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Ultrasound guided
vascular access &
pleural drainageMr Chris Blakeley MSc Emergency US
Consultant in Emergency Medicine
Croydon University Hospital
Vascular access
• Evidence for US in CVC insertion
• Considerations
• Techniques
• IJ
• Femoral
• Peripheral
Why?
Why?
NICE 2002
Why?
NICE 2002
Better evidence
• n = 900 critical care patients
• Randomised
• Well matched groups
• Physicians had 10 yrs experience
landmark & 5yrs experience US
• Karakitsos, D. Critical Care 2006;10:R162
Findings
• Karakitsos, D. Critical Care 2006;10:R162
All p<0.001
Central access with US
• Internal Jugular
• Neck movement
• Lie flat, head down
• Femoral
• Safest
• Infection risk highest
• Can lie flat
• PICU = first choice
Complications of CVC
• Air embolus
• Cardiac arrest
• Death
• Arterial puncture
• Tamponade
• PTX / HTX
• Failure
• Misplacement
• Arrhythmia
• Thoracic duct injury
Anatomy of Internal
Jugular
• External jugular superficial
and easily seen
• Internal jugular deeper –
found at apex of sternal
and clavicular heads of
Sternocleidomastoid.
Anatomic Variations:
IJ
Carotid
Thrombus /
AbsentMedial Lateral
%0-5
0-16
9-92
0-84 0-4
0-98-18
Anatomy of femoral vein
Femoral Line
USS Techniques
1 Check anatomy using US
- Find and mark
2 Real time US and cannulation
• Transverse
• Longitudinal
Real time: Transverse
• Easier to learn
• See adjacent structures
• Difficult to see needle
• Soft tissue movement
Artery or Vein?
Method
Video of transverse
method
• https://www.youtube.com/watch?v=ees
N9rGoXFM
Real time: Longitudinal
• Can see needle
• Technically more demanding
• Narrow beam width
• Slip off vessel
Video - longitudinal
approach
• https://www.youtube.com/watch?v=54K
4pN0pJzo
Equipment
• US machine with
high freq linear
probe
• Sterile Gel
• Sterile sheath
• CVC kit
Insertion Tips
• Start with 1 person doing US & 1 doing
line
• Probe orientation is key
• Use TS
• Steep angle when inserting needle
• Flatten angle once in vein
• Check still in vein before passing wire
More tips
• Can use US to confirm wire placement
prior to dilation
• Assess for PTX if clinical suspiction
Peripheral access
US of peripheral
veins
Peripheral Lines with US?• Costantino TG et al. Ultrasonography-guided
peripheral intravenous access versus traditional approaches in patients with difficult intravenous access. Ann Emerg Med 2005 Nov; 46:456-61
The ultrasound group had:
• higher success rate than the control group (97% vs. 33%)
• Shorter time to successful cannulation (13 vs. 30 minutes)
• Fewer percutaneous punctures (1.7 vs. 3.7)
Pleural Effusion
Pleural Effusion
• Anechoic
• Pus / blood gives some echogenicity
• Dependent
Normal anatomy
Liver
Diaphragm
Pleural space
Spotter
Pleural effusion with septae
1 - lung
2 - pleural effusion
with septae
3 - liver
4 - kidney
Small arrows: diaphragm
Pleural or Pericardial effusion?
• What landmarks
help
differentiate?
Differentiating between Pleural
and Pericardial Effusions
• Pericardial effusion anterior to descending aorta
• Pleural effusion posterior to descending aorta
Regulations around
chest drain insertion
• BTS – British Thoracic Society
Chest drain insertion with US
• Identify diaphragm – may be surprisingly high in the supine patient
• Identify the heart (and keep well away)
• Beware loculations!
• Angle transducer to get good image that best avoids adjacent structures
• The angle of the transducer will determine the angle of insertion of the needle
• Sterile field & sterile probe cover in case rescan required
Pleural effusion video
• https://www.youtube.com/watch?v=x1
XR4AOi8q0
Summary
• CVC with US safer, less complications
• US useful for difficult peripheral access
• Transverse vs Longitudinal
• Pleural drains should be put in with US