Presentation on theme: "Ultrasound Guided Central Venous Cannulation (CVC)"— Presentation transcript:
1Ultrasound Guided Central Venous Cannulation (CVC) Shirley Lee MDCAEP 2008Disclaimer - unless same folks as last talk
2Why Ultrasound guidance? Traditionally, CVC mechanical complications occur up to 15%Insertion unsuccessful up to 12%Becoming standard of careThe use of ultrasound has obviated the absolute need for anatomical landmarks in the traditional method of CVC insertion. Ultrasound can readily identify the locations of veins relative to arteries and therefore can take into account for individual anatomic differences (Gordon AC, Troianos CA, Denys BG). The use of ultrasound in experienced hands decreases the number of attempts and arterial punctures compared with landmark method. It is also the preferred method in difficult cannulations such as those patients with obscure surface landmarks or hypotensive patients (Hind D, Calvert N, Miller AH, Keenan SP, Fyr WR). Several meta-analyses have been performed and national recommendations have been made by both the National Quality Forum in the United States and the National Institute of Clinical Excellence in the United Kingdom (The National Quality Forum, National Institute for Clinical Excellence). Merrer J, De Johnghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA. 286:700-7, 2001McGee and Gould, NEJM 2003; 348:Merrer, De Johnghe, Golliot, et al. JAMA. 286:700-7, 2001
4CVC ComplicationsPneumothorax, arterial puncture, hematoma, malposition, increased skin punctures with bleeding complications, delay and failure to catheterize, thoracic duct injury (left sided approach), air embolism, arrhythmias, and deathDelayed complications: infection and thrombosis
5Advantages Safer Markedly decreased pneumothorax rate Real-time visualization of targetSee needle enter target vein, avoiding adjacent arteries, nervesTseng, Sadler et al, CARJ 2001;5(6): (i.e., 0/3267 at Foothills Hospital), high success (>99%)
6Evidence In ER: Prospective, randomized trial of 130 patients Complication rate: 4.6% vs. 16.9%Success rate: 93.9% vs. 78.5%Time not significantly differentLeung, Duffy, Finckh. Ann Emerg Med 2006;48(5):540-7
7Evidence ICU – Prospective,randomized trial of 900 Success: 100% vs. 94%Carotid puncture 1% vs. 10%Pneumothorax 0% vs. 2.4%Hemothorax 0% vs. 1.7%Reduced time and number of attempts with USKarakitsos et al, Crit Care,2006;10(6):R162
9Compression confirms patency Landmarks: SCM muscle above, central vein larger, more irregular in shape vs carotid artery smaller, rounder, prominently pulsatile. Right side - vein compresses easily.Compression confirms patency
11Common indications for CVC Hemodynamic monitoringAdministration of drugs likely to induce phlebitisTemporary cardiac pacemakerHemodialysisLack of peripheral venous access
12Technique5-10 MHz probe - locate vein, ensure patency, then puncture blindly – but no safer than landmark techniqueReal-time visualization of needle tip helps prevent pneumothorax, arterial punctureStill need X-ray to document tip position, as catheter can still go wrong directionSTART by facing caudad, facing patient’s feet, probe marker to patient’s LEFT (not traditional patient’s right). SINGLE OPERATOR: Probe in non-dominant hand, needle and syringe in dominant hand.Beward catheter can go to other innominate vein, azygous, deep in right atrium!
13TechniqueUse either transverse or longitudinal orientation of ultrasound beam to needle pathTransverse supposedly easier for noviceAdvantage of longitudinal: see needle through entire courseWith either, you will NOT see needle tip if out of planeCan use needle guides to help
14Predictors of difficult cannulation Emergency PlacementObesityCoagulopathyIntubatedHypotensive/HypovolemicEdematous patientKnown previous difficult cannulation
16Static vs Dynamic technique Static technique:Using 2-3 ultrasound planes, mark with felt penDynamic technique:1 vs 2 person techniqueUse image as guideObserve needlethroughout procedure,as it penetrates vesselWatch tip!2 person process: Scan for vein first (non sterile), mark site. Then give probe to nurse to prep for sterility, while you prep sterile dress and patient and prep equipment, then probe handed back to you. While you scan patient, nurse preps for sterile dress, and when you find the vein, grab nurse’s hand to hold position (NB - sometimes better if nurse does not see imaging screen, so won’t keep moving around). You proceed with cannulation.
