American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Revised Statement on Recommendations for Use of Real-Time Ultrasound Guidance for Placement of Central Venous Catheters

Revisions to this statement were developed by the ACS Committee on Perioperative Care and approved by the Board of Regents in October 2010.

More than 5 million central venous catheters (CVCs) are placed each year in the U.S., with an associated complications rate of more than 15 percent.1,2 Mechanical complications such as arterial puncture and pneumothorax are seen in up to 21 percent of patients with CVC complications, and up to 35 percent of insertion attempts are not successful.3-6

Several prospective, randomized trials,7-15 as well as two meta-analyses,16-17 document that 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 vein and the subclavian vein.

Real-time (rather than static) ultrasound guidance is the safest, most cost-effective, and successful method for CVC placement compared with the traditional percutaneous landmark-based approach for cannulation of the internal jugular vein. The use of ultrasound for central venous catheterization increases success rate while simultaneously decreasing procedural time and complication rate. Although not as robust as for the internal jugular site, evidence favors ultrasound for the subclavian and femoral vein site, as well. Standardization of education, training, and practice is also an important component of this technique.18

In 2001, the Agency for Healthcare Research and Quality recommended the use of ultrasound guidance for the placement of CVCs as one of the top 11 evidence-based practices that health care providers can use to improve patient care and patient safety.19

The Guidance on the Use of Ultrasound Locating Devices for Placing Central Venous Catheters from the National Institute for Clinical Excellence had the following major recommendations20:

  • Two-dimensional (2-D) imaging ultrasound guidance is recommended as the preferred method for insertion of CVCs into the internal jugular vein in adults and children in elective situations
  • The use of 2-D imaging ultrasound guidance should be considered in most clinical circumstances where CVC insertion is necessary either electively or in an emergency situation
  • It is recommended that all those involved in placing CVCs using 2-D imaging ultrasound guidance should undertake appropriate training to achieve competence
  • Audio-guided Doppler ultrasound guidance is not recommended for CVC insertion

The American College of Surgeons (ACS) supports the use of real-time ultrasound guidance for the placement of central venous catheters.

The ACS encourages health care systems to provide for the appropriate education, training, and resources required.


  1. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348:1123-133.
  2. Merrer J, De Jonghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: A randomized controlled trial. JAMA. 2001;286:700-707.
  3. Bernard RW, Stahl WM. Subclavian vein catheterizations: A prospective study: Non-infectious complications. Ann Surg. 1971;173:184-190.
  4. Sznajder JI, Zveibil FR, Bitterman H, et al. Central vein catheterization: Failure and complication rates by three percutaneous approaches. Arch Intern Med. 1986;146:259-261.
  5. Defalque RJ. Percutaneous catheterization of the internal jugular vein. Anesth Analg. 1974;53:116-121.
  6. Bjerke R, Mangione M, Oravitz T. Major arterial injury need not be a risk of central venous catheterization. Anesth Analg. 2004;98:SCA1-134.
  7. Mallory DL, McGee WT, Shawker TH, et al. Ultrasound guidance improves the success rate of internal jugular vein cannulation: A prospective, randomized trial. Chest. 1990;98:157-160.
  8. Troianos CA, Jobes DR, Ellison N. Ultrasound-guided cannulation of the internal jugular vein: A prospective, randomized study. Anesth Analg. 1991;72:823-826.
  9. Denys BG, Uretsky BF, Reddy PS. Ultrasound-assisted cannulation of the internal jugular vein: A prospective comparison to the external landmark-guided technique. Circulation. 1993;87:1557-1562.
  10. Slama M, Novara A, Safavian A, et al. Improvement of internal jugular vein cannulation using an ultrasound-guided technique. Intensive Care Med. 1997;23:916-919.
  11. Teichgraber UK, Benter T, Gebel M, et al. A sonographically guided technique for central venous access. Am J Roentgenol. 1997;169:731-733.
  12. Nadig C, Leidig M, Schmiedeke T, et al. The use of ultrasound for the placement of dialysis catheters. Nephrol Dial Transplant. 1998;13:978-981.
  13. Hayashi H, Amano M. Does ultrasound imaging before puncture facilitate internal jugular vein cannulation? Prospective randomized comparison with landmark-guided puncture in ventilated patients. J Cardiothorac Vasc Anesth. 2002;16:572-575.
  14. Leung J, Duffy M, Finckh A. Real-time ultrasonographically guided internal jugular vein catheterization in the emergency department increases success rates and reduces complications:a randomized, prospective study. Ann Emerg Med. 2006;48:540-547.
  15. Karakitsos D, Labropoulos N, De Groot E, et al. Real-time ultrasound guided catheterization of the internal jugular vein: A prospective comparison to the landmark technique in critical care patients. Crit Care. 2006;10:R162.
  16. Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: A meta-analysis of the literature. Crit Care Med. 1996;24:2053-2058.
  17. Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C, Thomas S. Ultrasonic locating devices for central venous cannulation: Meta-analysis. BMJ. 2003;327:361.
  18. Feller-Kopman D. Ultrasound-guided internal jugular access: A proposed standardized approach and implications for training and practice. Chest. 2007;132(1):302-309.
  19. Rothschild JM. Ultrasound guidance of central vein catheterization. In: On Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville, MD: AHRQ Publications; 2001; Chapter 21: 245–255. Available at: Accessed February, 2008.
  20. National Institute for Clinical Excellence (NICE). Guidance on the Use of Ultrasound Locating Devices for Placing Central Venous Catheters. London UK: NICE; 2002. Technology appraisal guidance no. 49.

Additional Resources

  • Procedure videos: Ultrasound-guided central venous catheter placement.
  • Gibbs FJ, Murphy MC. Ultrasound guidance for central venous catheter placement. Clinical review article. Hosp Phys. March 2006: 23-31. Available at: Accessed December 6, 2010.
  • AHRQ. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. 2001. Available at: Accessed February 25, 2008.