When ultrasound-guided catheterization is useless: back to landmarks!

A study by Maizel and colleagues [1] in a recent issue of Critical Care shows that a resident skilled at inserting a central venous catheter (CVC) via the ultrasound-guided (UG) technique may face difficulties inserting a CVC via the anatomical landmark (LM) technique. Because several studies have demonstrated significantly increased safety, effectiveness, and efficiency of UG vascular access, as compared with cannulation by anatomical LMs, the UG technique became the more broadly recommended procedure [2-4]. However, as residents are trained only in this technique, they are no longer able to perform the LM technique, even when ultrasound is not available or applicable. In fact, we recently had a patient with extensive subcutaneous emphysema requiring veno-venous extracorporeal membrane oxygenation. Percutaneous cannula implantation, usually performed under ultrasound