Ultrasound Guided Peripheral Intravenous Access

Transcription

1 Ultrasound Guided Peripheral Intravenous Access J. Christian Fox, MD, RDMS, FACEP, FAAEM, FAIUM Professor and Interim Chair of Emergency Medicine Director of Instructional Ultrasound University of California, Irvine School of Medicine

2 Ultrasound Guidance eadily visualizes vascular tructures rovides real-time eyes proves accuracy hortens time ecreases complications

3 Ultrasound Guided Procedures Vascular access Bladder aspiration Pericardiocentesis Nerve blocks Paracentesis Foreign bodies Thoracentesis Lumbar Puncture Abscess localization Fracture reduction

4 Ultrasound Guidance Decreases Complications Less arterial punctures Less pneumothoraces Less needle stick attempts Less needle redirects Increased Patient Comfort

5 Ultrasound guidance during central line insertion prevents complications Shojania KG, Duncan BW, McDonald KM, et al. Making health care safer: a critical analysis of patient safety practices. Evid Rep Technol Assess (Summ) 2001;(42):i-x,

6 Do we put in less central lines after implementation of an ultrasound-guided peripheral intravenous access program?

7 Ultrasound Guided Peripheral Lines - Methods Retrospective cohort searching the electronic patient database Total number of patients that had a CVC placed was recorded from 2006 to 2011 The rate of CVC placement was obtained by dividing that number by the total number of patients treated in the ED ED Residents and ED technicians (received 2 hours of training) were placing the peripheral lines Ann Emerg Med. Feb 2013

8 Ultrasound Guided Peripheral Lines - Results Overall rate of CVC decreased by 80%, from 0.81% in 2006 to 0.16% in 2011 Ward: decreased by 4.8% per month (95% CI 4.2% to 5.3%) Telemetry, decreased by 4.4% per month (95% CI 3.6% to 5.1%) Discharged home decreased by 7.6% ( 95% CI 6.2% to 9.1%) By the last year of the study, there were no CVC placed in patients directly discharged home from the ED Ann Emerg Med. Feb 2013

9 Ann Emerg Med. Feb 2013

10 Vessel Selection

11 Vessel Selection Superficial vs. deep veins Avoid using deep veins because they underlie more fascia and can contribute to compartment syndrome if infiltration occurs

12 Vessel Selection Looking with the ultrasound start at the AC and move down the arm, or start at the wrist (thumb side) and move up the arm Go as distal on the arm as possible so the next IV attempt can go above that site Likewise, avoid being below previously used sites

13 Soft and Hard Tissue Epidermis Hypodermis Subcutaneous fascia Muscle Bone

14 Tendons Readily identifiable by ultrasound dense connective tissue is more hyperechoic than muscle Fibrillar pattern Can be evaluated throughout range of motion

15 Muscle Imaging on Ultrasound Muscle appears hypoechoic Hyperechoic linear fibrillar striae seen within muscle Hyperechoic connective tissue surrounds muscle bundles Long-Axis View

16 Muscle Imaging on Ultrasound Muscle appears hypoechoic Hyperechoic punctate striae within muscle Bone appears very dense and echogenic Short-Axis View

17 Bone

18 What do Nerves look like on Ultrasound? Move probe quickly back and forth along suspected nerve If it disappears after a short distance it's not a nerve If it bifurcates its likely a nerve

19 Discriminating Vascular Structures Color Doppler can easily discriminate vascular structures from other targets Holding the probe still will obviate pulsation in arteries, pressing with the probe will cause patent veins to collapse

20 Beam Angle B-Mode versus Doppler Perpendicular offers the best reflection for B-Mode Doppler B Mode

21 Cover the probe with a Tegaderm

22 Prevent Infection Perform hand hygiene where PPE and always use Chlorhexidine to prep when starting the IV (in the IV start kit) Gives 48+ hours of coverage vs. <4 hours with alcohol alone

23 Proper Transducer Hand Placement Holding the probe correctly allows for better vein visualization Very lightly scan the patient to reduce vessel compression by holding probe with thumb and index finger (C Grip)

24 Apply Tourniquet

25 Angiocath Length Although a catheter is fully advanced, the entire catheter does not reside in the vessel. A portion of the catheter is left in the tissue and is required to reach the vessel. When using ultrasound we encourage the use of a longer IV (1 ¾ ) catheter so that >50% of the catheter is in the vessel post placement, this will help reduce infiltrations.

26 Peripheral Technique Requires use of longer angiocatheter

27 Indicator towards the procedure doer s left Going left to right under the probe will have the same effect on the screen

28 Short Axis Technique Locate vein in short axis Vein is easily compressible

29 Short Axis Technique As long as vessel is CENTERED on screen then it must be underneath CENTER of probe

30 Short Axis Technique As long as vessel is CENTERED on screen then it must be underneath CENTER of probe

31 Short Axis Technique As long as vessel is CENTERED on screen then it must be underneath CENTER of probe

32 Short Axis Technique As long as vessel is CENTERED on screen then it must be underneath CENTER of probe

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34 Out of Plane Issue

35 In vs Out

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37 Why Not Start in Long Axis Dr. Fox?

38 Long Axis (In Plane) Technique

39 In Plane Success Vein and needle both in-plane with ultrasound beam

40 In Plane Technique with Catheter Advancement Vein and needle both in-plane with ultrasound beam

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42 Take Home Points Strong evidence in the literature confirms superiority of ultrasound guidance versus landmark approach Use linear high frequency transducer with sterile covering Use longer angiocatheter (1.75 inches) Aim probe indicator to operator s left Center vein under probe and aim needle for the center of the probe Troubleshoot difficult lines using in-plane technique