Disclosures Central and Peripheral Venous Access I have nothing - PDF document

3/22/2016 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 Internal Jugular Ultrasound? • Decreases complications Right Left • Excessive bleeding, inadvertent 18% 14% 1% 1% 70% 66% arterial 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 1

3/22/2016 Central Venous Access Why Use Ultrasound? US Landmark Success 100% 88.1% Technical • 982 US First guided 78% 38% Considerations Attempt • 302 landmark Skin to 10 secs 44 secs based vein 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 Two-Operator Vascular Probe Technique • One person holds the ultrasound probe • Linear array probe • Other person places cannulates vessel • high frequency (4-10 MHz) • Allows use of both hands for manipulating syringe • very detailed images of superficial • Often preferred when first learning technique structures 2

3/22/2016 Technical Considerations Technical Considerations One-Operator Approach Technique • Single operator • Static approach controls probe and needle • Ultrasound used to confirm anatomy • Allows greater precision and mark position of vessel • Often preferred by • Dynamic approach advanced practitioners • 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 Venous Access • Sterile gel (outside) • Clean skin and transducer • Similar to standard IV placement 3

3/22/2016 Central Venous Access Artery vs Vein Central Venous • Shape Access • Compression • Color Flow Central Venous Access Central Venous Access Artery vs Vein Artery vs Vein • Shape • arteries: circular • Color Flow • veins: angular • Compression 4

3/22/2016 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 5

3/22/2016 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 Longitudinal Approach Approach 6

3/22/2016 Central Venous Access Central Venous Access Transverse vs Anatomic Sites Longitudinal Longitudinal Transverse • Safer (no • Central • Easier to learn overshoot) • Internal jugular • See other • Depth and slope • Femoral anatomy • Harder to learn • 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 external vein jugular common vein carotid artery subclavian vein Transverse Approach 7

3/22/2016 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. 8

3/22/2016 Central Venous Access Central Venous Access Femoral Subclavian compression used to differentiate arteries and veins color may be used but is not always reliable Transverse Orientation Central Venous Access Central Venous Access Subclavian Subclavian Transverse Orientation Longitudinal Orientation 9

3/22/2016 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 10

3/22/2016 Peripheral Venous Access Peripheral Venous Access Preparation Catheter Length • In general, longer • Similar to standard preparation for IV catheters are needed for access standard 1 1/4” (32mm) • Clean skin and transducer ultrasound-guided IV’s 1 3/4” (45mm) • Have all materials readily accessible • Deeper vessels • Placement of ultrasound machine 2 1/2” (64mm) usually cannulated • Get comfortable! Peripheral Venous Access Peripheral Venous Access Catheter Length Catheter Length • However at the shallower angle needed (22 degrees), 16mm • Standard catheters are “used up” to reach are 1 inch (32mm). the vein • To cannulate a vein • Only leaves 1/2 inch in 16mm 7mm 10mm 7mm 7mm deep at a 45 the vein degree angle “uses • ED should stock 1.5-2 up” 10mm inch catheters • sto 11

3/22/2016 Peripheral Venous Access Peripheral Venous Access Anatomy Anatomy • Cephalic vein runs • Brachial veins are along anterior deeper along medial aspect of upper arm cephalic aspect of upper arm vein • Basilic vein runs • Usually require a cephalic vein along superficial longer catheter basilic vein medial aspect of • Closer to radial upper arm basilic vein artery 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 12

3/22/2016 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 13

3/22/2016 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 Longitudinal Approach Approach • Needle slope and tip may be seen • More technically challenging Consider using Seldinger technique for deeper veins 14

3/22/2016 Pearls and Pitfalls Setup is Crucial • Prepare all material before starting • Sterile covers, flushes, syringes, etc Pearls and Pitfalls • Adjust ultrasound machine to a comfortable position • Extra catheters available • Position marker/monitor correctly Pearls and Pitfalls Pearls and Pitfalls Valsalva & Compression Trendelenberg Both maneuvers will Compression is the significantly increase most reliable way to the size of internal differentiate arteries and jugular vein veins 15

3/22/2016 Pearls and Pitfalls Pearls and Pitfalls Locate the Needle Angle of Approach Steep angle of approach makes posterior wall puncture more likely Bouncing Technique Posterior Wall Puncture Pearls and Pitfalls Pearls and Pitfalls Angle of Approach Thread the Catheter Steep angle of approach makes kinking of catheter more likely Once flash is obtained, advance needle to make sure catheter is in Catheter kinks in vein vein 16

3/22/2016 Pearls and Pitfalls Pearls and Pitfalls Thread the Catheter Confirm Placement Visually check that catheter is inside vein before advancing Agitated saline “Bubble” Test Pearls and Pitfalls Pearls and Pitfalls Quick Punch Echotip Needle A quick jabbing motion Commercially made may be needed to “echotip” needles are pierce wall of the vein available and may aid visualization 67 17