Peripheral vasadilators (Summary) Assoc. Prof. Iv. Lambev E-mail: [email protected]@mail.bg.
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Vascular Access Using Ultrasound-Guidance
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This presentation provides an overview of Peripheral IV Access using Ultrasound-Guidance and is not intended to
replace formal training through CME courses or other programs. This presentation does not constitute
professional medical advice or a complete course of training. You should not perform an Ultrasound-Guided
Peripheral IV insertion solely in reliance upon the information in this presentation.
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Program Objectives• Discuss advantages of using ultrasound for Peripheral IVs • Identify vascular and anatomic
landmarks
• Explore needle visualization technique
• Cover potential pitfalls
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Why Use Ultrasound?
‣Complication Rates
‣Arterial Punctures
‣Time to Venipuncture
‣Needle Stick Attempts
Patient Satisfaction
DECREASES
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Keyes LE, et al., prospectively enrolled 101 emergency department patients who had ultrasound-guided brachial
and basilic vein cannulation with difficult IV access
Results: -- 2 unsuccessful attempts without ultrasound-guidance were made prior to using ultrasound
-- 50 were IVDU and 21 were obese Conclusion:
-- US guided cannulation successful in 91% -- Average time was 77 seconds
Keyes LE, Frazee BW, Snoey ER, Simon BC, Christy D: Ultrasound guided brachial and basilic vein cannulation in emergency department patients with
difficult intravenous access
Peripheral IV Access - Study 1
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Costantino et al,. compared ultrasound-guided PIV access with the traditional blind technique
Results - Ultrasound-guided PIV placement was: -- More successful -- Required less time -- Reduced the number of needle punctures -- Improved patient satisfaction
Costantino TG, Parikh AK, Satz WA, Fojtik JP. Ultrasonography-guided peripheral intravenous access versus traditional approaches in patientswith difficult intravenous access. Am J Emerg Med. Nov 2005;46(5):456-61.[Medline].
Peripheral IV Access-Study 2
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Peripheral IV Access - Study 3AU, A et al., enrolled 100 emergency medicine patients with difficult IVs by placing an Ultrasound-Guided Peripheral IV (USGPIV) to decrease Central Venous Catheters (CVC)
Results: -- All 100 patients successfully received a USGPIV-- 15 Patients who received the USGPIV proceeded to need a CVC -- 1 out of the 15 patients who received a CVC went on to develop further complications from infection
Conclusion:-- The use of USGPIV for difficult IV access reduce the need for CVC placement by 85% and may have the potential to reduces morbidity in patients with difficult IVs.
Au A et al., Decrease in central venous catheter placement and complications due to utilization of ultrasound-guided peripheral intravenous catheters [abstract]. American College of Emergency Physicians Scientific Congress 2011. October 2011.
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Benefits of Ultrasound-Guided Vascular Access
• Quality• Safety• Cost Reduction• Increase in Patient Satisfaction
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Quality
A 54% reduction in the number of attempts with ultrasound-guidance compared to the landmark technique
(Constan9no TG, et al.)FUJIFILM SonoSite, Inc. | 2012
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Safety
Prevention of central line placement in 85% of patients with difficult IV access
(Au A, et al.)
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Cost Reduction
The introduction of a registered nurse ultrasound-guided peripheral IV program reduced the number of one-time use PICC lines, saving approximately $200,000 per year at their institution
(Miles G, et al.)
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Patient Satisfaction
69% of patients rated their experience of ultrasound-guided peripheral IVs higher than peripheral IVs alone
(Schoenfeld EM, et al.)
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Endorsed By:
ACEP
ADVANCING EMERGENCY CARE
American College of Emergency Physicians ®
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Success Rate
99% SUCCESS RATE OF INSERTION WITH ULTRASOUND GUIDANCE
(Gregg SC, et al.)
