Notes On Sonography-Assisted Venous Access



Sonography-Assisted Venous Access: Details of Technique, Pearls, Pitfalls

Anthony J. Dean, M.D.

Assistant Professor of Emergency Medicine

University of Pennsylvania

Ultrasound technical and knobology issues

1. Depth

2. Frequency

3. Focus

4. Gain

5. Angle of insonation

Ultrasound beams are reflected back towards the transducer with maximum efficiency if the reflecting surface is at right angles to the beam. This is especially true of highly reflective surfaces (“specular reflectors”) such as a needle or a vessel wall. Therefore, to get the sharp images in sono-guided venous access, it’s necessary to rock the probe continually to optimize visualization of these structures, especially since there is usually at least a 30 degree angle between the needle and the vessel (i.e. they cannot both be imaged simultaneously with a 90 degree angle of insonation).

6. Important artifacts

a. Shadowing

b. Reverberation

c. Gain (“Black is Black”)

Transverse vs. longitudinal imaging of the vessel

1. Transverse

|Advantages |Disadvantages |

|Needle and vessel never completely out of “plane” |Need to keep scanning back and forth to find location of needle tip. |

| |Cannot tell path of vessel or projected path of needle above or below |

| |plane of ultrasound. |

|Easier with less experience | |

2. Longitudinal

|Advantages |Disadvantages |

|Can see relationship of entire needle w vessel and progress of needle as|If needle goes ‘out of plane’ of vessel, harder to determine adjustments |

|it approaches and enters vessel. Advance needle /cath within vessel w/o|needed to redirect |

|contact w posterior wall under direct visualization. | |

|Favored by more experienced practitioners | |

Techniques

1. One person, real-time

|Advantages |Disadvantages |

|Real-time hand-brain-hand information |Takes a bit more practice |

|Can watch the needle through proximal wall and advanced within lumen | |

|without damage to distal wall | |

|Human resource issues | |

|Can more easily use both TRV and Longi views | |

2. One person, localization, marking, then ‘anatomic’

Works for ascites and pleural taps, but for veins, “localization” w/o real time guidance is little better than plain LM technique (Armstrong 1993 Mansfield 1994[i]).

3. One person using needle guides: practical impediments in the ED: stocking and cost issues.

4. Two person

Personnel / resource issues. Difficult without a sono-savvy assistant.

By far the easiest technique to master is single operator. From this point on, this is the technique that is discussed and advocated.

While starting out, especially if a preceptor is available, an assistant may be helpful to organize the space, adjust lighting, take the probe once the vein is entered, etc.

Choice of vein and location

1. Peripheral

a. In the very obese, will often be able to locate otherwise undetectable veins in usual locations: remember courses of cephalic and basilic veins in upper extremities.

b. In patients with damaged veins (chemo, IVDA, etc) often find the deep brachial intact: bicipital groove above antecubital fossa. Watch out for the nerve (easily identified by US).

2. Central

a. IJ is by far the most studied and easiest. If this is absent or unavailable, experienced operators find the supraclavicular approach to the IJ-subclavian confluence preferable to the subclavicular approach to the SC.

b. Lower IJ is more tethered, therefore more desirable access location, but closer to thorax, therefore often avoided (Denys 1993).

Issues of technique

… prepare, prepare, prepare!

90% preparation + 10% perspiration 25 IJ caths, “inexperience” < 25 IJ caths |operators | | |

|operators + and - | | | | | |

|sono | | | | | |

|SC(85%); IJ(13%), |Fry WR. Arch Surg 134: 738-41,|Prospective case series. Complicated pts | 52 |Success 100% | |

|Innominate (2%) |1999. |(coagulopathy, hypovolemia, unable to lay flat, | |Complication: 1 PTX only | |

| | |stenosis, etc) | | | |

| | |5 – 7 MHz, no guide | | | |

| | |Surgeons | | | |

|Fem (75%), IJ |Miller AH: Acad EM 9: 800-5, |Prosp random |71 |Sticks: 1.6 vs 3.5 (p10 proced] and 16 ‘not | | | |

| | |experienced’ operators | | | |

|IJ |Leung J et al: Ann Emerg Med, |PRCT in the ED |130 |Success 94 vs 79% | |

| |2006 [xiii] |Sonosite TRV real-time vs. landmark |Linear array 10-5|1st attempt success: 82 vs 71% | |

| | | |MHz |Complications 5 vs. 17% | |

| | | | |No difference in time. | |

Notes

For LM technique, typical overall success rates 90-95%; carotid stick rates 4-8%; 1st – 2nd pass rates 50 - 60%. (Daily 1970, Schwartz 1979, Golfarb 1982).

Cost: Modest savings $3249 per 1000 procedures anticipated by analysis in Hind article, although this analysis assumes cost of purchase of dedicated equipment for US guided.

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[i] Mansfield PF. Hohn DC. Fornage BD. Gregurich MA. Ota DM. Complications and failures of subclavian-vein catheterization. New England Journal of Medicine. 331(26):1735-8, 1994.

[ii] Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment: Number 43. AHRQ Publication No. 01-E058, July 2001. Agency for Healthcare Research and Quality, Rockville, MD.

[iii] Koski EM. Suhonen M. Mattila MA. Ultrasound-facilitated central venous cannulation. Critical Care Medicine. 20(3):424-6, 1992 Mar.

[iv] Troianos CA. Jobes DR. Ellison N. Ultrasound-guided cannulation of the internal jugular vein. A prospective, randomized study. Anesthesia & Analgesia. 72(6):823-6, 1991 Jun.

[v] Denys BG. Uretsky BF. Reddy PS. Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external landmark-guided technique. Circulation. 87(5):1557-62, 1993.

[vi] Randolph AG. Cook DJ. Gonzales CA. Pribble CG. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Critical Care Medicine. 24(12):2053-8, 1996.

[vii] The National Health Service Health Technology Assessment 2003; vol 7(12), The effectiveness and cost-effectiveness of ultrasound locating devices for central venous access: a systematic review and economic evaluation.  Queen's Printer and Controller of HMSO 2003. cexpress/hta/summ/summ712.pdf

[viii] Hind D. Calvert N. McWilliams R. Davidson A. Paisley S. Beverley C. Thomas S. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ. 327(7411):361, 2003 Aug 16.

[ix] Miller AH. Roth BA. Mills TJ. Woody JR. Longmoor CE. Foster B. Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Academic Emergency Medicine. 9(8):800-5, 2002.

[x] Sofocleous CT. Schur I. Cooper SG. Quintas JC. Brody L. Shelin R. Sonographically guided placement of peripherally inserted central venous catheters: review of 355 procedures. AJR. American Journal of Roentgenology. 170(6):1613-6, 1998.

[xi] LaRue GD. Efficacy of ultrasonography in peripheral venous cannulation. Journal of Intravenous Nursing. 23(1):29-34, 2000.

[xii] Costantino TG. Bruno EC. Handly N. Dean AJ. Accuracy of emergency medicine ultrasound in the evaluation of abdominal aortic aneurysm. Journal of Emergency Medicine; 2005: 29(4):455-60.

[xiii] Leung J. Duffy M. Finckh A. Real-time ultrasonographically-guided internal jugular vein catheterization in the emergency department increases success rates and reduces complications: a randomized, prospective study. Annals of Emergency Medicine, 2006; 48(5):540-7.

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