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Ultrasound Guided Vascular Access

Goals. Understand the necessity for US Guided Central AccessUnderstand the difference between Static, Dynamic, Assisted and Guided US accessBe able to perform Dynamic US Guided IJ or Femoral Line. Introduction. This presentation is only one part of an integrated process to teach you and insure com

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Ultrasound Guided Vascular Access

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    1. Ultrasound Guided Vascular Access Gary Dufresne, DO Emergency Medicine Physician SAUSHEC

    2. Goals Understand the necessity for US Guided Central Access Understand the difference between Static, Dynamic, Assisted and Guided US access Be able to perform Dynamic US Guided IJ or Femoral Line

    3. Introduction This presentation is only one part of an integrated process to teach you and insure competence in US guided vascular access. The resident learner will achieve competency by: Attending US Introduction Course during Intern Orientation Complete Vascular Access Learning Module Participate in Animal Labs with integration of US Guided Central Venous access Completing the SAUSHEC Emergency Ultrasound Rotation Applying US Guided Vascular Access skills in real life clinical applications throughout residency

    4. Numbers Overall Complication Rates*

    5. Standard of care? 2001 Healthcare Research and Quality Evidence Report “Top 11 Highly Proven” pt safety practices “All central cannula placements be guided by real-time, dynamic US.” Discussion: What do you think?

    6. Research Ultrasonic locating devices for central access 2003, BMJ, Meta-analysis of randomized trials 18 trials, n- 1646 Clear improvement in success rates in using US for IJ cannulation in adults and peds compared to LM Not so much for subclavian or femoral

    7. Research SOAP3- Sonography Outcomes Assessment Program, US assisted central access (IJ) 2005, Crit Care Med, Prospective Randomized Dynamic (D) vs. Static (S) vs. Landmark (LM) n- 201 Primary Outcome (Success Rate) D- 98% S- 82% LM- 64% Complication Rate D- 3% S- 3% LM- 13%* *Limitation- lead author performed HALF of sticks

    8. Research Single-operator (D1) vs. two-operator (D2) US for IJ 2006, Acad Emerg Med, Prospective Randomized n- 44 pts D1 96% D2 95% D1 and D2 techniques are equivalent *Limitation- Only 3 operators and 2 were study investigators

    9. Guided vs. Assisted Landmark- “Old School” Static US- US look plus 2 skin markers US Assisted- static technique plus “improper” dynamic technique US Guided- dynamic real-time visualization of needle entering the vein!!!

    10. Probe Selection Linear 7.5Mhz, Vascular, Soft Tissue, Ocular Phased Array 5-1Mhz, Echo, Abd, OB, ?Vascular Access Pros and Cons

    11. Technique Transverse Longitudinal Common Position equipment Prep sterile supplies and patient Get Sterile Sterile probe cover

    12. Technique

    13. Technique Transverse ID and Center Anatomy Pythagorean Theorem ID depth to center of vessel Back off the transducer equal distance Enter at 45 degree angle

    14. Technique Transverse (Cont) Watch for tissue invagination Look for “ring-down” artifact You have to be aware of both US images and Needle/Syringe at the same time

    15. Technique Longitudinal ID, confirm, and maintain largest diameter image Needle centered on probe Visualize entire needle Move needle to vessel- NEVER probe to find needle

    16. Novel Applications Peripheral IVs EJs are fun but not for the patient Arterial Lines (Radial, brachial, etc…) Why do a procedure blind? Potentially reduce complications Principles and technique are essentially the same as central access but the target is smaller

    17. Peripheral Anatomy

    18. Summary US Guided- NOT Assisted Pythagoras? TRV Approach- back up equal to depth and use 45° angle Try the Phased Array Probe and Longitudinal Technique IJ Complication Rate with US is sig. reduced 13%? 3% ** Use US correctly but have other vascular access tools.

    19. References

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