Disclosures Central and Peripheral Venous Access • I have nothing to disclose Gavin Budhram, MD ! Department of Emergency Medicine ! Baystate Medical Center Central Venous Access Central Venous Access Why Use Ultrasound? Internal Jugular • Decreases complications ! Right Left 18% • Excessive bleeding, inadvertent arterial 14% 1% 1% 70% 66% puncture, vessel laceration, pneumothorax, hemothorax ! 14% 14% • Anatomic variation ! 1% 0% • Quicker venous access ! Variable position of IJ vein • Avoid multiple attempts Denys et al . Anatomical variations of internal jugular vein location: impact on central venous access. Crit Care Med, 1991; 19(12):1516-9 Central Venous Access Why Use Ultrasound? US Landmark Success 100% 88.1% Technical Considerations • 982 US guided ! First 78% 38% • 302 landmark Attempt based Skin to vein 10 secs 44 secs Carotid ! 1.7% 8.3% puncture Denys et al . Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external landmark-guided technique. Circulation, 1993; 87(5):1557-62.
Technical Considerations Technical Considerations Vascular Probe Two-Operator Technique • Linear array probe ! • One person holds the ultrasound probe ! • high frequency (4-10 MHz) ! • Other person places cannulates vessel ! • very detailed images of superficial • Allows use of both hands for manipulating syringe ! • Often preferred when first learning technique structures ! Technical Considerations Technical Considerations Approach One-Operator Technique • Static approach ! • Single operator controls probe and needle ! • Ultrasound used to confirm anatomy and • Allows greater precision ! • Often preferred by mark position of vessel ! advanced practitioners • Dynamic approach ! • Operator actually watches the needle enter the vessel in real-time Technical Considerations Technical Considerations Infection Precautions Sterile Probe Covers • Many commercially • Central Venous Access ! available probe covers ! • Utilize sterile procedures ! • Standard gel (inside) ! • Sterile gloves and probe covers ! • Avoid air bubbles ! • Peripheral • Sterile gel (outside) Venous Access ! • Clean skin and transducer ! • Similar to standard IV placement
Central Venous Access Artery vs Vein • Shape ! Central Venous Access • Compression ! • Color Flow Central Venous Access Central Venous Access Artery vs Vein Artery vs Vein • Shape ! • arteries: circular ! • Color Flow • veins: angular ! • Compression Central Venous Access Central Venous Access Artery vs Vein Transverse Approach V A • Color Flow veins may be pulsatile ! place the probe so that the vein is in the middle ! red vs blue of the screen
Central Venous Access Central Venous Access Transverse Approach Transverse Approach • needle not directly seen ! • localized by artifacts: • reverberation • shadowing The needle is aimed for the middle of the probe Central Venous Access Central Venous Access Transverse Approach Transverse Approach Risk of Overshoot: ! Needle still appears to be in vessel Central Venous Access Central Venous Access Longitudinal Approach Longitudinal Approach
Central Venous Access Central Venous Access Anatomic Sites Transverse vs Longitudinal Transverse ! Longitudinal ! • Central • Easier to learn ! • Safer (no overshoot) ! • Depth and slope ! • See other • Internal jugular ! • Harder to learn • Femoral ! anatomy ! • Risk overshoot ! • Subclavian (distal) - Advanced ! • Supraclavicular (IJ/SC confluence) - Advanced • ‘Ring-down’ artifact Central Venous Access Central Venous Access Internal Jugular Internal Jugular internal jugular vein external jugular vein common carotid artery subclavian vein Transverse Approach Central Venous Access Central Venous Access Internal Jugular Internal Jugular internal jugular carotid Longitudinal Approach Longitudinal Approach
Central Venous Access Central Venous Access Femoral Femoral common femoral artery • In a study of femoral anatomy in 50 adult common femoral vein deep femoral artery patients: ! saphenous vein superficial femoral artery • At 4cm from the inguinal ligament: ! superficial femoral vein • all subjects have at least 50% overlap of deep femoral vein (not pictured) femoral artery over vein ! • 50% of patients had COMPLETE overlap Hughes P et al. Ultrasonography of the femoral vessels in the groin: implications for vascular access. Anaesthesia 2000, Dec; 55(12): 1198-202. Central Venous Access Central Venous Access Femoral Subclavian compression used to differentiate arteries and veins color may be used but is not always reliable Longitudinal Orientation Central Venous Access Central Venous Access Subclavian Subclavian Transverse Orientation Transverse Orientation
Central Venous Access Central Venous Access Supraclavicular Supraclavicular confluence of IJ ! and subclavian Peripheral Venous Access Why Use Ultrasound? • Difficult IV access ! Peripheral Venous • Dialysis patients, IV drug users, obesity ! Access • Central access not needed ! • Avoid multiple attempts ! • Increase patient satisfaction Peripheral Venous Access Peripheral Venous Access Preparation Catheter Length • In general, longer • Similar to standard preparation for IV catheters are needed access ! standard 1 1/4” (32mm) for ultrasound-guided • Clean skin and transducer ! IV’s ! 1 3/4” (45mm) • Deeper vessels usually • Have all materials readily accessible ! cannulated • Placement of ultrasound machine ! 2 1/2” (64mm) • Get comfortable!
