Surface Echo for Vascular Access

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1 Surface Echo for Vascular Access Christopher A. Troianos, M.D. Professor and Chair, Department of Anesthesiology Western Pennsylvania Hospital West Penn Allegheny Health System Pittsburgh, PA Introduction: A 2003 estimate cited the insertion of more than 5 million central venous catheters annually in the US alone, with a mechanical complication rate of 5-19%. 1 The Agency for Healthcare Research and Quality (AHRQ) in their 2001 report Making health care safer: a critical analysis of patient safety practices, recommended the use of ultrasound for the placement of all central venous catheters as one of their eleven practices aimed at improving patient care. 2,3 Practice recommendations for ultrasound guided vascular cannulation emerged from the National Institute of Clinical Excellence (NICE), 4 American College of Emergency Physicians, and American College of Surgeons. Practice guidelines for ultrasound guided vascular access first appeared in the anesthesiology literature from the American Society of Echocardiography (ASE) and Society of Cardiovascular Anesthesiologists (SCA). 5 Most recently the American Society of Anesthesiologists Task Force on Central Venous Access recommended real time ultrasound use for cannulation of the IJ, and that ultrasound may be used during femoral and SC vein cannulation. 6 The ASE/SCA guidelines recommend: 1. internal jugular use real-time ultrasound whenever possible during cannulation and to confirm successful vessel cannulation in adult & pediatric patients; 2. femoral vein (FV) use real-time ultrasound whenever possible during cannulation and to confirm successful vessel cannulation in pediatric patients, and to identify vessel patency and overlap in adult patients; 3. subclavian (SC) vein ultrasound screening in high-risk patients for vessel patency; real time use for rescue after two unsuccessful landmark guided attempts; 4. arterial cannulation as a rescue technique; 5. training - perform 10 ultrasound-guided procedures under supervision. Ultrasound allows imaging of the vascular structures and improves success rates and decreases the complications associated with adult internal jugular 7 and pediatric internal jugular and femoral vein cannulation. Commercial equipment specifically designed for this purpose is available and requires a sterile sheath to maintain sterility during real-time use. Clinicians lacking dedicated equipment for ultrasound guided cannulation can use echocardiographic equipment used for intraoperative TEE. 8 Pediatric transthoracic probes usually work best for this purpose because of the smaller probe size and higher frequency. TEE probes may also be used if transthoracic probes are not available.

2 Real-time Use: The use of ultrasound for vessel location alone has no effect on the complication or success rate of subclavian vein cannulation, but must be used in real time during catheter placement in order to be effective. Ultrasonography identifies anatomy conducive for carotid artery puncture, in which the internal jugular vein overlies the carotid artery. The ultrasound probe is adjusted to locate an insertion site with a more favorable anatomic relation between the carotid artery and internal jugular vein (vein lateral to the artery instead of overlying the artery), thereby decreasing the likelihood of carotid puncture by a needle that punctures the posterior wall of the vein. Two-dimensional imaging allows identification of the carotid artery and internal jugular vein by their relative position, compressibility of the vein, expansion of the vein during Valsalva maneuver, and pulsation of the artery. Ultrasound guidance improves success on the first needle pass and decreases the time to successful cannulation. 7 Complications: Attempted cannulation of the internal jugular vein carries the risk of unintentional puncture of surrounding structures including the carotid artery, the cervical plexus, the lung, and the thoracic duct (left side only), and venous air embolism. The incidence of pneumothorax is low with needle insertion sites higher in the neck, but increases with lower insertion sites. Patients usually complain of ipsilateral arm pain when a needle is directed too laterally at the cervical plexus. The most serious and potentially life threatening complication of internal jugular vein cannulation is arterial puncture. Puncture of the aorta is rare, but may occur with a low (supraclavicular posterior) approach and lead to cardiac tamponade. Arterial puncture of the carotid artery is more common with an incidence of 2%-16% Carotid artery puncture is potentially lethal when a large bore catheter is inserted into the carotid artery. Strategies for reducing the incidence and severity of this complication include the use of ultrasound to guide needle placement, use of a small 25 gauge finder needle, transducing the cannulating needle, and using the external jugular vein when possible. Arterial puncture is of greater concern in anticoagulated patients, patients with carotid artery disease, and when a large bore catheter is inserted into the artery. Carotid artery puncture can occur primarily (directly into the carotid artery) or secondarily (after the needle traverses the IJV). The best management approach to carotid artery puncture is avoidance. Ultrasound guided techniques decrease the incidence of carotid artery puncture, but the incidence is not zero. 7 It is therefore important to identify carotid artery puncture with the smaller cannulating needle to avoid insertion of large bore catheters, which may produce lethal consequences. The pressure within the cannulating needle should always be transduced with either a fluid column or electrical transducer to verify venous placement. Observation of the color of the aspirated blood is not a reliable method to confirm venous access, particularly when blood is aspirated into a saline-filled syringe. Syringes that allow insertion of a guide wire into the needle through the barrel without disconnecting the syringe from the needle may also play a role in arterial puncture. The simple act of disconnecting the syringe from the cannulating needle may in itself reveal an arterial puncture. Ultrasound can also be used to confirm correct placement after initially transducing the catheter. Imaging the wire in the vein with the absence of the wire in the artery confirms correct placement.

