CME 09/04/15 – Ultrasound Guided Vascular Access Practical Session

Here is a reminder of things covered in this practical session:

 

Here is Richie’s talk on the general principles regarding procedural ultrasound.

 

General Tips & Tricks:

  • ALWAYS!! use a STERILE PROBE COVER to protect the patient and probe when placing US guided IVC’s

Slide1

 

  • Make sure both yourself and the patient are in a comfortable position
    • This means placing the ultrasound machine in your direct line of sight with the patient between you and the machine – hence the ultrasound machine is usually on the opposite side of the bed to where you are placing the line
  • Scan for appropriate vessels
    • try and use more superficial and distal vessels if possible
  • Check for vessel characteristics – compressibility, wall thickness, pulsatility
    • arteries are still compressible, depending on amount of force and patients arterial blood pressure, but should be less compressible compared to veins
    • veins may have pulsations – transmitted from nearby arteries, or if proximal to any valves (ie. IJV), then from reflections of the right atrial pressure fluctuations (triple pulsations)
  • Check the longitudinal orientation/course of vessel (if using transverse / out of plane approach)
    • assess for most superficial and most distal access point
  • Chose appropriate cannula
    • Length – dependent on depth of vessel
    • Calibre – dependent on intended use
  • Center your probe over the dead center of the vessel (transverse or longitudinal)
    • When using a transverse (out of plane) approach
      • The left side of the screen should correspond to the right side of the patient as you are looking at them (hence movement of the probe will correspond to the same direction of movement on the image screen)
    • When using a longitudinal (in plane) approach
      • Start in transverse with vessel in the middle of the probe and rotate (clockwise) so that the left side of the screen is the proximal portion of vessel (your cannula will then enter from the right side of the screen = distal vessel)
  • Insert your cannula in the dead center of the probe
  • Move your probe, or fan (if out of plane) / heel-toe movement (if in plane) your probe, towards the cannula until it is identified with small movements
    • Transverse (out of plane) – you can only identify the position of the cannula tip if you fan away from the cannula until the cannula is no longer seen (see videos below)
    • Longitudinal (in plane) – because of beam width artefact, it may appear that the cannula is in the vessel when it is actually on either side of the vessel – slide the probe to either side of the vessel to identify which side the cannula is located (it will appear brighter) then move your probe back to be centered over the vessel and make the appropriate correction of the cannula position (note – this may require just a small realignment to fully withdrawing cannula and redirecting it in the correct alignment)
  • Steady your probe hand (non-dominant hand) by stabilising with your little finger against the patients skin
  • Guide your needle with your dominant hand with small movements (see videos below) making appropriate adjustments with your probe hand (depending on whether in plane / out of plane)
  • When you get a flashback – flatten your approach angle and advance needle a small distance and then deploy cannula – this can be done under direct US vision (preferable) or you can place US probe to the side use both hands
  • Clean area of gel thoroughly! prior to securing cannula

Publication of how to make your own “chicken fillet IV access phantoms”, for practice purposes, to be published soon in The Journal of Vascular Access……link to come

 

 

Resources:

 

Videos from the above talk:

 

Transverse (out of plane / short access) IVC insertion

 

Longitudinal  (in plane / long access) IVC insertion

Other Useful Videos:

 

Ultrasound Podcast on peripheral IVC placement:

 

Ultrasound Podcast on central line placement:

Society for Academic Emergency Medicine –  Academy of Emergency US Video Lectures (more here):

Ultrasound Guided Peripheral IV Placement from AEUS on Vimeo.

by Dr. Jennifer Marin

Ultrasound-Guided Central Venous Cannulation from AEUS on Vimeo.

by Dr. Arun Nagdev, MD

Looking after the Ultrasound Probe:

 

This video, courtesy of the Sono Cave, describes:

  • How and when to use an ultrasound probe cover
  • How to clean the transducer after day to day use
  • It also touches on how the probe should be cleaned if it comes in contact with bodily fluids

 

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