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