Ultrasound Ultrasound GuidedGuided
Vascular AccessVascular AccessGary Dufresne, DOGary Dufresne, DO
Emergency Medicine Emergency Medicine PhysicianPhysician
SAUSHECSAUSHEC
GoalsGoals
Understand the necessity for US Understand the necessity for US Guided Central AccessGuided Central Access
Understand the difference between Understand the difference between Static, Dynamic, Assisted and Static, Dynamic, Assisted and Guided US accessGuided US access
Be able to perform Dynamic US Be able to perform Dynamic US Guided IJ or Femoral LineGuided IJ or Femoral Line
IntroductionIntroduction This presentation is only one part of an This presentation is only one part of an
integrated process to teach you and integrated process to teach you and insure competence in US guided insure competence in US guided vascular access.vascular access. The resident learner will achieve The resident learner will achieve
competency by:competency by: Attending US Introduction Course during Intern Attending US Introduction Course during Intern
OrientationOrientation Complete Vascular Access Learning ModuleComplete Vascular Access Learning Module Participate in Animal Labs with integration of US Participate in Animal Labs with integration of US
Guided Central Venous accessGuided Central Venous access Completing the SAUSHEC Emergency Completing the SAUSHEC Emergency
Ultrasound RotationUltrasound Rotation Applying US Guided Vascular Access skills in real Applying US Guided Vascular Access skills in real
life clinical applications throughout residencylife clinical applications throughout residency
NumbersNumbersOverall Complication Overall Complication
Rates*Rates*Internal Internal JugularJugular
SubclavianSubclavian FemoralFemoral
6-12%6-12% 6-11%6-11% 13-19%13-19%
•NON-INFECTIOUS Complications*
•Arterial Puncture, Hematoma, PTX, HTX
Standard of care?Standard of care?
2001 Healthcare Research and 2001 Healthcare Research and Quality Evidence ReportQuality Evidence Report ““Top 11 Highly Proven” pt safety Top 11 Highly Proven” pt safety
practicespractices ““All central cannula placements be All central cannula placements be
guided by real-time, dynamic US.”guided by real-time, dynamic US.” Discussion: Discussion:
What do you think?What do you think?
ResearchResearch
Ultrasonic locating devices for Ultrasonic locating devices for central accesscentral access 2003, BMJ, Meta-analysis of 2003, BMJ, Meta-analysis of
randomized trialsrandomized trials 18 trials, n- 164618 trials, n- 1646 Clear improvement in success rates in Clear improvement in success rates in
using US for IJ cannulation in adults using US for IJ cannulation in adults and peds compared to LMand peds compared to LM
Not so much for subclavian or femoralNot so much for subclavian or femoral
ResearchResearch SOAP3- Sonography Outcomes SOAP3- Sonography Outcomes
Assessment Program, US assisted central Assessment Program, US assisted central access (IJ)access (IJ) 2005, Crit Care Med, Prospective Randomized 2005, Crit Care Med, Prospective Randomized
Dynamic (D) vs. Static (S) vs. Landmark (LM)Dynamic (D) vs. Static (S) vs. Landmark (LM) n- 201n- 201 Primary Outcome (Success Rate)Primary Outcome (Success Rate)
D- 98%D- 98% S- 82%S- 82% LM- 64%LM- 64% Complication RateComplication Rate
D- 3%D- 3% S- 3%S- 3% LM- 13%*LM- 13%* *Limitation- lead author performed HALF of *Limitation- lead author performed HALF of
stickssticks
ResearchResearch Single-operator (D1) vs. two-operator Single-operator (D1) vs. two-operator
(D2) US (D2) US
for IJfor IJ 2006, Acad Emerg Med, Prospective 2006, Acad Emerg Med, Prospective
RandomizedRandomized n- 44 ptsn- 44 pts D1 96%D1 96% D2 95%D2 95% D1 and D2 techniques are equivalentD1 and D2 techniques are equivalent *Limitation- Only 3 operators and 2 were *Limitation- Only 3 operators and 2 were
study investigatorsstudy investigators
Guided vs. AssistedGuided vs. Assisted
Landmark-Landmark- “Old School” “Old School” Static US-Static US- US look plus 2 skin US look plus 2 skin
markersmarkers US Assisted-US Assisted- static technique plus static technique plus
“improper” dynamic technique“improper” dynamic technique US Guided-US Guided- dynamic real-time dynamic real-time
visualization of needle entering the visualization of needle entering the vein!!!vein!!!
Probe SelectionProbe Selection
LinearLinear 7.5Mhz, Vascular, Soft Tissue, Ocular7.5Mhz, Vascular, Soft Tissue, Ocular
Phased ArrayPhased Array 5-1Mhz, Echo, Abd, OB, ?Vascular 5-1Mhz, Echo, Abd, OB, ?Vascular
AccessAccess Pros and ConsPros and Cons
TechniqueTechnique
TransverseTransverse LongitudinalLongitudinal CommonCommon
Position equipmentPosition equipment Prep sterile supplies Prep sterile supplies
and patientand patient Get SterileGet Sterile Sterile probe coverSterile probe cover
TechniqueTechnique
TechniqueTechnique
TransverseTransverse ID and Center ID and Center
AnatomyAnatomy Pythagorean Pythagorean
TheoremTheorem ID depth to center of ID depth to center of
vesselvessel Back off the Back off the
transducer equal transducer equal distancedistance
Enter at 45 degree Enter at 45 degree angleangle
TechniqueTechnique Transverse (Cont)Transverse (Cont)
Watch for tissue invaginationWatch for tissue invagination Look for “ring-down” artifactLook for “ring-down” artifact
You have to be aware of both US You have to be aware of both US images and Needle/Syringe at the images and Needle/Syringe at the same timesame time
TechniqueTechnique LongitudinalLongitudinal
ID, confirm, and maintain largest ID, confirm, and maintain largest diameter imagediameter image
Needle centered on probeNeedle centered on probe Visualize entire needleVisualize entire needle Move needle to vessel- NEVER probe to Move needle to vessel- NEVER probe to
find needlefind needle
Novel ApplicationsNovel Applications
Peripheral IVsPeripheral IVs EJs are fun but not for the patientEJs are fun but not for the patient
Arterial Lines (Radial, brachial, etc…)Arterial Lines (Radial, brachial, etc…) Why do a procedure blind?Why do a procedure blind? Potentially reduce complicationsPotentially reduce complications
Principles and technique are Principles and technique are essentially the same as central access essentially the same as central access but the target is smallerbut the target is smaller
Peripheral AnatomyPeripheral Anatomy
SummarySummary US Guided- NOT AssistedUS Guided- NOT Assisted PythagorasPythagoras TRV Approach- back TRV Approach- back
up equal to depth and use 45° angleup equal to depth and use 45° angle Try the Phased Array Probe and Try the Phased Array Probe and
Longitudinal TechniqueLongitudinal Technique IJ Complication Rate with US is sig. IJ Complication Rate with US is sig.
reduced 13%reduced 13% 3% ** 3% ** Use US correctly but have other Use US correctly but have other
vascular access tools.vascular access tools.
ReferencesReferences
Noble VE et al. Manual of Emergency and Critical Care Ultrasound. Ch 12 Vascular Access. 2007
www.sonoguide.com
Randomized controlled trial of single-operator vs. two-operator ultrasound guidance for internal jugular central venous cannulation. - Milling T - Acad Emerg Med - 01-MAR-2006; 13(3): 245-7
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
Ma OJ et al. Emergency Ultrasound. Ch 19 Vascular Access. 2008, 2nd Edition