17Venous access – easiest to more challenging 1st CHOICE: Internal/External Jugular2nd CHOICE: Femoral – easy3rd CHOICE: Subclavian/Axillary – harder due to location, more difficult to visualize while you puncture4th CHOICE: Cephalic/Basilic/Antecubital –4th choice: harder due to small size
18Jugular Vein Large, easy to see, good choice Trendelenberg, head contralaterally turned 30 degreesPut probe transversely across vein, just superior to clavicle btn two SCM heads, just superior to clavicleBring needle in from laterally above probe (in same plane as transducer), aiming just slightly down to toes ~ degrees (Posterior approach)Watch needle well away from vein, indenting vein wall, and pop through…and know where carotid is!Beware of anatomical variants:Widest diameter just superior to clavicle - is closer to lung, hence need steeper angle of degrees to safely avoid lung.
19Subclavian VeinMore challenging to see needle and vein at puncture siteJugular much easier, less risk of venous stenosis, thrombosis, catheter fracture from pinch off syndromePlace probe inferior to most lateral aspect of claviclePuncture axillary-subclavian junction close to clavicleInfraclavicular or supraclavicular technique.
20Femoral veinAlso easyOrient transducer longitudinally, along course of vein, bring needle in from below, parallel to transducer and veinValsalva often helps distend vein, bigger targetExternally rotate leg to move artery more lateralNAVEL (lateral to medial leg) . Avoid going too distal for needle insertion, as femoral artery tends to become more anterior to femoral vein, the more distal you go from the inguinal ligament.
21U/S CVC Pitfalls 1. Failure to identify the vein correctly 2. Failure to locate the needle in tissue
22TipsAwake patient - Check position. If patient has moved after you have landmarked, this results in a change in anatomical position of the veinCentre vein in middle of the screenLighten probe pressure, as may be collapsing veinInsert needle at sharper angle ( degrees), to properly intersect with the vein directly under transducerKeep acoustic shadow and ring down artifact in center of vessel, if is off center, withdraw slowly and redirect, using depth markers to help guide needle insertion.ALSO to prevent drift of the transducer due to slippery gel, a steady US position can be maintained by resting BOTH hand and transducer onto the patient’s body (be careful not to place undure pressure that may collapse the target vessel during the procedure)
237 Steps to Success: Use adequate gel Confirm orientation of probe - conventionally probe head pointing to RIGHT (rub edge with finger, look at screen)Do preliminary US - find patent target veinMark site (static vs direct technique)Consider local anestheticSterilize skin, sterile probe, sterile technique!Advance the needle!
24Sterile preparation of US transducer Apply non-sterile gel to probeSlip sterile sleeve over transducer, smooth all air bubbles away from scanning surface to prevent artifactSecure sleeve with rubber bandAlternate: large sterile glove, with fingers folded over, palmar surface of glove is scan surface.Sterile gel applies outer surface of glove/sterile sleeve
25General Tips on CVC insertion Be aware that more than 3 failed attempts to cannulate the vein can result in a 6 fold increase in mechanical complication. (McGee)Aids to distinguish arterial vs. venous cannulationA pressure transducer can be attached to the needle cannulating the vessel to confirm the presence of venous waveforms and pressureBlood gases from the needle in the vessel can be measured and compared with known a known arterial sample
26SummaryUS guided procedures have a number of clinical utilities in the EDUS can improve the safety of specific procedures and success rateInitially, can be more time consuming due to learning curve, but with practice, patience and good hand-eye coordination improve efficiency and efficacy of patient care
27ReferencesAbboud PAC and Kendall JL. Ultrasound guidance for vascular access. Emergency Clinics of North America. 22(3): , 2004Leung, Duffy and Finckh. Ann Emerg Med 2006;48(5):540-7McGee DC and Gould MK. Preventing complications of central venous catheterization. NEJM. 348(12): , 2003Miller AH, Roth BA, Mills TJ et al. Ultrasound guidance versus the landmark technique for the placement of central venous catheters in the emergency department. Academic Emergency Medicine. 9(8) : , 2002.
28Procedure Video Reference NEJM video - (look under Procedure videos on right side of webpage) – download to ipod, mem stick, etc.
29ReferencesNational Institute for Clinical Excellence. NICE technology appraisal guidance No.49: guidance on the use of ultrasound locating devices for placing central venous catheters. London: NICE, September (accessed 21 Apr 2004)The National Quality Forum. Safe Practices for Better Health Care. A consensus report.Washington, D.C (accessed 27 Jan 2005).