Venous access is an integral part of General Surgery and all of the subspecialties, particularly Critical Care, Trauma, and Vascular. Central Venous Catheterization (CVC) is a method of venous access employed by all of these surgeons. Since the 1940's CVC using anatomic landmarks has been the hallmark of Central Venous Access. However, there is an inherent problem with this procedure, namely, that some of the central veins are not cannulatable. This leads to the unpleasant situation, wherein a physician is blindly sticking an uncannulatable vein and he or she is unaware of the situation.

The video has two parts. In part one, I address the underlying assumptions that a physician makes every time he/she attempts CVC using landmarks (blindly) to guide the needle insertion. These assumptions are the following:

1. The patient has a central vein.
2. The vein is patent.
3. The vein is in a typical anatomic location.
4. The vein is of sufficient caliber.
5. The patient has prominent surface landmarks.
6. There is an absence of profound respiratory collapse.

Part one will demonstrate that these assumptions are not true all of the time. The main point is that abnormalities can be detected sonographically, prior to subjecting the patient to an invasive procedure that carries significant risks.

Part two of the video demonstrates some tricks of the trade.

1. Demonstration of the sono-guided technique.
2. Percutaneous puncture of a Cephalic Vein (in the Delto-pectoral groove) in a 530 pound man.
3. How to detect and redirect a catheter that is malpositioned from the Axillo-subclavian vein up into the Internal Jugular vein, prior to obtaining a radiograph.

There is a summary slide in which I state the reasons why I believe that sono-guided central line placement is a superior procedure, namely:

- Avoiding non-patent veins.
- Time the opening and closing of Respiratory Variation
- Fewer attempts
- Fewer complications
- Practicing for the difficult situation (I can't give this reason enough significance. I believe that the familiarity gained by using sono-guidance over and over in "normal" situations permits the operator to succeed in some very difficult access problems).