The widespread availability of portable ultrasound has increased bedside use of this technology in a variety of healthcare settings [1]. Ultrasound technology is relatively cheap and delivers no ionizing radiation to the patient or the provider. Concomitantly, the house of medicine is witnessing the largest expansion to point-of-care ultrasound in history as it moves beyond fields such as emergency medicine, critical care, and anesthesiology. With internal medicine, family medicine, and others quickly taking up point-of-care ultrasound and expanding its utilization, ultrasound may soon be at the bedside of most patients being treated in the developed and developing worlds. The use of point-of-care ultrasound for procedural guidance is rapidly increasing in clinical practice as providers realize that ultrasound allows guidance of almost any needle or device as long as an image can be obtained from the skin surface to the target organ or tissue [2]. Recent data suggests that nonradiologists are performing more ultrasound-guided procedures than radiologists and are responsible for a majority of growth in procedure volume [3].

Performing invasive procedures safely is an important aspect of both medical education and clinical practice. Ultrasound guidance helps visualize the target precisely for directing a needle’s path and avoiding adjacent structures. Ultrasound procedural guidance may involve use of a freehand technique or utilize some sort of guidance device such as a needle guide. Needle guides can take on varied shapes and sizes depending on the ultrasound transducer they will be attaching to and the type of procedure for which they will be used. Further, needle and other guides have matured significantly in the last two decades, becoming more streamlined, functional, and versatile [4].

The use of ultrasound as an adjunct to perform invasive procedures has been shown to enhance procedural success, decrease complications, improve satisfaction, and decrease time required to perform procedures. There is a robust body of evidence demonstrating that ultrasound guidance can significantly increase the safety and quality of patient care, while reducing complications and costs among patients undergoing invasive procedures [5]. The clinical efficacy of ultrasound guidance for performing procedures can be translated into significant cost savings in multiple fashions, including reduction of procedure-related complications and associated costs, decreased procedure times, reduced hospital length of stay, improved throughput, and more consistent success across a broader range of qualified healthcare providers [6].

Ultrasound guidance has been shown to improve success for a simple procedure, such as peripheral intravenous catheter placement, to the most complex and technically challenging procedure, such as transvenous pacemaker placement. The use of real-time ultrasound guidance not only improves success rate but also reduces the number of attempts and the amount of anesthetic needed for certain procedures. Although less well studied, the introduction of ultrasound guidance can have a tremendous impact on provider satisfaction, feeling of competence, or mastery and even breathe new life into some clinician practices by allowing them to competently perform procedures which were once out of reach such as nerve blocks in emergency medicine, precise tendon injections in primary care, and many other examples. The use of ultrasound guidance for central venous access has become the standard of care after being recommended by multiple medical societies and supported by ample number of studies in the literature [7]. Although currently the highest quality evidence may be present for ultrasound-guided vascular access, the evidence for the use of ultrasound guidance for other procedures is rapidly increasing as well. Considerable evidence is building which demonstrates the benefits of real-time ultrasound guidance for procedures such as paracentesis, thoracentesis, arthrocentesis, and other procedures.

This technique can be broadly categorized into two groups: ultrasound assistance and real-time ultrasound guidance. Ultrasound-assisted procedures refer to evaluating patient anatomy and localization of procedure site (including target and surrounding structures) with ultrasound and do not involve real-time visualization of the needle and the target. This static method is less favored because of the potential for complications. Real-time ultrasound-guided procedures refer to the continuous visualization of the needle to direct needle placement while performing the procedure. This is the preferred technique since the location of the needle tip and target structure are continuously visualized.

Successful performance of ultrasound-guided procedures is dependent on training, experience, competence, and skills of the operator. Ultrasound-guided technique has been shown to increase operator confidence and is frequently replacing the anatomical landmark approach as the new standard for various invasive procedures. However, healthcare providers who perform ultrasound-guided procedures should be qualified to perform invasive procedures within their scope of practice. It is crucial to understand the principles of needle guidance to achieve success while using ultrasound for procedural guidance. They should receive training in the basic physical principles, ultrasound equipment, imaging modes, scanning planes, relevant sonographic anatomy needle guidance techniques, and limitations of ultrasound as they pertain to invasive procedures.

Despite growing evidence referenced above, the use of ultrasound-guided procedures is growing more slowly in nonacademic clinical settings [8]. Most of the research published to date has naturally occurred in academic settings, and more attention needs to be paid in community practice settings which represent the majority of patients seen worldwide. To have a larger and meaningful impact on patient care, it is imperative to integrate ultrasound guidance into clinical practice outside of academic centers. Providers in these settings may not even be aware of the potential available with ultrasound technology, its ever-lowering cost, and its ease of use as well as its capability. Technological advances such as beam steering software can potentially increase the ease of use and therefore adoption. In addition, artificial intelligence is rapidly making an impact on medical imaging, and multiple studies of deep learning applications in point-of-care ultrasound will soon be emerging as well and as commercially available artificial intelligence aps for real ultrasound machines.

In summary, adopting ultrasound guidance for procedural performance can increase safety, improve speed, simply comply with the new standard of care, improve patient satisfaction, and also radically improve the feeling of mastery and accomplishment by clinicians who gain access to procedures they were once unable to perform. Anecdotally, we have seen this in a variety of practice settings, and this repeatable finding is not limited to any provider age or experience group. It is likely that ultrasound guidance will one day be the standard of care for virtually every procedure in which ultrasound can visualize the intended target, but long before that, both providers and patients are increasingly benefiting from its increased utilization. We hope this book will move you forward in your discovery and mastery of ultrasound guidance in procedural performance.