenomastoid mus- Figure 3. A 10-mL syringe with 1 mL of room air and a 10-mL syringe
cle to visualize the internal jugular vein. The internal jugu- with 9 mL of saline are attached to a 3-way stopcock, which is attached
to distal port of the central venous catheter.
lar vein is scanned inferiorly, to its junction with the
subclavian vein, and then laterally as far as possible above
the clavicle as it becomes the axillary vein. The examination
is then repeated on the contralateral side. Last, a low-
frequency transducer is used in the subcostal view to visu-
alize the inferior vena cava and the right side of the heart,
looking for the catheter tip.
Maury et al44 performed this protocol on 85 patients.
All 4 incorrect catheter tip locations were correctly identi-
fied, and of the 6 intracardiac tip positions found on radi-
ography, 5 were noted with ultrasound. The one that was
missed was in a severely obese patient with limited cardiac
windows. Zanobetti et al45 similarly enrolled 204 patients.
Of the 9 incorrect catheter locations, all were inserted via
the right subclavian vein. All 5 catheters in the ipsilateral
internal jugular vein were noted with ultrasound, but all 4 Figure 4. Dense laminar flow of microbubbles in the right atrium (arrow)
catheters placed into the contralateral subclavian vein were after injection of 5 mL of air-saline contrast in a central venous catheter
correctly placed in the superior vena cava.
missed with ultrasound. Ultrasound imaging confirmed tip
placement with high specificity and sensitivity compared to
chest radiography: 89% and 94%, respectively.
Visualization of the catheter tip position may also be
facilitated by the use of intravenous contrast-enhanced
ultrasound. Ultrasound contrast uses agitated saline with
microbubbles of air, which has a very different acoustic
impedance than blood and is therefore highly echogenic
on ultrasound imaging. The contrast may be made by mix-
ing 90% saline and 10% air, although a 80% saline, 10% air,
and 10% blood mixture has been shown to be superior in
a variety of settings.46,47
To use this method, a 10-mL syringe with 1 mL of room
air and a 10-mL syringe with 9 mL of saline are each attached
to a 3-way stopcock, which is attached to the distal port of
the central venous catheter. The port to the central venous Figure 5. Turbulent flow of microbubbles in the right atrium (arrow) after
injection of 5 mL of air-saline contrast in a central venous catheter
catheter is closed, and the air and saline are mixed vigor- malpositioned in the right atrium.
ously by injecting the solution from one syringe back into
the other (Figure 3). The solution is then collected into
one syringe, and any visible air is removed to prevent air
emboli. While observing the heart in the subcostal view, 5
mL of the microbubble solution is injected. A central
venous catheter with its tip in the lower superior vena cava
will result in a dense laminar flow of microbubbles seen flow-
ing into the right atrium 1 to 2 seconds after injection (Figure
4). If the central venous catheter is in the right atrium, tur-
bulent flow will immediately be seen (Figure 5). Placement
elsewhere will cause a delay in microbubble appearance (>2
seconds) with decreased echogenicity. The operator must
also consider anatomically anomalous venous return when
there is either a delay in the expected timing or echogenicity

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Saul et al—Ultrasound-Only Central Venous Catheter Placement and Confirmation Procedure
of the microbubble solution. This test may be repeated
with the remaining solution.
Two studies described the use of contrast-enhanced
ultrasound for improving catheter tip visualization.
Vezzani et al48 studied 111 patients, first without contrast
enhancement and then with a rapid injection of 5 mL of a
saline/air microbubble mixture and noted 6 additional mal-
positioned intracardiac catheter tips when the microbubble
contrast was used. Wen et al49 evaluated 219 dialysis
catheters and found that contrast-enhanced ultrasound
was able to identify both catheters in incorrect locations:
1 placed in the contralateral internal jugular vein and 1
placed intracardially.
Conclusions
We have provided a comprehensive summary of the liter-
ature supporting point-of-care ultrasound as a guide not
only in the placement but also in the confirmation of cen-
tral venous catheters. Future studies should focus on the
time- and cost-saving aspects of this procedural approach.
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