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