Peripheral Venous Access Peripheral Venous Access Catheter Length Catheter Length • However at the shallower angle needed (22 • Standard catheters are degrees), 16mm are “used up” to reach the vein ! 1 inch (32mm). ! • Only leaves 1/2 inch in • To cannulate a vein 16mm 7mm 10mm 7mm the vein ! 7mm deep at a 45 • ED should stock 1.5-2 degree angle “uses up” 10mm inch catheters ! ! • sto Peripheral Venous Access Peripheral Venous Access Anatomy Anatomy • Cephalic vein runs • Brachial veins are along anterior aspect deeper along medial cephalic ! of upper arm ! aspect of upper arm ! vein • Basilic vein runs along • Usually require a cephalic vein superficial medial longer catheter ! basilic vein aspect of upper arm • Closer to radial artery basilic vein and nerve antecubital vein Superficial Upper Arm Veins brachial veins Peripheral Venous Access Peripheral Venous Access Anatomy Artery vs Vein basilic vein • Compression ! brachial veins • Both arteries and radial artery veins may be compressible ! humerus • Arteries will usually still be pulsatile
Peripheral Venous Access Peripheral Venous Access Artery vs Vein Vein Selection • Optimal vein: ! • Less than 1 cm deep ! • Color Flow • At least 3cm long ! • relatively straight ! • At least 3mm wide arteries usually more ! pulsatile Peripheral Venous Access Peripheral Venous Access Vein Selection Vein Selection Optimal Vein Vein should be relatively straight Peripheral Venous Access Peripheral Venous Access Transverse Approach Transverse Approach • Needle not usually seen directly ! • Location inferred by artifact and movement of surrounding tissues “Bouncing” technique to localize needle
Peripheral Venous Access Peripheral Venous Access Longitudinal Approach Longitudinal Approach • Needle slope and tip may be seen ! • More technically challenging ! Consider using Seldinger technique for ! deeper veins Pearls and Pitfalls Pearls and Pitfalls Pearls and Pitfalls Setup is Crucial Compression • Prepare all material before starting ! Compression is the most • Sterile covers, flushes, syringes, etc ! reliable way to differentiate arteries and • Adjust ultrasound machine to a veins comfortable position ! • Extra catheters available ! • Position marker/monitor correctly
Pearls and Pitfalls Pearls and Pitfalls Valsalva & Trendelenberg Locate the Needle Both maneuvers will significantly increase the size of internal jugular vein Bouncing Technique Pearls and Pitfalls Pearls and Pitfalls Angle of Approach Angle of Approach Steep angle of approach Steep angle of approach makes posterior wall makes kinking of catheter puncture more likely more likely Catheter kinks in vein Posterior Wall Puncture Pearls and Pitfalls Pearls and Pitfalls Thread the Catheter Thread the Catheter Visually check that catheter is inside vein before advancing Once flash is obtained, advance needle to make sure catheter is in vein
Pearls and Pitfalls Pearls and Pitfalls Confirm Placement Quick Punch A quick jabbing motion may be needed to pierce wall of the vein Agitated saline “Bubble” Test ! 68 Pearls and Pitfalls Pearls and Pitfalls Echotip Needle Troubleshooting Commercially made “echotip” needles are available and may aid visualization “Guidewire will not thread” Needle no longer in vessel Pearls and Pitfalls Pearls and Pitfalls Trouble-shooting Trouble-shooting IV in basilic vein Saline flow through brachials ! 71 “IV has stopped working” “IV has stopped working” Clot has developed inside vein Clot has developed inside vein
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