Performing procedures on acutely ill patients can be one of the most rewarding and challenging aspects of emergency medicine and critical care practice. These patients present unique challenges to the clinician for a variety of reasons. Most notably, since they are acutely ill or decompensating, there is an urgency to perform procedures in suboptimal conditions. The patients themselves often pose unique challenges. Many patients have abnormal anatomy due to prior surgical procedures, scarring, trauma, or acute or chronic illness. In addition, obesity can obscure standard anatomic landmarks. Perhaps the clinician attempting to perform the procedure will not be the first operator or must navigate through a prior failed procedural attempt. Finally, due to the acuity of their illness, many patients do not have the functional capacity to remain in standard procedural positions (i.e., laying in Trendelenburg position or sitting upright), and this often makes successful procedural outcomes more challenging. These conditions are found in many critical care settings; therefore, the benefits of ultrasound guidance for procedures are not limited to the ED.

Any advantage over standard surface anatomy or landmark-based techniques should be a welcome addition to the arsenal of all critical care physicians. As with the diagnostic applications of ultrasound, ultrasound for procedure guidance is meant as an adjunct to the physical exam. When the sternocleidomastoid muscle cannot be seen or felt, ultrasound can help visualize the internal jugular vein and obviate the need for such landmarks.