3 Carotid artery puncture may occur after the cannulating needle has traversed the internal jugular vein. The ease by which the internal jugular vein is compressed accounts for the initial undetected entry into the vein. Slow needle withdrawal after the initial advance is an important step before advancing the needle too far and into the carotid artery. The mean distance to the internal jugular vein via a high anterior approach is between 15.0 and 21.5 mm and the initial aspiration of blood is more likely during withdrawal rather than insertion, particularly with larger (16gauge) needles. It is important not to advance the needle beyond this distance and to withdrawal the needle slowly allowing the vein to reexpand with the needle tip in the lumen. The close proximity of the two vessels allows for the development of a carotid artery-internal jugular vein fistula from puncturing the posterior wall of the internal jugular vein and the anterior wall of the carotid artery. The ASA Practice Guidelines for Central Venous Access provide an algorithm (see below) for confirmation of central venous placement. 6 The methods listed in these guidelines for confirming that the catheter or thin-wall needle resides in the vein include, ultrasound, manometry, pressurewaveform analysis, or venous blood gas measurement.

4 Vessel Anatomy: The anatomic position of the internal jugular vein is classically described as lateral to the carotid artery. This anatomic relation describes the relation of these structures in the coronal plane and not in the direction of the cannulating needle with the head turned to the contralateral side. 11 Turning the head produces overlap between the two vessels, 11 possibly increasing the likelihood of carotid puncture after the needle traverses the internal jugular vein. Older patients have a higher incidence of having an internal jugular vein that overlies the carotid artery, 11 presumably because the common carotid artery becomes elongated and tortuous in older patients with arteriosclerosis. Head rotation does not appear to affect the likelihood of cannulating the internal jugular vein. Real-time ultrasound guided cannulation provides imaging of the internal jugular vein and carotid artery, directs placement of the cannulating needle at a level in the neck with minimal vessel overlap, monitors compression of the vein during needle advancement, and determines depth of insertion to minimize puncture of an underlying carotid artery. Three-D procedure with 2-D Equipment: Ultrasound-guided systems that employ needle guides that direct the needle depth by controlling the insertion angle are the most useful for avoiding carotid artery puncture. The depth of the internal jugular vein is determined by two-dimensional ultrasound and the corresponding needle guide is chosen to direct needle insertion to that particular depth. Use of a needle guide directs the needle to the axis of the ultrasound beam, thus reducing the possibility of operator error. The ultrasound image must be observed continuously during needle advancement until it is imaged within the lumen of the internal jugular vein. Techniques that employ ultrasound to merely localize the entry site on the skin, do not demonstrate a benefit of ultrasound guided cannulation. The ultrasound probe is removed from the needle and the catheter is advanced into the vein. Blood is aspirated from the catheter and the pressure within the catheter is transduced to confirm venous placement. Ultrasound is also used to confirm correct placement by observing the wire within the lumen of the vein and by the absence of the wire in the lumen of the artery. This latter step is important for ensuring that the wire has not traversed the vein and entered the artery. A large bore introducer and catheter may then be inserted into the vein over the guide wire. REFERENCES 1. McGee DC, Gould, MK: Preventing complications of central venous catheterization. N Engl J Med 2003; 348: Bodenham AR: Can you justify not using ultrasound guidance for central venous access? Critical Care 2006;10: Rothschild JM: Ultrasound guidance of central vein catheterization. Making Healthcare Safer: A critical analysis of Patient Safety Practices. AHCRQ Publication No. 01-E ; National Institute for Clinical Excellence. NICE technology appraisal No. 49: guidance on the use of ultrasound locating devices for placing central venous catheters. London: NICE September 2002 ( 5. Troianos et al: Guidelines for Performing Ultrasound Guided Vascular Cannulation:

5 Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesth Analg 2012; 144: Practice Guidelines for Central Venous Access A Report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology 2012;116: Troianos CA, Jobes DR, Ellison N: Ultrasound-guided cannulation of the internal jugular vein. A prospective, randomized study, Anesth Analg 72:823-6, Troianos CA, Savino JS: Internal jugular vein cannulation guided by echocardiography, Anesthesiology 74:787-9, Jobes DR, Schwartz AJ, Greenhow DE, et al: Safer jugular vein cannulation: recognition of arterial puncture and preferential use of the external jugular route, Anesthesiology 59:353-5, Johnson FE: Internal jugular vein catheterization, N Y State J Med 78: , Troianos CA, Kuwik RJ, Pasqual JR, et al: Internal jugular vein and carotid artery anatomic relation as determined by ultrasonography, Anesthesiology 85:43-8, 1996