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Guidewire within jugular vein - short axis. Ultrasound guided placement of a left internal jugular central line. The guidewire (arrow) can be seen within the internal jugular vein (V) lateral and superficial to the artery (A) in the short axis.
Source publication
Ultrasound guidance during central line insertion has significantly reduced complications associated with this procedure and has led to it being incorporated as standard of care in many institutions. However, inadvertent arterial penetration and dilation remains a problem despite ultrasound guidance and can result in significant morbidity and even...
Contexts in source publication
Context 1
... veins were cannulated using a standard Seldinger technique under direct ultrasound guidance in the short axis using either a Sonosite MicroMaxx or M Turbo (Sonosite Corporation, Bothell, WA). Once the guidewire was successfully placed intravascular, its position within the vein was confirmed by direct visualization with ultra- sound along its entire visible course (Figure 1, 2 ...Context 2
... method utilizes dynamic ultrasound visualization of the guidewire within the vein along its entire course as a method to confirm intravenous guidewire placement prior to dilation. In this way the guide wire can be fol- lowed from the point of insertion until well past the nee- dle puncture site in the vein in both the short (Figure 1, Additional File 1) and long axis (Figure 2, Additional File 2). Unless the patient is in cardiac arrest or profoundly hypotensive, the artery and vein should be easily differen- tiated by complete obliteration of the vein with compres- sion compared with the artery (Figure 3, Additional File 3) and by pulsation of the artery (Additional File 4). ...Citations
... 63 In a retrospective review of CVC insertions where the guidewire position was routinely confirmed in the target vessel prior to dilation, there were no cases of arterial dilation, suggesting confirmation of guidewire position can potentially eliminate the morbidity and mortality associated with arterial dilation during CVC insertion. 64 9. To increase the success rate of ultrasound-guided vascular access procedures, we recommend that providers should utilize echogenic needles, plastic needle guides, and/or ultrasound beam steering when available. ...
Preprocedure:
1) We recommend that providers should be familiar with the operation of their specific ultrasound machine prior to initiation of a vascular access procedure.2) We recommend that providers should use a high-frequency linear transducer with a sterile sheath and sterile gel to perform vascular access procedures.3) We recommend that providers should use two-dimensional ultrasound to evaluate for anatomical variations and absence of vascular thrombosis during preprocedural site selection.4) We recommend that providers should evaluate the target blood vessel size and depth during preprocedural ultrasound evaluation.
Techniques:
GENERAL TECHNIQUES: 5) We recommend that providers should avoid using static ultrasound alone to mark the needle insertion site for vascular access procedures.6) We recommend that providers should use real-time (dynamic), two-dimensional ultrasound guidance with a high-frequency linear transducer for central venous catheter (CVC) insertion, regardless of the provider's level of experience.7) We suggest using either a transverse (short-axis) or longitudinal (long-axis) approach when performing real-time ultrasound-guided vascular access procedures.8) We recommend that providers should visualize the needle tip and guidewire in the target vein prior to vessel dilatation.9) To increase the success rate of ultrasound-guided vascular access procedures, we recommend that providers should utilize echogenic needles, plastic needle guides, and/or ultrasound beam steering when available.
Central venous access techniques:
10) We recommend that providers should use a standardized procedure checklist that includes the use of real-time ultrasound guidance to reduce the risk of central line-associated bloodstream infection (CLABSI) from CVC insertion.11) We recommend that providers should use real-time ultrasound guidance, combined with aseptic technique and maximal sterile barrier precautions, to reduce the incidence of infectious complications from CVC insertion.12) We recommend that providers should use real-time ultrasound guidance for internal jugular vein catheterization, which reduces the risk of mechanical and infectious complications, the number of needle passes, and time to cannulation and increases overall procedure success rates.13) We recommend that providers who routinely insert subclavian vein CVCs should use real-time ultrasound guidance, which has been shown to reduce the risk of mechanical complications and number of needle passes and increase overall procedure success rates compared with landmark-based techniques.14) We recommend that providers should use real-time ultrasound guidance for femoral venous access, which has been shown to reduce the risk of arterial punctures and total procedure time and increase overall procedure success rates.
