Ultrasound Guided Vascular Access

Gary Dufresne, DO Emergency Medicine Physician SAUSHEC

Goals

Understand the necessity for US Guided Central Access Understand the difference between Static, Dynamic, Assisted and Guided US access Be able to perform Dynamic US Guided IJ or Femoral Line

Introduction

This presentation is only one part of an integrated process to teach you and insure competence in US guided vascular access.

The resident learner will achieve competency by:

Attending US Introduction Course during Intern Orientation Complete Vascular Access Learning Module Participate in Animal Labs with integration of US Guided Central Venous access Completing the SAUSHEC Emergency Ultrasound Rotation Applying US Guided Vascular Access skills in real life clinical applications throughout residency

Numbers Overall Complication Rates*

Internal Jugular Subclavian Femoral

6-12%

6-11%

13-19%

NON-INFECTIOUS Complications*
Arterial Puncture, Hematoma, PTX, HTX

Standard of care?

2001 Healthcare Research and Quality Evidence Report

Top 11 Highly Proven pt safety practices All central cannula placements be guided by realtime, dynamic US.

Discussion:
What do you think?

Research

Ultrasonic locating devices for central access

2003, BMJ, Meta-analysis of randomized trials 18 trials, n- 1646 Clear improvement in success rates in using US for IJ cannulation in adults and peds compared to LM Not so much for subclavian or femoral

Research

SOAP3- Sonography Outcomes Assessment Program, US assisted central access (IJ)

2005, Crit Care Med, Prospective Randomized Dynamic (D) vs. Static (S) vs. Landmark (LM) n- 201 Primary Outcome (Success Rate) D- 98% S- 82% LM- 64% Complication Rate D- 3% S- 3% LM- 13%* *Limitation- lead author performed HALF of sticks

Research

Single-operator (D1) vs. two-operator (D2) US for IJ

2006, Acad Emerg Med, Prospective Randomized n- 44 pts D1 96% D2 95% D1 and D2 techniques are equivalent *Limitation- Only 3 operators and 2 were study investigators

Guided vs. Assisted

Landmark- Old School Static US- US look plus 2 skin markers US Assisted- static technique plus improper dynamic technique US Guided- dynamic real-time visualization of needle entering the vein!!!

Probe Selection

Linear

7.5Mhz, Vascular, Soft Tissue, Ocular

5-1Mhz, Echo, Abd, OB, ?Vascular Access

Phased Array

Pros and Cons

Technique

Transverse Longitudinal Common

Position equipment Prep sterile supplies and patient Get Sterile Sterile probe cover

Technique

Technique

Transverse

ID and Center Anatomy Pythagorean Theorem ID depth to center of vessel Back off the transducer equal distance Enter at 45 degree angle

Technique

Transverse (Cont)
Watch for tissue invagination Look for ring-down artifact

You have to be aware of both US images and Needle/Syringe at the same time

Longitudinal

Technique

ID, confirm, and maintain largest diameter image Needle centered on probe Visualize entire needle Move needle to vessel- NEVER probe to find needle

Novel Applications

Peripheral IVs

EJs are fun but not for the patient

Arterial Lines (Radial, brachial, etc)

Why do a procedure blind? Potentially reduce complications

Principles and technique are essentially the same as central access but the target is smaller

Peripheral Anatomy

Summary

US Guided- NOT Assisted Pythagoras TRV Approach- back up equal to depth and use 45 angle Try the Phased Array Probe and Longitudinal Technique IJ Complication Rate with US is sig. reduced 13% 3% ** Use US correctly but have other vascular access tools.

References
Ultrasonic locating devices for central venous cannulation: meta-analysis. - Hind D BMJ - 16-AUG-2003; 327(7411): 361 Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial Crit Care Med. 2005 Aug;33(8):1875-7 Randomized controlled trial of single-operator vs. two-operator ultrasound guidance for internal jugular central venous cannulation. - Milling T - Acad Emerg Med - 01-MAR2006; 13(3): 245-7 Noble VE et al. Manual of Emergency and Critical Care Ultrasound. Ch 12 Vascular Access. 2007 Ma OJ et al. Emergency Ultrasound. Ch 19 Vascular Access. 2008, 2nd Edition www.sonoguide.com