Ultrasonography Guided Venous Cannulation

Transcription

1 Ultrasonography Guided Venous Cannulation Srinivasan Rajagopal, M.D. Assistant Professor Division of Cardiothoracic Anesthesia Objectives Describe the technique of ultrasound guided central line placement Know literature of ultrasound use for cannulation Describe the technique of ultrasound guided peripheral IV placement Describe the technique of ultrasound guided arterial line placement 1

2 Outline Practical approach for US-guided vascular access Physics Frequency Gain Depth US-guided vascular access General Approach (Internal Jugular vein) How to avoid complications Mechanism of arterial puncture Wire malposition Pediatrics, peripheral access Guidelines for Performing Ultrasound Guided Vascular Cannulation: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists Anesthesia & Analgesia January 2012 On the basis of scientific evidence, properly trained clinicians should use real-time ultrasound during internal jugular cannulation whenever possible to improve success and reduce complications Use real time US for IJ and FV cannulation in pediatric patients Use US to screen SC vein in obese and coagulopathic patients 2

3 Guidelines Recommendation US improves first pass success in radial artery cannulation (category A, level 1) No recommendation for peripheral access Use for PICC line (category B, level 2) Use real time US for access confirmation Visualize guidewire in the vessel 10 supervised procedures adequate for competence / independence Real-time Two-dimensional Ultrasound Guidance for Central Venous Cannulation: A Meta-analysis Wu, S; et al: Anesthesiology 2013 Compared to anatomical technique for central venous cannulation, real time ultrasound guidance was associated with decreased risk of cannulation failure, arterial puncture, hematoma and hemothorax in adults 3

4 Meta-analysis cont d 26 studies Over 4000 CVC RTUS versus landmark Results Cannulation failure: RR 0.18 ( ) Arterial puncture: RR 0.25 ( ) Pneumothorax: RR 0.21 ( ) This study did not show significance in children or infants Preventing Complications of Central Venous Catheterization McGee DC, Gould MK. NEJM 2003 In hospitals where US equipment is available and physicians have adequate training the use of US guidance should be routinely considered for IJ venous catheterization 4

5 Hind D. et al BMJ RCT( ), Total n=1646 US significantly lowers failure rate in Adult IJ - overall (RR 0.14,CI ) - first attempt (0.59, ) US lowers the complications rate (0.43, ) Fewer attempts and less time with US Use of US in Practice Anesth Analg Survey of the Use of Ultrasound During Central Venous Catheterization 1500 SCA member 50/50% University/Private hospital 5

6 Survey of the Use of Ultrasound During Central Venous Catheterization Description of US use for CVC Anesth Analg Mar;104(3):491-7 Reason for Not Using US US does not improve CVC technique Time delay to perform CVC with US Lack of availability of US Time delay to obtain US 6

7 Cognitive Skills Physical principles of ultrasound Operation of the equipment, controls Infection control standards and sterile preparation Surface anatomy and ultrasound anatomy Recognize the location and patency of the target vessel Recognize atypical anatomy of vessel location and redirect the needle entry to minimize complications Color flow and spectral Doppler flow patterns that identify arterial and venous flow characteristics Technical Skills Ability to operate the ultrasound equipment and controls Dexterity to coordinate needle guidance in the desired direction and depth on the basis of the imaging data Ability to insert the catheter into the target vessel using ultrasound information Ability to confirm catheter placement into the target vessel and the absence of the catheter in unintended vessels and structures 7

8 Real-time US-guided Vascular Access 1. Adjust US image 2. Identify IJ and measure the depth of IJ 3. Determine needle insertion point 4. Show the tip of needle in the image 5. Confirm the wire position Where is the needle tip?? Frequency Higher Frequency - Better resolution Lower Frequency - Better penetration Frequency MHz (3-5cm in depth) for adult > 12 MHz(1-2cm) for Pediatrics and radial arterial cannulation 8

9 1. Adjust US image (Gain) High Low 9

10 1. Adjust image (Depth) 2cm 3cm 8cm 2. Identify IJ and Measure the Depth CA IJ 10

11 Pythagorean theorem: In any right triangle, the hypotenuse is 1.4 times the length of the equilateral sides Isosceles-right triangle Determine needle insertion point

12 4. Show the tip of needle in the image Two-dimensional image of the right IJ vein (IJV) and CA from the head of the patient over their right shoulder. Troianos C A et al. Anesth Analg 2012;114:

13 The anterior wall of the IJ vein (IJV) recesses as the needle approaches the vein (left) Troianos C A et al. Anesth Analg 2012;114:46-72 Confirm the Wire Position 13

14 CA-IJ Relationship Position range in % medial anterior 0 16 (54*) anterio-lateral 9-92 far lateral 0-4 lateral 0 84 posterior 0 9 medial lateral not visible/ thrombosed 0 18 Crit Care Med May;35(5 Suppl):S Christopher A. Troianos, Gregg S. Hartman, Kathryn E. Glas, Nikolaos J. Skubas, Robert T. Eberhardt, Jennifer... Guidelines for Performing Ultrasound Guided Vascular Cannulation: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists Journal of the American Society of Echocardiography Volume 24, Issue

15 Direction of Probe Anterolateral-posteromedial Anterior-posterior Anteromedial-posterolateral Pneumothorax Hemothorax Arterial puncture Complications Hematoma formation Neck, groin, mediastinum Failure to obtain access 15

16 Risk Factors for Arterial Cannulation Spontaneous ventilation IJ-CA relationship Hypovolemia, Hypotension Venipuncture needle Lack of confirmation of wire position Reckless needle advancement 1: Stone; Annals of Emergency Medicine (2007) 2: Blaivas; J Ultrasound Med (2008) 3: Parsons; Anesthesia and Analgesia (2009) 4: Blaivas; J Ultrasound Med (2009) How to Avoid Complications Mechanism of arterial puncture Carotid arterial puncture through Internal Jugular Vein Subclavian arterial puncture 16

17 Mechanism of Subclavian Arterial Puncture RIJ Subclavian artery Needle CA Probe CA IJ Needle shaft is in the US image Needle tip is at subclavian artery How to Avoid Complications US probe position Needle insertion site Needle angle Needle direction Length of needle advancement 17

18 How to Avoid Complications Guide wire malposition J Ultrasound Med 2008; 27: Artery or Vein? Artery Thicker walls Non-compressible Pulsatile Smaller Color flow Vein Thinner walls Compressible Non-pulsatile Distendable 18

19 Artreryvsvein 19

20 US-guided Peripheral Vascular Access Adults Cephalic vein Less complications Basilic vein Deep location Brachial vein Next to Brachial artery US-guided Peripheral Vascular Access 20

21 Saphenous Vein Medial Malleolus Saphenous vein Summary The goal of real time US-guided vascular access technique is to show the needle tip in the image Appropriate real time US-guided vascular access technique is safe and reliable improves success rate and reduces complications rate Only routine use of real time US vascular access technique could achieve 100% success rate with no complications Requires training and experience 21