Peripheral venous access techniques:
15) We recommend that providers should use real-time ultrasound guidance for the insertion of peripherally inserted central catheters (PICCs), which is associated with higher procedure success rates and may be more cost effective compared with landmark-based techniques.16) We recommend that providers should use real-time ultrasound guidance for the placement of peripheral intravenous lines (PIV) in patients with difficult peripheral venous access to reduce the total procedure time, needle insertion attempts, and needle redirections. Ultrasound-guided PIV insertion is also an effective alternative to CVC insertion in patients with difficult venous access.17) We suggest using real-time ultrasound guidance to reduce the risk of vascular, infectious, and neurological complications during PIV insertion, particularly in patients with difficult venous access.
Arterial access techniques:
18) We recommend that providers should use real-time ultrasound guidance for arterial access, which has been shown to increase first-pass success rates, reduce the time to cannulation, and reduce the risk of hematoma development compared with landmark-based techniques.19) We recommend that providers should use real-time ultrasound guidance for femoral arterial access, which has been shown to increase first-pass success rates and reduce the risk of vascular complications.20) We recommend that providers should use real-time ultrasound guidance for radial arterial access, which has been shown to increase first-pass success rates, reduce the time to successful cannulation, and reduce the risk of complications compared with landmark-based techniques.
Postprocedure:
21) We recommend that post-procedure pneumothorax should be ruled out by the detection of bilateral lung sliding using a high-frequency linear transducer before and after insertion of internal jugular and subclavian vein CVCs.22) We recommend that providers should use ultrasound with rapid infusion of agitated saline to visualize a right atrial swirl sign (RASS) for detecting catheter tip misplacement during CVC insertion. The use of RASS to detect the catheter tip may be considered an advanced skill that requires specific training and expertise.
Training:
23) To reduce the risk of mechanical and infectious complications, we recommend that novice providers should complete a systematic training program that includes a combination of simulation-based practice, supervised insertion on patients, and evaluation by an expert operator before attempting ultrasound-guided CVC insertion independently on patients.24) We recommend that cognitive training in ultrasound-guided CVC insertion should include basic anatomy, ultrasound physics, ultrasound machine knobology, fundamentals of image acquisition and interpretation, detection and management of procedural complications, infection prevention strategies, and pathways to attain competency.25) We recommend that trainees should demonstrate minimal competence before placing ultrasound-guided CVCs independently. A minimum number of CVC insertions may inform this determination, but a proctored assessment of competence is most important.26) We recommend that didactic and hands-on training for trainees should coincide with anticipated times of increased performance of vascular access procedures. Refresher training sessions should be offered periodically.27) We recommend that competency assessments should include formal evaluation of knowledge and technical skills using standardized assessment tools.28) We recommend that competency assessments should evaluate for proficiency in the following knowledge and skills of CVC insertion: (a) Knowledge of the target vein anatomy, proper vessel identification, and recognition of anatomical variants; (b) Demonstration of CVC insertion with no technical errors based on a procedural checklist; (c) Recognition and management of acute complications, including emergency management of life-threatening complications; (d) Real-time needle tip tracking with ultrasound and cannulation on the first attempt in at least five consecutive simulation.29) We recommend a periodic proficiency assessment of all operators should be conducted to ensure maintenance of competency.
... This step is crucially important. Accidental cannulation of the artery is a serious complication in this procedure with the potential to cause significant morbidity or mortality [3]. Other serious complications include pneumothorax (collapsed lung), infection, air embolus, and losing the guidewire into the vasculature. ...
PURPOSE: This paper describes an open-source ultrasound-guided central line insertion training system. Modern clinical guidelines are increasingly recommending ultrasound guidance for this procedure due to the decrease in morbidity it provides. However, there are no adequate low-cost systems for helping new clinicians train their inter-hand coordination for this demanding procedure. METHODS: This paper details a training platform which can be recreated with any standard ultrasound machine using inexpensive components. We describe the hardware, software, and calibration procedures with the intention that a reader can recreate this system themselves. RESULTS: The reproducibility and accuracy of the ultrasound calibration for this system was examined. We found that across the ultrasound image the calibration error was less than 2 mm. In a small feasibility study, two participants performed 5 needle insertions each with an average of slightly above 2 mm error. CONCLUSION: We conclude that the accuracy of the system is sufficient for clinician training.
... The initial proper identification of the site of the initial skin incision is crucial specially in obese female patient and can avoid going to false tracs and flaps and missing the vein [33]. The use of the bedside ultrasound machines is becoming routinely used in the operating theatres during insertion of the central lines by anesthesia doctors and proved to decrease complications and the outcome [34,35]. Ultrasound systems are easy to use, and require no novel training or equipment. ...
