The Anaesthetic Period: Guidelines on the use of Ultrasound in Anaesthesia
Vascular access Transthoracic echocardiography The use of ultrasound (US) has significantly improved patient safety. It is sufficiently pervasive in both the training of anaesthetists and usage among SASA members to warrant the drafting of some guidance. Vascular access Based on available evidence, using real-time US during internal jugular (IJ) cannulation improves success and reduces the incide
Transthoracic echocardiography
The use of ultrasound (US) has significantly improved patient safety. It is sufficiently pervasive in both the training of anaesthetists and usage among SASA members to warrant the drafting of some guidance.
Vascular access
Based on available evidence, using real-time US during internal jugular (IJ) cannulation improves success and reduces the incidence of complications associated with the insertion of central venous catheters (CVC).
In adults, complications during performance of femoral vein (FV) cannulation are less severe than those that occur with subclavian (SC) and IJ vein cannulation. US guidance for FV access may improve the success rate and reduce complications for FV cannulation. However, this benefit may be more important with novice operators, paediatric patients, or patients with difficult anatomical landmarks. It should be noted that prolonged FV cannulation is associated with a higher incidence of DVT. An individualised and holistic patient risk-benefit assessment for site and type of line should always be considered.
Obese and coagulopathic patients should have US screening of the SC vein before attempted cannulation to identify vessel location and patency. If real-time US is not used as the initial technique for SC vein cannulation, it should be used as a rescue device.
Static US with skin marking is useful for identifying vessel anatomy and thrombosis but may not improve cannulation success or reduce complications as real-time US needle guidance does.
The major advantages of US-guided venous access are correct identification of the target vessel, confirmation of successful cannulation, avoidance of inadvertent arterial puncture and damage to juxtavenous anatomy, reduction in procedure time and a reduction in serious complications.
Current published evidence implies that adult and paediatric patients may benefit from using US when placing intra-arterial pressure monitoring lines. US reduces the number of attempts, shortens the procedure time and increases the rate of successful cannulation. It may be particularly advantageous in patients with abnormal anatomy, low perfusion states or previous unsuccessful cannulation attempts.
The cost-effectiveness of using US, particularly during CVC has been studied and well described. The calculated cost of managing potential complications outweighs the cost of incorporating this technology into the practice of anaesthesiology.
It is thus the opinion of SASA that, based on currently available evidence, the following recommendations relating to US-guided vascular access can be made:
- Support its use whenever available for the cannulation of IJ veins. There is clear, high-quality evidence that the use of US is superior to a landmark technique.
- It may be used for the cannulation of SC and FVs.
- Equivocal evidence supports the use of the US for arterial cannulation.
There have already been several cases where adverse incidents have occurred, and the affected doctors were specifically questioned as to whether they used US. If the answer was negative, their cases were deemed less likely to be defensible and against international best practices. Such cases have led to an essential precautionary application of US.
Transthoracic echocardiography
Focused assessment using TTE may be an invaluable perioperative extension to the clinical examination, and the skill can be acquired relatively easily. It should, however, not be seen as replacing a complete echocardiographic examination by an experienced operator if the indication for a thorough examination exists.
The use of US is now standard such that it is included in the training of anaesthesiologists from the outset. There have also been, and will continue to be, many CPD programmes and courses for people to get up to date with the latest usage and available equipment. Technology is advancing, in all areas, including new drugs and other equipment. It is part of the daily maintenance of an anaesthetist’s skill. This is a specific skill, but certainly not outside of a member’s normal capability to assimilate. No different mechanism of staying abreast of technology is needed for US over any other form of advancement in the field of medicine.
It is now an expected standard skill of an anaesthesiologist and should be included as part of the basic skill set. There should, therefore, be no different or additional accreditation required.
There is additional work required in applying this skill in practice, and an anaesthesiologist should be able to be reimbursed for this additional time and skill applied in the interests of patient safety.
It is thus the opinion of SASA that, based on currently available evidence, the following recommendations relating to US-guided vascular access can be made:
- Support its use whenever available for the cannulation of IJ veins. There is clear, high-quality evidence that the use of US is superior to a landmark technique.
- It may be used for the cannulation of SC and FVs.
- Equivocal evidence supports the use of the US for arterial cannulation.
South African Society of Anaesthesiologists (SASA) Practice Guidelines_2022_To be Reviewed in 2026