KDIGO Clinical Practice Guideline for Acute Kidney Injury
Using ultrasound guidance for dialysis catheter insertion: Recommendations and Rationale

• 5.4.3: We recommend using ultrasound guidance for dialysis catheter insertion. (1A):

Rationale

For several decades, techniques involving the use of anatomic landmarks have been the traditional mainstay of accessing the central venous system. Using the ‘‘blind’’ landmark technique is not without significant morbidity and mortality. Complications of central venous catheterization include arterial puncture (0.5–6%), hematoma (0.1–4.4%), hemothorax (0.4–0.6%), pneumothorax (0.1–3.1%), and up to 10–20% of insertion attempts are not successful.^666,667 In view of their large size, the risk of complications of dialysis catheters is expected to be even higher. Two meta-analyses have addressed the role of real-time two-dimensional ultrasound for central vein cannulation, and concluded that, compared to the landmark method, ultrasound-guided venous access increases the probability of successful catheter placement and reduces the risk of complications, the need for multiple catheter placement attempts, and the time required for the procedure. The advantage appears most pronounced for the jugular vein, whereas the evidence is scarce for the subclavian and femoral vein.^668,669 Subsequent large randomized trials have confirmed the superiority of ultrasound guidance.^670,671 Trials evaluating the placement of dialysis catheters in ESRD patients, mostly with observational design, yield a similar conclusion.^672-678 The KDOQI guideline for vascular access also recommends using ultrasound-assisted insertion.⁶⁴⁰