Real‐time ultrasound guidance for central venous access

The Safe Vascular Access 2025 consensus statement is an excellent and comprehensive document that rightly emphasises system-wide safety processes, device selection, long-term vein health and robust training standards [1]. Many of the recommendations, particularly those relating to Local Safety Standards for Invasive Procedures (LocSSIPs), catheter–vessel ratios and workforce development, are highly relevant to improving the consistency and safety of vascular access across the United Kingdom. While we agree with the majority of the recommendations, we would like to offer specific comments regarding recommendation six, which states that real-time ultrasound guidance should be employed for all central vein access and other applicable access sites. Although this is an entirely appropriate standard for controlled in-hospital practice, we would caution against interpreting this as universally applicable to time-critical prehospital trauma care, where clinicians face circumstances occasionally in which ultrasound use is either impossible or harmful because of delay. In the prehospital environment, particularly within London's Air Ambulance, wide-bore central venous access is undertaken exclusively in patients with exsanguinating haemorrhagic shock, many already in traumatic cardiac arrest, to facilitate resuscitation. Obtaining wide-bore access to facilitate rapid blood product transfusion is often the single most important prehospital intervention, and in these patients, any treatment delay worsens survival. Mandating point-of-care ultrasound requires preparation and set-up and introduces a delay which could inadvertently harm patients. Many of the sites for which ultrasound guidance is most valuable (e.g. internal jugular, femoral vein) are frequently inaccessible or inappropriate in major trauma. Cervical spine immobilisation prevents effective internal jugular vein use, and groin or pelvic trauma or major abdominal haemorrhage may preclude femoral access. Even axillary approaches can be obstructed by patient position, clothing, armour or confined environments. Our recent large cohort study of 346 prehospital central line insertions (2019–2023) shows that landmark-guided central access is safe and effective [2]. The rate of success was 80%, with a complication rate of 4%, which is comparable with ultrasound-guided complication rates. Successful placement was associated strongly with higher prehospital transfusion volumes and increased rates of return of spontaneous circulation in traumatic cardiac arrest [2]. In our system, the landmark infraclavicular technique is often used due to its reliable anatomical location and rapidity of access. Clinicians may also use internal jugular or femoral sites with ultrasound guidance if they judge it to be quicker or safer. All clinicians working within the service undergo a training package and patients are followed up for complications. We support strongly the principle that ultrasound improves safety and should be used whenever feasible. However, a blanket requirement for its use in all settings risks unintended harm in the unique context of prehospital trauma. A more flexible phrasing, allowing clinician judgement in emergencies where delay could endanger life, would maintain alignment with the safety aims of the guideline while reflecting real-world constraints.