UltrasoundGuided Vascular Access

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Ultrasound-GuidedVascular Access
Introduction to Emergency Ultrasound

• Keith Boniface, MD, RDMS
• Department of Emergency Medicine
• George Washington University Medical Center

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Vascular access in the ED

• Peripheral IV
• External jugular IV
• Landmark-based central line

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The problem...

• Complications
• Pneumothorax
• Hemothorax
• Arterial puncture
• Hematoma formation
• Neck, groin, mediastinum
• Failure to obtain access

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Complications
McGee DC, Gould MK. Preventing Complications of
Central Venous Catheterization. NEJM
20033481123-33
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The plan for today...

• Ultrasound guided central lines
• Literature review
• Technique
• Ultrasound guided peripheral IV access
• (arterial lines)

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Ultrasound guided vascular access

• Agency for Healthcare Research and Quality
• Making Health Care Safer A Critical Analysis of
  Patient Safety Practices
• Use of real-time ultrasound guidance during
  central line insertion to prevent complications
• http//www.ahcpr.gov/clinic/ptsafety/chap21.htm

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Ultrasound guided vascular access

• In hospitals where US equipment is available and
  physicians have adequate training, the use of US
  guidance should be routinely considered for cases
  in which IJ venous catheterization will be
  attempted

McGee DC, Gould MK. Preventing Complications of
Central Venous Catheterization. NEJM
20033481123-33
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Ultrasound guided vascular access

• US guided internal jugular cannulation
• Anesthesia
• Critical care
• Emergency medicine
• Nephrology
• Ob/gyn
• Radiology
• Surgery

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Adult IJ US vs landmark
Failed catheter placement
US
Landmark
Relative Risk (95CI)
Hind DH, Calvert N, Davidson A, et al. BMJ 2003
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Adult IJ

• Denys et al randomized patients to IJ- US
  guided928, Landmark302
• Overall success 100 vs 88.1
• First attempt success 78 vs 38
• Skin to vein time 9.8 (2-68) vs 44.5 (2-1000) sec
• Carotid puncture 1.7 vs 8.3
• Denys BG, Uretsky BF, Reddy PS.
  Ultrasound-assisted cannulation of the internal
  jugular vein a prospective comparison to the
  external landmark-guided technique. Circulation
  1993871557-62

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IJ EM literature

• Hudson and Rose reported first EM experience with
  US guided central lines
• Case report of two US guided IJs
• Description of techniques
• Literature review
• Hudson PA, Rose JS. Real-time ultrasound guided
  internal jugular vein catheterization in the
  emergency department. American Journal of
  Emergency Medicine 199715(1)79-82

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IJ EM literature

• Hrics et al reported a case series of 32
  ultrasound-guided IJ attempts
• 30 punctured successfully
• 26 subsequently cannulated
• Includes 7/7 attempts in patients with no visual
  or palpable landmarks
• Hrics P, Wilber S, Blanda MP et al.
  Ultrasound-assisted IJ vein catheterization in
  the ED. American Journal of Emergency Medicine
  199816(4)401-3

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Femoral Vein

• US has been demonstrated to be useful in
  localizing/evaluating femoral vessels
• DVT
• Interventional radiology
• Post-cath
• Paucity of literature on US guided femoral vein
  access

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Femoral Vein

• Hilty et al enrolled 20 ED CPR patients and
  placed 2 femoral lines in each patient
• One US guided, one landmark guided
• Both lines placed by one of 2 investigators
• Initial side and initial technique random
• US technique slightly faster
• US more successful than landmark technique
• 90 vs 65, p0.058
• Lower rate of arterial cannulation with US
• 0 vs 20, p0.025
• Hilty WM, Hudson PA, Levitt MA, Hall JB.
  Real-time ultrasound-guided femoral vein
  catheterization during cardiopulmonary
  resuscitation. Annals of Emergency Medicine
  199729331-6

