KT échoguidé

Benjamin Repusseau

SAR 2

Réanimation Thoracique

Practice Guidelines for Central Venous Access

A Report by the American Society of Anesthesiologists TaskForce on Central Venous Access

vein is selected.

• Use real-time ultrasound guidance for vessel localization andvenipuncture when the internal jugular vein is selected forcannulation.

C Real-time ultrasound may be used when the subclavian orfemoral vein is selected.

C Real-time ultrasound may not be feasible in emergencycircumstances or in the presence of other clinicalconstraints.

Anesthesiology 2012; 116:539 –73

Downloaded From: http://anesthesiology.pubs.asahq.org/pdfaccess.ashx?url=/data/Journals/JASA/934495/ on 03/04/2016

Massimo LampertiAndrew R. BodenhamMauro PittirutiMichael BlaivasJohn G. AugoustidesMahmoud ElbarbaryThierry PirotteDimitrios KarakitsosJack LeDonneStephanie DonigerGiancarlo ScoppettuoloDavid Feller-KopmanWolfram SchummerRoberto BiffiEric DesruennesLawrence A. MelnikerSusan T. Verghese

International evidence-based

recommendations on ultrasound-guided

vascular access

Intensive Care Med (2012) 38:1105–1117DOI 10.1007/s00134-012-2597-x CONFERENCE REPORTS AND EXPERT PANEL

Compression ultrasound allows the detection ofthrombosed veins and it is a very accurate and time-

ring method to detect thrombosis, whether partial or]. The conventional risk factors for thrombosis

are summarised in the Virchow’s triad: vascular injury,stasis and hypercoagulability. On this basis, factorsinvolved in the pathogenesis of catheter-related throm-

training and accreditation and further research is neededto clarify the role of ultrasound in infectious risk reduc-tion. In conclusion, given the evidence from literature andbased on voting results, ultrasound guidance has to besuggested as the method of choice for any kind of vas-cular cannulation given its higher safety and efficacy.

, ultrasound guidance has to bessuggested as the method of choice for any kind of vas-d f h i f ki d fgg ycular cannulation given its higher safety and efficacy.cular cannulation given its higher safety and efficacygg yl l ti i it hi h f t d ffi

Recommandations sur l'utilisationde l'échographie lors de la mise en placedes accès vasculaires

Paul J. Zetlaoui 1, Hervé Bouaziz 2, Denis Jochum 3, Eric Desruennes 4, Nicolas Fritsch 5, Frédéric Lapostolle 6,Thierry Pirotte 7, Stéphane Villiers 8, Sébastien Pierre 9

Reco

mmandationsform

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esd'experts

Anesth Reanim. 2015; 1: 183–189

Ces complications peuvent être favorisées par des variations de

l'anatomie. L'utilisation de l'échographie permet la visualisation

des vaisseaux, de ses structures adjacentes et de l'aiguille de

ponction tout au long de son trajet. Cette technique dite écho-

guidée permet de réduire significativement les complications et

devrait être utilisée par défaut.

Cette techhnique ddite échho-

guiidddéée permet ddde rééddduiire siigniifffiicatiivement les complications ett l li ti t

devrait être utilisée par défaut.d it êt tili é déf t

•Eisen LA, Narasimhan M, Berger JS, Mayo PH, Rosen MJ, Schneider RF. Mechanical complications of central venous catheters. J Intensive Care Med. 2006 Jan-Feb;21(1):40-6.•Merrer J, De Jonghe B, Golliot F, Lefrant JY, Raffy B, Barre E, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA. 2001 Aug 8;286(6):700-7.•Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med. 1994 Dec 29;331(26):1735-8.•Durbec O, Viviand X, Potie F, Vialet R, Albanese J, Martin C. A prospective evaluation of the use of femoral venous catheters in critically ill adults. Crit Care Med. 1997 Dec;25(12):1986-9.•Parienti JJ, Thirion M, Megarbane B, Souweine B, Ouchikhe A, Polito A, et al. Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial. JAMA. 2008 May 28;299(20):2413-22.•Augoustides JG, Diaz D, Weiner J, Clarke C, Jobes DR. Current practice of internal jugular venous cannulation in a university anesthesia department: influence of operator experience on success of cannulation and arterial injury. J Cardiothorac Vasc Anesth. 2002 Oct;16(5):567-71.•Sznajder JI, Zveibil FR, Bitterman H, Weiner P, Bursztein S. Central vein catheterization. Failure and complication rates by three percutaneous approaches. Arch Intern Med. 1986 Feb;146(2):259-61.•Schummer W, Schummer C, Rose N, Niesen WD, Sakka SG. Mechanical complications and malpositions of central venous cannulations by experienced operators. A prospective study of 1794 catheterizations in critically ill patients. Intensive Care Med. 2007 Jun;33(6):1055-9.•Karakitsos D, Labropoulos N, De Groot E, Patrianakos AP, Kouraklis G, Poularas J, et al. Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients. Crit Care. 2006;10(6):R162.

