Peripheral IV PDF[1]

Saturday, January 19, 13

Vascular Access Using Ultrasound-Guidance

FUJIFILM SonoSite, Inc. | 2012


This presentation provides an overview of Peripheral IV Access using Ultrasound-Guidance and is not intended to

replace formal training through CME courses or other programs. This presentation does not constitute

professional medical advice or a complete course of training. You should not perform an Ultrasound-Guided

Peripheral IV insertion solely in reliance upon the information in this presentation.



Program Objectives• Discuss advantages of using ultrasound for Peripheral IVs • Identify vascular and anatomic

landmarks

• Explore needle visualization technique

• Cover potential pitfalls



Why Use Ultrasound?

‣Complication Rates

‣Arterial Punctures

‣Time to Venipuncture

‣Needle Stick Attempts

Patient Satisfaction

DECREASES



Keyes LE, et al., prospectively enrolled 101 emergency department patients who had ultrasound-guided brachial

and basilic vein cannulation with difficult IV access

Results: -- 2 unsuccessful attempts without ultrasound-guidance were made prior to using ultrasound

-- 50 were IVDU and 21 were obese Conclusion:

-- US guided cannulation successful in 91% -- Average time was 77 seconds

Keyes LE, Frazee BW, Snoey ER, Simon BC, Christy D: Ultrasound guided brachial and basilic vein cannulation in emergency department patients with

difficult intravenous access

Peripheral IV Access - Study 1



Costantino et al,. compared ultrasound-guided PIV access with the traditional blind technique

Results - Ultrasound-guided PIV placement was: -- More successful -- Required less time -- Reduced the number of needle punctures -- Improved patient satisfaction

Costantino TG, Parikh AK, Satz WA, Fojtik JP. Ultrasonography-guided peripheral intravenous access versus traditional approaches in patientswith difficult intravenous access. Am J Emerg Med. Nov 2005;46(5):456-61.[Medline].

Peripheral IV Access-Study 2



Peripheral IV Access - Study 3AU, A et al., enrolled 100 emergency medicine patients with difficult IVs by placing an Ultrasound-Guided Peripheral IV (USGPIV) to decrease Central Venous Catheters (CVC)

Results: -- All 100 patients successfully received a USGPIV-- 15 Patients who received the USGPIV proceeded to need a CVC -- 1 out of the 15 patients who received a CVC went on to develop further complications from infection

Conclusion:-- The use of USGPIV for difficult IV access reduce the need for CVC placement by 85% and may have the potential to reduces morbidity in patients with difficult IVs.

Au A et al., Decrease in central venous catheter placement and complications due to utilization of ultrasound-guided peripheral intravenous catheters [abstract]. American College of Emergency Physicians Scientific Congress 2011. October 2011.



Benefits of Ultrasound-Guided Vascular Access

• Quality• Safety• Cost Reduction• Increase in Patient Satisfaction



Quality

A 54% reduction in the number of attempts with ultrasound-guidance compared to the landmark technique

(Constan9no TG, et al.)FUJIFILM SonoSite, Inc. | 2012


Safety

Prevention of central line placement in 85% of patients with difficult IV access

(Au A, et al.)



Cost Reduction

The introduction of a registered nurse ultrasound-guided peripheral IV program reduced the number of one-time use PICC lines, saving approximately $200,000 per year at their institution

(Miles G, et al.)

$FUJIFILM SonoSite, Inc. | 2012


Patient Satisfaction

69% of patients rated their experience of ultrasound-guided peripheral IVs higher than peripheral IVs alone

(Schoenfeld EM, et al.)



Endorsed By:

ACEP

ADVANCING EMERGENCY CARE

American College of Emergency Physicians ®



Success Rate

99% SUCCESS RATE OF INSERTION WITH ULTRASOUND GUIDANCE

(Gregg SC, et al.)



Indications

• Renal Failure• Hypovolemia• Vascular Pathology• IV Drug Use• Obese Patients• Small, “rolling” veins• Pediatrics



• Avoid areas of flexion• Work distal to proximal• Vein Choice:

- Basilic - always attempt first- Cephalic - Brachial - can be paired

Choosing a Site



Assessment of Vessels

• Presence, size and patency

• Distensibility and compressibility

• Presence of thrombus

• Position of vein relative to the artery

V

V

V

V

A



Ultrasound Appearance

•Artery- Round- Regular Shape- Pulsatile

•Vein- Oval - Irregular Shape- Compressible



Vein Compression

A

V



Ultrasound Appearance

Characteristic Vein Artery

Appearance Black[anechoic]

