Ultrasound for vascular access

1
Ultrasound for vascular access
Dr Neil Orford Intensive Care Unit The Geelong
Hospital
2
Introduction

• Traditional approach anatomical landmarks for
  central venous access
• Normal variation, distorted anatomy
  difficulties
• Complications
• Arterial puncture
• Pneumothorax
• Bleeding

3
A safer way.?
4
NICE(National Institute of Clinical Excellence)

• 2D US guidance is recommended as preferred method
  for insertion of CVCs into IJV in adults and
  children in elective situations
• 2D should be considered where CVC necessary
  elective or emergency
• Training required

5
NICE

• Ultrasound guidance avoided 90 arterial punctures
  for every 1000 patients treated
• No reason not to apply to all anatomical sites
• Reduced costs by 2 pounds per patient
• gt11 US per machine / week
• gt3 per practitioner / month

6
NICE

• Do we accept recommendations ie all lines placed
  with CVC?
• Do we answer questions ourselves?

7
Questions

• What is the complication rate for traditional
  central vein cannulation?
• Does US guidance improve safety of CVC insertion?
• Experienced vs novice
• Sites of access
• Real time vs static
• Infection risk
• De-skilling in settings US not available
• Training in US

8
Problems with landmark method

• Complication
• Bleeding
• Arterial puncture
• Pneumothorax
• Failure
• Multiple attempts

• Contributing
• Experience
• Obesity
• Anatomical variation
• Age
• Coagulopathy
• Ventilation
• Repeat lines
• Pathology

9
(No Transcript)
10
Does US guidance improve safety of CVC insertion?

• Experienced vs novice
• Sites of access
• Real time vs static
• Infection risk
• De-skilling in settings US not available
• Training in US

11
Literature search
12
Meta-analysis

• 200,000 CVCs / yr UK
• NCEPOD 2000 - one death from CVC pneumothorax
• Morbidity greater
• Methods
• 15 databases relevant terms for US guided line
  placement up to Oct 2001
• Results
• 27 RCT identified
• Rejected if US identification followed by blind
  placement
• Overall favour US for IJV, SCV (small no.s)
• Basis of NICE recommendation
• Studies report 20-50 failure rate

13
SOAP-3 Trial

• Prospective, RCT
• Insertion techniques
• D (dynamic) real time sterile transverse plane
• S (static) 2 marks 2-3cm apart, insert in one
  aim for the other
• LM anatomical landmarks
• Inclusion needed CVC
• Location ED,ICU
• Operators
• Emergency residents, attendings
• 1 hr training on iLook, then performed 10
  insertions
• All minimum 30 CVCs

14
SOAP-3 Trial

• Primary outcome - cannulation success
• Secondary outcomes
• First attempt success
• No. attempts
• Time to placement
• Complications
• Results controlled for pretest difficulty
  assessment of landmarks

15
SOAP-3 Trial

• Results 6 mth trial period, 235 pts eligible,
  201, enrolled

16
SOAP-3 Trial

• S and D better than LM, D gtS
• D required more training and extra person
• Static
• Easy
• Identifies thrombosed, small (uni or bilateral)
  IJ
• Close to D in improvement
• Refutes dismissal of static

17
SOAP-3 Trial

• Suggest
• US assist for all central line placements
• Protocol based on vein size
• lt5mm diameter relative contraindication , go to
  other site where may be compensatory enlargement
• 5-10mm may benefit from dynamic US
• gt10mm attempt static (max 3 passes)

18
IJV US in the ED

• Leung J, Duffy M, Finckh, A.
• Prospective RCT Aug 03- May 05
• Exclude trauma with collar, severe coagulopathy
• Include need CVC
• Landmark vs Ultrasound (realtime)
• 130 pts
• Experienced operator gt25 IJVs
• Real time US with 2 hrs training

19
IJV US in the ED
20
IJV US in the ED

• Overall higher success with US
• 15 LM, 12 crossover to US, 11 success
• Complications
• US 4.6 (haematoma 3.1, carotid 1.6)
• LM 16.9 (haematoma 10.8, carotid 6.2, PTX
  1.5)

21
Real-time US in ICU for IJV CVC

• Karkakitsos et al.
• Prospective RCT
• Experienced operators (gt10 yrs)
• LM vs RT US
• RT US
• Transverse and longitudinal view
• 5 yrs experience US guided CVC
• 900 pts

22
Real-time US in ICU for IJV CVC
23
Real-time US in ICU for IJV CVC

• With experienced operators real-time US led to
  improved outcomes
• Large trial, well designed, impressive outcomes
• Higher than expected complication rate in control
  group
• Experience defined by duration rather than
  ongoing activity

24
Static US guided IJV in cardiac anaesthetics

• Hayashi, H
• Prospective RCT
• LM vs static US (look and mark then blind)
• 240 pts
• 6 operators, 40 each (20 LM, 20 US)
• Standard techniques
• Access rate frequency of cannulation with
  minimal pass
• Success rate no arterial puncture and less than
  3 attempts

25
Static US guided IJV in cardiac anaesthetics

• Results
• Overall
• access rate LM 74vs US 103 86 plt0.05)
• success rate LM 93.3 vs US 96.7 (ns)
• Difficult landmarks
• access rate LM 30.4 vs US 86.2 (plt0.001)
• success rate LM 78.3 vs US 100 (plt0.05)

26
Static US guided IJV in cardiac anaesthetics

• Conclude
• Static US not superior overall to LM in
  anaesthetised cardiac surgical patients
• Is superior in patients where landmarks difficult
  to identify
• Did not use real-time

27
Effect of implementation NICE guidelines for
elective surgery

• Wigmore et al.
• Pre and post implementation
• Patients requiring CVC for elective surgery
• Operator choice between US or LM

28
Effect of implementation NICE guidelines for
elective surgery
29
Effect of implementation NICE guidelines for
elective surgery
30
Effect of implementation NICE guidelines for
elective surgery

• US guided
• Decreases failure rate
• Decreased complications
• More pronounced effect with SRs

31
US guided subclavian lines

• Prospective RCT
• Smart needle vs LM
• Smart needle
• Oncology outpatients
• 240 pts14-MHz CWD device

32
US guided subclavian lines
33
US guided subclavian lines

• No benefit with US
• Improved overall success with standard

34
Summary

• Increasing body of evidence that US guidance for
  IJ cannulation safer
• Requires
• Training
• Supervised before solo
• Guidelines (SOAP)

35
Suggestions

• Technique
• Static
• Transverse x 2 / longitudinal
• Dynamic
• Gel in sheath
• Wet external surface sheath
• Angles
• Transverse / longitudinal

36
(No Transcript)
37
(No Transcript)
38
Humming

• Vasalva vs trendelburg vs humming
• Femoral, Internal Jugular, External Jugular
• 7 subjects (healthy volunteers)
• Measured vein size
• All 3 maneuvers distended EJ, IJ, CFV
• (Lewin M, Stein J, Wang R, et al. Annals of
  Emrgency Medicine July 2007)

39
(No Transcript)