Background: The required high degree of technical expertise is much more with the small caliber saphenous vein (SV) grafts using Endoscopic Saphenous Vein Harvesting (ESVH) during CABG Surgery and the patency may be affected. We thought to compare these small caliber vein grafted patients (GroupI) regarding their operative difficulties and mid-term graft patency with a controlled normal caliber grafted patients (groupII).
Methods: Retrospective data collection was from June 2013 to June 2016 in a consecutive order after exclusion of the first 50 patients done in our center. A cutoff point of 3 mm diameter of the SV was identified. GroupI (3 mm) (100patients). ESVH procedure time and SV characteristics were compared between the groups and the incidence of perioperative myocardial infarction as well as the Myocardial Perfusion Imaging (MPI) for the mid-term patency rate. Patients who had been commented as having clinical varicosity and those who refused the (MPI) evaluation during the follow up period were excluded.
Results: Significant difference in the number of side branches and repaired small avulsed branches (GroupI vs. GroupII)(11.7 ± 4.8 vs. 9.7 ± 3.4) (P
... It was noted that the ultrasound-guided placement of femoral artery catheters is more challenging than femoral vein cannulation because the artery is smaller and not amenable to expansion with positioning or volume loading (15). To identify the femoral artery, we used the out-ofplane technique but the in-plane technique may help confirming that the catheter is in the lumen of the vessel and has also been proposed for CVC placement (22,23). To a certain extent, we can assume that ultrasound technique facilitated attending supervision/guidance of the procedure because direct visualization of the needle tip on the ultrasound screen enables the attending to give more useful instruction on how to redirect the introducer or repeat the maneuver. ...
Background
Percutaneous cannulation of the femoral artery in the pediatric age group can be technically challenging, especially when performed by residents in training. Objective
We examined whether the use of real-time ultrasound guidance is superior to a palpation landmark technique for femoral artery catheterization in children undergoing heart surgery. Methods
Patients were prospectively randomized into two groups. In the palpation group, the femoral artery was cannulated using the traditional landmark method of palpation of arterial pulse. In the ultrasound group, cannulation was guided by real-time scanning with an ultrasound probe. Ten minutes were set as time limit for the resident's trials during which the time taken for attempted cannulation (primary outcome), number of attempts, number of successful cannulations on first attempt, and success rate were compared between the two groups. Adverse events were monitored on postoperative days 1 and 3. ResultsA total of 106 patients were included in the study. The time taken for attempted femoral artery cannulation was shorter (301 234 vs 420 +/- 248 s; difference in mean: 119; 95% confidence interval (CI) of difference: 26-212; P = 0.012) and the number of attempts was lower [1 (1-10) vs 2 (1-5); difference in median: 1, 95% CI of difference: 0.28-1.72; P = 0.003] in the ultrasound group compared with the palpation group. The number of successful cannulations on first attempt was higher in the ultrasound group compared with palpation group [24/53 (45%) vs 13/53 (25%); odds ratio (OR): 2.54, 95% CI: 1.11-5.82; P = 0.025]. The number of patients who had successful cannulation was 31 of 55 (58%) in the palpation group and 40 of 53 (75%) in the ultrasound group (OR: 2.18, 95% CI: 0.95-5.01; P = 0.06). None of the patients had adverse events at days 1 and 3. Conclusions
Ultrasound-guided femoral arterial cannulation in children when performed by anesthesia residents is superior to the palpation technique based on the reduction of the time taken for attempted cannulation and the number of attempts, and improvement in first attempt success.
... The incorrect location of skin incision on the donor leg can promote the formation of flaps and difficulty finding veins, especially in obese patients [50,54]. The current literature has reported that central lines in many centres are inserted with the guidance of ultrasound, which decreases complications and improves success rate [55,56]. Ultrasound systems are easy to use, and require no novel training or equipment (this has been used in central line placement and other surgical procedures for a number of years). ...