Black[anechoic]

Movement None Pulsatile

Compressible Yes No

Color Flow Constant FlowAugmentable Pulsatile



basilic vein

ulnar veinmedian vein

radial vein

median cephalic vein

cephalic vein

Anatomy

axillary vein

brachial vein

subclavian

ext jugular vein

medial basilic vein



Basilic Vein

• Superficial• Largest vein in the arm• Courses along medial arm• Begins at dorsal part of hand• Drains into brachial vein

Basilic Vein



Transverse Basilic Vein

BV



Cephalic Vein

• Superficial vein• 4-6mm• Courses along lateral arm • Wrist to shoulder• Empties into axillary vein

Cephalic Vein



Transverse Cephalic Vein

V



Brachial Vein

Brachial Vein

• Deep veins of upper arm• Usually paired • Travel on either side of brachial artery• Joins basilic vein to form

the axillary vein



Brachial Vein Grouping

V

VA



High Frequency Linear Array - 7.5 MHZ or higher

Static or Dynamic Technique

• High Frequency Linear Array - 7.5 MHZ or higher

• Static or Dynamic Technique

Transducers

L25

HFL38



Ultrasound Beam

1 mm beam slice

Beam comes out as a slice

Beam thickness approx. 1 mm

Beam produces 2-D image

YOU CONTROL THE AIM



Orientation Marker

V

V

V

A



Acoustic Gel

• Ultrasound will not travel through air

• A transmission gel is required to eliminate surface air



Holding the Transducer

• Hold the transducer comfortably

• Keep a light touch

• Stabilize your hand

• RELAX



TOURNIQUET

Preparation



ChloraPrep


R


Tegaderm


3MTM TM


Needles 18 GA, 1.88 IN



Planes of Introduction

•SHORT AXIS- Out-of-Plane Technique- Needle inserted in cross-

sectional plane of the vessel

• LONG AXIS- In-Plane Technique- Needle inserted along

long axis of the vessel



Needle Transducer OrientationParallel and Perpendicular

In-PlaneOut-of-PlaneFUJIFILM SonoSite, Inc. | 2012


Transverse - Short Axis Approach



Longitudinal - Long Axis Approach




43



BEDirectly parallel to the vessel (longitudinal)

OR

Directly perpendicular to the vessel

(transverse)

Scanning Pitfalls

LONG AXIS

SHORT AXISFUJIFILM SonoSite, Inc. | 2012


Scanning Pitfalls

46

Do not rotate the transduceror scan obliquely across the vessel



Remember

Regardless of your technique,ALWAYS know where your needle tip is located



In some cases, even slight pressure of transducer may compress vessel eliminating ability to visualize

non-compressed compressed

Scanning Pearls



Ultrasound Guided PIV



COLOR FLOW

BASILIC VEIN CONFLUENCE



Catheter Line Images

Catheter tips in transverse viewFUJIFILM SonoSite, Inc. | 2012


Catheter Line Images

Longitudinal Views



Venous Pathology

Basilic Vein Thrombus



Venous Pathology

Thrombus at valve site



Venous Pathology

Transverse view of thrombus with and without color Doppler



Risks and Complications

• Infection

• Perforation of vessel

• Extravasation

• Accidental removal

• Thrombus at tip



Summary

• Easily identifies vascular structures and anatomic variation

• Provides real-time visualization of needle tip in procedures

• Improves safety / accuracy & decreases complication rates

• Shortens time for procedureFUJIFILM SonoSite, Inc. | 2012


Thank You



Additional Evidence1. Au A, et al. Decrease in central venous catheter placement and complications due to utilization of ultrasound-guided peripheral intravenous catheters [abstract]. American College of Emergency Physicians Scientific Congress 2011. October 2011.

2. Gregg SC, et al. Ultrasound-guided peripheral intravenous access in the intensive care unit. J Critical Care 2010;25(3):514-9.

3. Miles G, et al. Implementation of a successful registered nurse peripheral ultrasound-guided intravenous catheter program in an emergency department. J Emergency Nurse 2011. [Epub ahead of print].

4. Schoenfeld EM, et al. Ultrasound-guided peripheral intravenous access in the emergency department: patient-centered survey. West J Emerg Med 2011;12(4):475-7.


FUJIFILM SonoSite, Inc. the SonoSite logo and other trademarks not owned by third parties are registered and unregistered trademarks of FUJIFILM SonoSite, Inc. in various jurisdictions. All other trademarks are the property of their respective owners. ©2012 FUJIFILM SonoSite, Inc. All rights reserved. EDU00875


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