Central and Disclosures Peripheral Venous Access
3/22/2016
Central and Peripheral Venous
Access
Gavin Budhram, MD Department of Emergency
Medicine Baystate Medical Center
Disclosures
? I have nothing to disclose
Why Use Central Venous Access
Ultrasound?
? Decreases complications ? Excessive bleeding, inadvertent
arterial puncture, vessel laceration, pneumothorax, hemothorax
? Anatomic variation ? Quicker venous access ? Avoid multiple attempts
Central Venous Access
Internal Jugular
Right
70%
14% 1%
1% 18%
Left
66%
14%
14%
0%
1%
Variable position of IJ vein
Denys et al. Anatomical variations of internal jugular vein location: impact on central venous access. Crit Care Med, 1991; 19(12):1516-9
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3/22/2016
Why Use Central Venous Access Ultrasound?
US
Landmark
? 982 US
guided
? 302 landmark
based
Success 100% 88.1%
First Attempt
Skin to vein
Carotid puncture
78% 10 secs
1.7%
38% 44 secs
8.3%
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 Technical Considerations Technique
?Linear array probe ?high frequency (4-10 MHz) ?very detailed images of superficial
structures
?One person holds the ultrasound probe ?Other person places cannulates vessel ?Allows use of both hands for manipulating syringe ?Often preferred when first learning technique
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3/22/2016
One-Operator Technical Considerations
Technique ?Single operator controls probe and needle ?Allows greater precision ?Often preferred by advanced practitioners
Technical Considerations
Approach
? Static approach ? Ultrasound used to confirm anatomy
and mark position of vessel
? Dynamic approach ? Operator actually watches the needle
enter the vessel in real-time
Technical Considerations
Infection Precautions
? Central Venous Access ? Utilize sterile procedures ? Sterile gloves and probe covers ? Peripheral Venous Access ? Clean skin and transducer ? Similar to standard IV placement
Technical Considerations
Sterile Probe Covers
? Many commercially
available probe covers
? Standard gel (inside) ? Avoid air bubbles ? Sterile gel (outside)
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Central Venous Access
Central Venous Access
Artery vs Vein
? Shape ? Compression ? Color Flow
Central Venous Access
Artery vs Vein
? Shape ? arteries: circular ? veins: angular
? Compression
Central Venous Access
Artery vs Vein
? Color Flow
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3/22/2016
Central Venous Access
Artery vs Vein
? Color Flow
veins may be pulsatile red vs blue
Central Venous Access
Transverse Approach
A
V
place the probe so that the vein is in the middle of the screen
Central Venous Access
Transverse Approach
The needle is aimed for the middle of the probe
Central Venous Access
Transverse Approach
?needle not directly
seen
?localized by
artifacts:
?reverberation ?shadowing
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