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Indications
• Renal Failure• Hypovolemia• Vascular Pathology• IV Drug Use• Obese Patients• Small, “rolling” veins• Pediatrics
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• Avoid areas of flexion• Work distal to proximal• Vein Choice:
- Basilic - always attempt first- Cephalic - Brachial - can be paired
Choosing a Site
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Assessment of Vessels
• Presence, size and patency
• Distensibility and compressibility
• Presence of thrombus
• Position of vein relative to the artery
V
V
V
V
A
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Ultrasound Appearance
•Artery- Round- Regular Shape- Pulsatile
•Vein- Oval - Irregular Shape- Compressible
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Vein Compression
A
V
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Ultrasound Appearance
Characteristic Vein Artery
Appearance Black[anechoic]
Black[anechoic]
Movement None Pulsatile
Compressible Yes No
Color Flow Constant FlowAugmentable Pulsatile
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basilic vein
ulnar veinmedian vein
radial vein
median cephalic vein
cephalic vein
Anatomy
axillary vein
brachial vein
subclavian
ext jugular vein
medial basilic vein
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Basilic Vein
• Superficial• Largest vein in the arm• Courses along medial arm• Begins at dorsal part of hand• Drains into brachial vein
Basilic Vein
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Transverse Basilic Vein
BV
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Cephalic Vein
• Superficial vein• 4-6mm• Courses along lateral arm • Wrist to shoulder• Empties into axillary vein
Cephalic Vein
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Transverse Cephalic Vein
V
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Brachial Vein
Brachial Vein
• Deep veins of upper arm• Usually paired • Travel on either side of brachial artery• Joins basilic vein to form
the axillary vein
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Brachial Vein Grouping
V
VA
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High Frequency Linear Array - 7.5 MHZ or higher
Static or Dynamic Technique
• High Frequency Linear Array - 7.5 MHZ or higher
• Static or Dynamic Technique
Transducers
L25
HFL38
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Ultrasound Beam
1 mm beam slice
Beam comes out as a slice
Beam thickness approx. 1 mm
Beam produces 2-D image
YOU CONTROL THE AIM
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Orientation Marker
V
V
V
A
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Acoustic Gel
• Ultrasound will not travel through air
• A transmission gel is required to eliminate surface air
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Holding the Transducer
• Hold the transducer comfortably
• Keep a light touch
• Stabilize your hand
• RELAX
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TOURNIQUET
Preparation
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ChloraPrep
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R
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Tegaderm
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3MTM TM
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Needles 18 GA, 1.88 IN
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Planes of Introduction
•SHORT AXIS- Out-of-Plane Technique- Needle inserted in cross-
sectional plane of the vessel
• LONG AXIS- In-Plane Technique- Needle inserted along
long axis of the vessel
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Needle Transducer OrientationParallel and Perpendicular
In-PlaneOut-of-PlaneFUJIFILM SonoSite, Inc. | 2012
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Transverse - Short Axis Approach
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Longitudinal - Long Axis Approach
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43
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BEDirectly parallel to the vessel (longitudinal)
OR
Directly perpendicular to the vessel
(transverse)
Scanning Pitfalls
LONG AXIS
SHORT AXISFUJIFILM SonoSite, Inc. | 2012
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Scanning Pitfalls
46
Do not rotate the transduceror scan obliquely across the vessel
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Remember
Regardless of your technique,ALWAYS know where your needle tip is located
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In some cases, even slight pressure of transducer may compress vessel eliminating ability to visualize
non-compressed compressed
Scanning Pearls
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Ultrasound Guided PIV
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COLOR FLOW
BASILIC VEIN CONFLUENCE
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Catheter Line Images
Catheter tips in transverse viewFUJIFILM SonoSite, Inc. | 2012
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Catheter Line Images
Longitudinal Views
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Venous Pathology
Basilic Vein Thrombus
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Venous Pathology
Thrombus at valve site
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Venous Pathology
Transverse view of thrombus with and without color Doppler
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Risks and Complications
• Infection
• Perforation of vessel
• Extravasation
• Accidental removal
• Thrombus at tip
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Summary
• Easily identifies vascular structures and anatomic variation
• Provides real-time visualization of needle tip in procedures
• Improves safety / accuracy & decreases complication rates
• Shortens time for procedureFUJIFILM SonoSite, Inc. | 2012
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Thank You
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Additional Evidence1. Au A, et al. Decrease in central venous catheter placement and complications due to utilization of ultrasound-guided peripheral intravenous catheters [abstract]. American College of Emergency Physicians Scientific Congress 2011. October 2011.
2. Gregg SC, et al. Ultrasound-guided peripheral intravenous access in the intensive care unit. J Critical Care 2010;25(3):514-9.
3. Miles G, et al. Implementation of a successful registered nurse peripheral ultrasound-guided intravenous catheter program in an emergency department. J Emergency Nurse 2011. [Epub ahead of print].
4. Schoenfeld EM, et al. Ultrasound-guided peripheral intravenous access in the emergency department: patient-centered survey. West J Emerg Med 2011;12(4):475-7.
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