Endoscopic vein harvesting is becoming one of the most favourable vein harvesting techniques in multiple bypass coronary surgery, due to its short term post-operative benefits with high patient satisfaction. However, long-term graft patency has been both supported and questioned in the literature. Graft failure can be affected by harvesting methods and operator's experience. Endoscopic vein harvesting is associated with a learning curve period, during which the incidence of vein trauma is high due to unfamiliarity with the surgical technique. There is a paucity of structured learning tools for novice practitioners, meaning that training differs significantly between hospital centres. Inconsistent training methods can lead to poor surgical technique, which can have a significant impact on vein quality and stress level of the practitioner. In turn, this can lead to increased postoperative complications and longer surgical duration. The main aim of this literature review is to understand the impact of the learning curve on the vein conduit and whether there is a requirement for a standardised training programme for the novice practitioners.
... 8 This is because even under ultrasound guidance, the needle can temporarily slip out of the visualized field and penetrate deeper than the operator desires. 9 Arterial puncture is generally well tolerated and can be treated conservatively in most cases. Dilation, however, can lead to significant morbidity and mortality in the form of arterial dissection, hemorrhage, and arteriovenous fistula formation. ...
This is a case report describing the ultrasound-guided placement of a peripheral intravenous catheter into the internal jugular vein of a patient with difficult vascular access. Although this technique has been described in the past, this case is novel in that the Seldinger technique was used to place the catheter. This allows for safer placement of a longer catheter (2.25”) without the need for venous dilation, which is potentially hazardous.
... Si se logra adecuado retorno venoso pero inadecuado avance de la guía, se debe = Venu yugular = Arteria carótida A B C considerar la posibilidad de cambio en la lateralidad de la zona de punción, por la presencia potencial de trombos venosos. Durante el avance de la guía se debe evitar la presencia de arritmias; generar ectopias en algunos casos se ha asociado a morbilidad 31 . La evidencia no ha sido suficiente para evaluar la eficacia de ubicación intravascular con el uso de electrocardiografía continua, pero también reconoce la relación de ectopias de complejo angosto y la presencia de la guía intravascular 4,32,33 . ...
... Si se logra adecuado retorno venoso pero inadecuado avance de la guía, se debe = Venu yugular = Arteria carótida A B C considerar la posibilidad de cambio en la lateralidad de la zona de punción, por la presencia potencial de trombos venosos. Durante el avance de la guía se debe evitar la presencia de arritmias; generar ectopias en algunos casos se ha asociado a morbilidad 31 . La evidencia no ha sido suficiente para evaluar la eficacia de ubicación intravascular con el uso de electrocardiografía continua, pero también reconoce la relación de ectopias de complejo angosto y la presencia de la guía intravascular 4,32,33 . ...
La canulación venosa central por técnica de reparos anatómicos presenta complicaciones mecánicas entre en el 5-19% de los casos. Por tal motivo se han modificado e implementado técnicas buscando disminuir los riesgos para el paciente. La introducción de la ultrasonografía en la práctica clínica, y más recientemente en la colocación de catéteres venosos centrales, ha disminuido la incidencia de complicaciones.
... artery injury (18). To confirm wire placement, a longitudinal orientation is required to ensure that the wire stays within the vein distally (Video 9). ...
... It seems useful to confirm guidewires in the IJV using ultrasound [6,7]. However, we could not check the course of the guidewire in the present case due to his short neck (25 mm from the clavicle to the puncture point). ...
A 2-month-old baby boy, 52 cm in height and weighing 4.6 kg, underwent a Blalock-Taussig shunt operation under general anesthesia. The authors checked the internal jugular vein (IJV) using an ultrasound apparatus with a 5/10-MHz probe (TiTAN, SonoSite Co., Tokyo, Japan) at a mid-portion of the neck. We observed a 3.9-mm-wide and 7.6-mm-deep IJV for central venous catheter (CVC) placement. We started to videotape the procedure. The operator punctured the IJV using real-time ultrasound guidance with a 24 G plastic puncture needle (Jelco Plus, Smith Medical, Tokyo, Japan), and obtained the back flow of the vein. The operator could not advance a guidewire more than 5 cm into the IJV. We suspected that the straight type guidewire had advanced outside of the IJV, and removed the guidewire. We placed the CVC into the left IJV instead of the right IJV. We speculated that the guidewire had advanced into the IJV; however, we could not advance the tip of the guidewire from the IJV to the brachiocephalic vein because the angle between the IJV and the brachiocephalic vein was 90 degrees. We could have advanced a J-type guidewire from the IJV into the brachiocephalic vein.
