Article Data

  • Views 324
  • Dowloads 143

Original Research

Open Access

Barriers to the use of ultrasound guidance in central venous catheter placement by emergency physicians in Saudi Arabia: a cross-sectional study

  • Reema M Alhussein1,*,
  • Bader A Alyahya1
  • Abdulaziz S Alashaikh1
  • Mohammed A Malabarey1
  • Khaled N Alrajhi2
  • Zohair A Al Aseri1,3

1Department of Emergency Medicine, College of Medicine and medical city, King Saud University, 11362 Riyadh, Saudi Arabia

2Department of Emergency Medicine, King Faisal Specialist Hospital and Research Center, 11564 Riyadh, Saudi Arabia

3Clinical Sciences Department and Riyadh hospital, Dar Al Uloom University, 13314 Riyadh, Saudi Arabia

DOI: 10.22514/sv.2023.035

Submitted: 09 November 2022 Accepted: 01 December 2022

Online publish date: 09 May 2023

*Corresponding Author(s): Reema M Alhussein E-mail:


The use of ultrasound-guided central venous catheter (USG-CVC) placement is still low among emergency physicians in many countries, including Saudi Arabia, because of several inherent perceived barriers. We assessed the barriers to the use of USG-CVC placement in clinical practice among Saudis currently in training, residents and board-certified physicians and evaluated the association of these barriers with the demographic characteristics of EPs. We conducted a cross-sectional survey among all emergency physicians (EPs) practicing in Saudi Arabia who completed a residency program in emergency medicine (EM) or were board-certified emergency physicians from October to December 2018. The survey material was sent via SurveyMonkey through the Saudi Commission for Health Specialties to target EPs. Two hundred thirty-four EPs completed the survey (response rate: 66.9%), and 177 (75.6%) were males. EPs from nongovernment institutions tended to agree significantly more than EPs from government institutions with the perception that USG-CVC placement is a time-consuming process (17.9% vs. 20.3%, respectively, p = 0.022). Residents were 3.8 times more likely to perceive loss of their skill in using Ultrasound (US) for CVC placement Odds ratio (OR) = 3.806, 95% Confidence interval (CI) = 0.218–0.686, p < 0.001), 2 times more likely to believe that USG-CVC placement was not proven in randomized controlled trials (OR = 2.061, 95% CI = 0.010–0.460, p = 0.040), and 5.5 times more likely to believe that USG-CVC placement was not a cost-effective procedure (OR = 5.490, 95% CI = 0.411–0.870, p < 0.001) than board-certified EPs. Many EPs, particularly those in training, believe there are several barriers to using USG-CVC placement, including loss of skill, a lack of support of the procedure in randomized controlled trials and cost-effectiveness. This is true, although there is existing evidence and a consensus regarding the superiority of USG-CVC placement over the landmark technique. In comparison to the more experienced and well-trained board-certified EPs, residents’ confidence and skill in using USG-CVC placement may have been influenced by their training and experience.


Barriers; Ultrasound-guided central venous catheter placement; Emergency physicians; Factors; Saudi Arabia

Cite and Share

Reema M Alhussein,Bader A Alyahya,Abdulaziz S Alashaikh,Mohammed A Malabarey,Khaled N Alrajhi,Zohair A Al Aseri. Barriers to the use of ultrasound guidance in central venous catheter placement by emergency physicians in Saudi Arabia: a cross-sectional study. Signa Vitae. 2023.doi:10.22514/sv.2023.035.


[1] National Institute for Clinical Excellence. Guidance on the use of ultrasound locating devices for placing central venous catheters. 2002. Available at: (Accessed: 21 September 2022).

[2] Reusz G, Csomos A. The role of ultrasound guidance for vascular access. Current Opinion in Anaesthesiology. 2015; 28: 710–716.

[3] Howard ZD, Noble VE, Marill KA, Sajed D, Rodrigues M, Bertuzzi B, et al. Bedside ultrasound maximizes patient satisfaction. The Journal of Emergency Medicine. 2014; 46: 46–53.

[4] Maizel J, Bastide M, Richecoeur J, Frenoy E, Lemaire C, Sauneuf B, et al. Practice of ultrasound-guided central venous catheter technique by the French intensivists: a survey from the BoReal study group. Annals of Intensive Care. 2016; 6: 76.