Ponction à l’aveugle

Real-time Two-dimensional Ultrasound Guidance for

Central Venous Cannulation

A Meta-analysis

Shao-yong Wu, M.D.,* Quan Ling, M.D.,† Long-hui Cao, M.D., Ph.D.,‡ Jian Wang, M.D., §

Mei-xi Xu, M.D.,‡ Wei-an Zeng, M.D., Ph.D.‖

•  26 RCT , 4185 VVC •  Repères anatomiques vs echoguidage •  VJI / VF / SC

Downloaded From: http://anesthesiology.pubs.asahq.org/pdfaccess.ashx?url=/data/Journals/JASA/930996/ on 03/04/2016

• 26 RCT , 4185 VVC • Repères anatomiques vs echoguidage• VJI / VF / SC

NOTE: Weights are from random effects analysis

Overall (I−squared = 56.9%, p = 0.000)

Troianos (1991)28

Slama (1997)32

Grebenik (2004)37

Leung (2006)40

Author (Year)

Verghese (2000)35

Hilty (1997)31

Shrestha (2011)44

Karakitsos (2006)18

Prabhu (2010)3

Turker (2009)2

Bansal (2005)38

Milling (2005)39

Fragou (2011)19

Sulek (2000)34

Cajozzo (2004)36

Gualtieri (1995)30

Aouad (2010)42

Mallory (1990)27

Soyer (1993)29

Zhang (2011)45

Verghese (1999)33

Palepu−1 (2009)4

Ovezov (2010)43

Palepu−2 (2009)4

Cannulation failure

0.18 (0.10, 0.32)

0.15 (0.01, 2.93)

0.05 (0.00, 0.89)

2.05 (0.88, 4.78)

0.29 (0.10, 0.82)

RR (95% CI)

0.33 (0.04, 2.87)

0.29 (0.07, 1.21)

0.29 (0.06, 1.32)

0.02 (0.00, 0.32)

0.09 (0.01, 0.68)

0.20 (0.02, 1.70)

0.20 (0.01, 4.00)

0.05 (0.01, 0.33)

0.02 (0.00, 0.32)

0.60 (0.15, 2.40)

0.22 (0.05, 0.99)

0.14 (0.04, 0.57)

1.00 (0.07, 15.08)

0.11 (0.01, 1.73)

0.09 (0.01, 1.49)

0.06 (0.00, 0.99)

0.05 (0.00, 0.79)

0.28 (0.10, 0.74)

0.03 (0.00, 0.19)

0.32 (0.02, 6.34)

39/1991

0/77

0/37

13/59

4/65

RTUS

1/16

2/20

2/60

0/450

1/55

1/190

0/30

1/60

0/200

3/60

2/105

2/25

1/24

0/12

0/24

0/50

0/43

5/205

1/107

0/17

Events,

259/2014

3/83

10/42

7/65

14/65

ALM

3/16

7/20

7/60

25/450

11/55

5/190

2/30

25/69

25/201

5/60

8/91

15/27

1/24

6/17

5/23

8/50

12/52

17/194

36/102

2/28

Events,

100.00

2.67

2.86

7.19

6.63

Weight

3.92

5.57

5.35

2.87

4.21

3.95

2.61

4.30

2.87

5.73

5.36

5.77

2.98

2.88

2.81

2.83

2.86

6.85

4.30

2.63

%

RTUS

0/12

0/50

MLAsrovaFSUTRsrovaF

1.01 1 100

2.02.02.02.02.02.02.02.05 (5 (0.80.88, 8, 4.74.788))

0.20.20.20.2

0.00.00.00.0

0.20.20.20.2

0.00.00.00.0

0.20.20.20.28 (0.10, 0.74)

13/13/5599 7/7/6565 7.17.199

Taux d’échec

s analysiysiysiysiysiysiysiysiysiysiysiysiysisssssssssssssss

A

Ponction artérielle

Pneumothorax

Recommandations sur l'utilisationde l'échographie lors de la mise en placedes accès vasculaires

Paul J. Zetlaoui 1, Hervé Bouaziz 2, Denis Jochum 3, Eric Desruennes 4, Nicolas Fritsch 5, Frédéric Lapostolle 6,Thierry Pirotte 7, Stéphane Villiers 8, Sébastien Pierre 9

Reco

mmandationsform

alisé

esd'experts

Anesth Reanim. 2015; 1: 183–189

Recommandation

Il est recommandé d'utiliser une technique de ponction

échoguidée par rapport à une technique utilisant le repérage

anatomique lors de la mise en place d'un cathéter veineux

central par voie jugulaire interne chez l'adulte (GRADE 1+).