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Vein versus Artery

• Artery
• thicker walls
• non-compressible
• pulsatile
• (color flow)

• Vein
• thinner walls
• compressible
• non-pulsatile
• (color flow)

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Ultrasound access techniques

• Static
• mapping technique
• no sterile technique required for US
• Dynamic
• views needle entering vein
• freehand
• needle guide
• requires sterile technique

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Static technique

• Position patient as you will for procedure
• Look at vessels and confirm landmark-predicted
  anatomy
• Mark location, note depths and angles
• Remove ultrasound, prep patient without moving
• Vein cannulated as usual

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Dynamic technique

• Place gel in palm of sterile glove
• Place vascular probe in palm, avoid trapped air
  bubbles, and wrap free fingers out of way
• Sterile KY jelly for glove-skin interface

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Dynamic technique

• Two potential approaches
• Transverse
• Longitudinal

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Best approach?

• Blaivas et al looked at time to short vs long
  axis US guided IV access in a resusci-arm
• Short 2.36 min (1.15-3.58)
• Long 5.02 min (2.90-7.13)
• P0.03
• Blaivas M, Brannam L, Fernandez E. Short-axis
  versus long-axis approaches for teaching
  ultrasound-guided vascular access on a new
  inanimate model. Academic Emergency Medicine
  200310(12)1307-1311

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Dynamic technique

• Center vessel in center of screen
• Center of probe overlies center of vessel and
  serves as landmark for needle
• Needle creates bright echo with ringdown artifact
• Advance needle to vein, which is deformed by
  needle pressure and then recoils to original
  position as vein is cannulated

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Vessel specifics

• IJ
• Subclavian
• Femoral

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Internal jugular
Medial
Lateral
IJ
Carotid
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Internal jugular
Medial
Lateral
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Internal jugular
Medial
Lateral
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Femoral vein
Artery
Lateral
GSV
Medial
Femoral Vein
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Vascular Access
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US guided central line - pearls

• Distinguish vein from artery
• Static
• dont move patient between mapping vessels and
  procedure
• Dynamic
• make slow movements, STOP, fan beam along needle
  to find tip, reposition/ readvance, STOP, fan
  beam again

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Ultrasound guided peripheral IVs

• 51 patients that medics or ED RN could not get IV
  on
• 46/51 successfully cannulated using ultrasound,
  43 on first attempt
• 4 were in brachial vein
• Remainder in basilic, cephalic, antecubital, or
  forearm veins
• Average time 2.5 minutes
• Remaining 5 patients received central lines
• One brachial artery puncture
• Constantino TG, Fojtik JP. Success rate of
  peripheral IV catheter insertion by emergency
  physicians using ultrasound guidance (abstract).
  Academic Emergency Medicine 200310(5)487

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Sounds easy - can RNs do this?

• 23 RNs attempted IVs in 321 difficult patients
• 87 success rate
• 29 of "failure" patients ended up getting
  central lines, 22 EJ, and 49 received US guided
  IV by EP/other RN
• Emergency nurses' utilization of ultrasound
  guidance for placement of peripheral intravenous
  lines in difficult-access patients. Brannam L,
  Blaivas M, Lyon MFlake M. Acad Emerg Med
  200411(12)1361

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Basilic vein catheterization

• 101 pts (50 IVDA, 21 obese) with 2 unsuccessful
  IV attempts
• Deep brachial or basilic vein in medial upper arm
• 2-inch 18 or 20 gauge catheter
• readily visualized using US and cannulated with
  91 success, avg time 77 seconds
• 2 cases of brachial artery puncture
• Infiltrated or fell out in 1 hour in 8 of
  patients
• 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. Annals of
  Emergency Medicine 199934(6)711-714

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Vascular access options

• Peripheral IV
• External jugular IV
• US guided peripheral/basilic vein IV
• Midline/PICC US guided
• Central line landmark or US guided