[5] Al Aseri ZA, Al Hussein RM, Malabarey MA, AlYahya BA, Al Moaiqel FA, Al Ansari MA, et al. Use of ultrasound guidance in central venous catheter placement by emergency physicians in Saudi Arabia. Saudi Medical Journal. 2020; 41: 698–702.

[6] Bellows B, Totten J, Shah S, Adedipe A. Perceived barriers in the use of point of care ultrasound in the WWAMI Region. Journal of Emergency Medicine & Critical Care. 2015; 1: 4.

[7] Backlund B, Hopkins E, Kendall J. Ultrasound guidance for central venous access by emergency physicians in colorado. Western Journal of Emergency Medicine. 2012; 13: 320–325.

[8] Leschyna M, Hatam E, Britton S, Myslik F, Thompson D, Sedran R, et al. Current state of point-of-care ultrasound usage in canadian emergency departments. Cureus. 2019; 11: e4246.

[9] Howard ZD, Noble VE, Marill KA, Sajed D, Rodrigues M, Bertuzzi B, et al. Bedside ultrasound maximizes patient satisfaction. The Journal of Emergency Medicine. 2014; 46: 46–53.

[10] Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C, et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ. 2003; 327: 361.

[11] Hrics P, Wilber S, Blanda MP, Gallo U. Ultrasound-assisted internal jugular vein catheterization in the ED. The American Journal of Emergency Medicine. 1998; 16: 401–403.

[12] Miller AH, Roth BA, Mills TJ, Woody JR, Longmoor CE, Foster B. Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Academic Emergency Medicine. 2002; 9: 800–805.

[13] Milling TJ, Rose J, Briggs WM, Birkhahn R, Gaeta TJ, Bove JJ, et al. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: the third sonography outcomes assessment program (SOAP-3) trial. Critical Care Medicine. 2005; 33: 1764–1769.

[14] Leung J, Duffy M, Finckh A. Real-time ultrasonographically-guided internal jugular vein catheterization in the emergency department increases success rates and reduces complications: a randomized, prospective study. Annals of Emergency Medicine. 2006; 48: 540–547.

[15] Adhikari S, Theodoro D, Raio C, Nelson M, Lyon M, Leech S, et al. Central venous catheterization: are we using ultrasound guidance?Journal of Ultrasound in Medicine. 2015; 34: 2065–2070.

[16] Flynn CJ, Weppler A, Theodoro D, Haney E, Ken Milne W. Emergency medicine ultrasonography in rural communities. Canadian Journal of Rural Medicine. 2012; 17: 99–104.

[17] Zaver F, Boniface K, Wachira B, Wanjiku G, Shokoohi H. International scope of emergency ultrasound: barriers in applying ultrasound to guide central line placement by providers in Nairobi, Kenya. Emergency Medicine International. 2018; 2018: 1–5.

[18] Buchanan MS, Backlund B, Liao MM, Sun J, Cydulka RK, Smith-Coggins R, et al. Use of ultrasound guidance for central venous catheter placement: survey from the american board of emergency medicine longitudinal study of emergency physicians. Academic Emergency Medicine. 2014; 21: 416–421.

[19] Leibowitz A, Oren-Grinberg A, Matyal R. Ultrasound guidance for central venous access: current evidence and clinical recommendations. Journal of Intensive Care Medicine. 2020; 35: 303–321.

[20] Javeri Y, Jagathkar G, Dixit S, Chaudhary D, Zirpe KG, Mehta Y, et al. Indian society of critical care medicine position statement for central venous catheterization and management 2020. Indian Journal of Critical Care Medicine. 2020; 24: S6–S30.

[21] Crenshaw NA, Briones P, Gonzalez JM, Ortega J. A review of central venous access using ultrasound guidance technology. Advanced Emergency Nursing Journal. 2020; 42: 119–127.

[22] Ablordeppey EA, Drewry AM, Theodoro DL, Tian L, Fuller BM, Griffey RT. Current practices in central venous catheter position confirmation by point of care ultrasound: a survey of early adopters. Shock. 2019; 51: 613–618.

[23] LeMaster CH, Hoffart N, Chafe T, Benzer T, Schuur JD. Implementing the central venous catheter infection prevention bundle in the emergency department: experiences among early adopters. Annals of Emergency Medicine. 2014; 63: 340–350.e1.

[24] Khait L, Malik AN, Petrovich MP, Ajani AA, Favot MJ. Ultrasound-guided central venous catheters. Emergent Vascular Access. 2021; 146: 111–132.