Recommandation

Il est recommandé d'utiliser une technique de ponction

échoguidée par rapport à une technique utilisant le repérage

anatomique lors de la mise en place d'un cathéter veineux

central par voie sous-clavière chez l'adulte (GRADE 1+).

RRRRRecommandation

Il est recommandé d'utiliser une technique de ponction

échoguidée par rapport à une technique utilisant le repérage

anatomique lors de la mise en place d'un cathéter veineux

central par voie sous-clavière chez l'adulte (GRADE 1+).

Recommandation

Il est recommandé d'utiliser une technique de ponction

échoguidée par rapport à une technique utilisant le repérage

anatomique lors de la mise en place d'un cathéter veineux par

voie fémorale chez l'adulte (GRADE 1 + ).

•  Echoguidage pour Kta et VVP

Pourquoi ça ne marche pas à

l’aveugle ?

!  Variabilité anatomique

!  Hypovolémie

!  Thromboses

!  Modification des rapports

Variations de la VJI

Maecken et al. CCM 2007

Variations de la veine axillaire dte

!"#$"%&

'()**')"%&

+",)#%&

Fritsch et al. ASA 2009

Variations veine fémorale

Variations respiratoires de la ss-

claviere

Fin d’inspiration Fin d’expiration

Date of download: 3/22/2016Copyright © 2016 American Medical Association.

All rights reserved.

From: Effect of Patient Position on Size and Location of the Subclavian Vein for Percutaneous Puncture

Arch Surg. 2003;138(9):996-1000. doi:10.1001/archsurg.138.9.996

The change in vein diameter when all positions (ie, [1] flat [or supine], head and shoulders neutral; [2] flat, head neutral, shoulders arched; [3] flat, head opposite, shoulders arched; and [4] Trendelenburg, head opposite, shoulders arched) are compared with position 5 (ie, Trendelenburg, head and shoulders neutral). The bars represent the mean and SEM of the differences in all 10

subjects. Dunnett's comparison with position 5 shows a statistically significant (P<.02) reduction in vein size in all positions.

Figure Legend:

Tête neutre, épaule arquées

Modalités pratiques

Sondes de 7 à 12 Hz

Modalités pratiques

Skin antisepsis with chlorhexidine–alcohol versus povidone

iodine–alcohol, with and without skin scrubbing, for

prevention of intravascular-catheter-related infection (CLEAN):

an open-label, multicentre, randomised, controlled,

two-by-two factorial trial

Olivier Mimoz, Jean-Christophe Lucet, Thomas Kerforne, Julien Pascal, Bertrand Souweine, Véronique Goudet, Alain Mercat, Lila Bouadma,

Sigismond Lasocki, Serge Alfandari, Arnaud Friggeri, Florent Wallet, Nicolas Allou, Stéphane Ruckly, Dorothée Balayn, Alain Lepape,

Jean-François Timsit, for the CLEAN trial investigators*

www.thelancet.com Vol 386 November 21, 2015

•  11 réanimations françaises •  1181 patients / 2547 cathéters •  Betadine vs Chlorhexidine •  Detersion vs pas de detersion

0 5 10 15 20 25 30

0

5

10

100

Cumulative risk (%)

1277

1270

1326

1286

816

792

888

788

388

362

418

391

195

180

199

207

108

104

100

106

57

56

43

60

27

35

20

32

HR=0·15 (95% Cl 0·05−0·41);

p=0·0002

Number of

catheters at risk

CHG—no scrubbing

CHG—scrubbing

PVI—no scrubbing

PVI—scrubbing

A Catheter−related infection

Cumulative risk (%)

0 5 10 15 20 25 30

0

5

1277

1270

1326

1286

816

792

888

788

388

362

418

391

195

180

199

207

108

104

100

106

57

56

43

60

27

35

20

32

HR=0·21 (95% Cl 0·07−0·59);

p=0·003

10

100

Number of

catheters at risk

CHG—no scrubbing

CHG—scrubbing

PVI—no scrubbing

PVI—scrubbing

B Catheter-related bloodstream infection

Modalités pratiques

Modalités pratiques

Taille du KT

•  SCD = taille/10 – 2 •  SCG = taille/10 + 2 •  JID = taille/10 – 1 •  JIG = taille/10 + 3

Czepizak et al. Chest 1995

Veine ou artère ?

Dans ou en dehors du plan ?

VJI par voie post

VJI par voie post

VJI par voie post

VJI par voie post

VJI par voie post

VJI par voie post

VJI par voie post

Conclusion

•  Recommandations FORTES internationales

•  À pratiquer le plus tôt possible!

•  ...et le plus souvent possible +++