[25] Pinelli F, Franco A. Ultrasound-guided central and peripheral vein cannulation. Textbook of Echocardiography for Intensivists and Emergency Physicians. 2019; 9: 483–488.

[26] Gjesteby LA, Pare JR, Brattain LJ. Ultrasound for the emergency department and prehospital care. Engineering and Medicine in Extreme Environments. 2022; 48: 209–234.

[27] Brenner LA, Koehler DJ, Rottenstreich y. Remarks on support theory: recent advances and future directions. Heuristics and Biases. 2002; 13: 489–509.

[28] Duffy FD, Holmboe ES. Self-assessment in lifelong learning and improving performance in practice: physician know thyself. JAMA. 2006; 296: 1137–1139.

[29] Pronovost PJ. Enhancing physicians’ use of clinical guidelines. JAMA. 2013; 310: 2501–2502.

[30] Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. The Cochrane Database of Systematic Reviews. 2015; 1: CD011447.

[31] Calvert N, Hind D, McWilliams R, Davidson A, Beverley CA, Thomas SM. Ultrasound for central venous cannulation: economic evaluation of cost-effectiveness. Anaesthesia. 2004; 59: 1116–1120.

[32] Sibbitt WL, Band PA, Kettwich LG, Chavez-Chiang NR, DeLea SL, Bankhurst AD. A randomized controlled trial evaluating the cost-effectiveness of sonographic guidance for intra-articular injection of the osteoarthritic knee. Journal of Clinical Rheumatology. 2011; 17: 409–415.

[33] Saugel B, Scheeren TWL, Teboul J. Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Critical Care. 2017; 21: 225.

[34] Safety Committee of Japanese Society of Anesthesiologists. Practical guide for safe central venous catheterization and management 2017. Journal of Anesthesia. 2020; 34: 167–186.

[35] Peltan ID, Shiga T, Gordon JA, Currier PF. Simulation improves procedural protocol adherence during central venous catheter placement: a randomized controlled trial. Simulation in Healthcare. 2015; 10: 270–276.

[36] Hameeteman M, Bode AS, Peppelenbosch AG, van der Sande FM, Tordoir JH. Ultrasound-guided central venous catheter placement by surgical trainees: a safe procedure? The Journal of Vascular Access. 2010; 11: 288–292.

Abstracted / indexed in

Science Citation Index Expanded (SciSearch) Created as SCI in 1964, Science Citation Index Expanded now indexes over 9,200 of the world’s most impactful journals across 178 scientific disciplines. More than 53 million records and 1.18 billion cited references date back from 1900 to present.

Journal Citation Reports/Science Edition Journal Citation Reports/Science Edition aims to evaluate a journal’s value from multiple perspectives including the journal impact factor, descriptive data about a journal’s open access content as well as contributing authors, and provide readers a transparent and publisher-neutral data & statistics information about the journal.

Chemical Abstracts Service Source Index The CAS Source Index (CASSI) Search Tool is an online resource that can quickly identify or confirm journal titles and abbreviations for publications indexed by CAS since 1907, including serial and non-serial scientific and technical publications.

Index Copernicus The Index Copernicus International (ICI) Journals database’s is an international indexation database of scientific journals. It covered international scientific journals which divided into general information, contents of individual issues, detailed bibliography (references) sections for every publication, as well as full texts of publications in the form of attached files (optional). For now, there are more than 58,000 scientific journals registered at ICI.

Geneva Foundation for Medical Education and Research The Geneva Foundation for Medical Education and Research (GFMER) is a non-profit organization established in 2002 and it works in close collaboration with the World Health Organization (WHO). The overall objectives of the Foundation are to promote and develop health education and research programs.

Scopus: CiteScore 0.5(2021) Scopus is Elsevier's abstract and citation database launched in 2004. Scopus covers nearly 36,377 titles (22,794 active titles and 13,583 Inactive titles) from approximately 11,678 publishers, of which 34,346 are peer-reviewed journals in top-level subject fields: life sciences, social sciences, physical sciences and health sciences.

Embase Embase (often styled EMBASE for Excerpta Medica dataBASE), produced by Elsevier, is a biomedical and pharmacological database of published literature designed to support information managers and pharmacovigilance in complying with the regulatory requirements of a licensed drug.

Submission Turnaround Time