Ultrasound Guided Venous Access - SD

Introduction

Hi, I am Bon K
and I'm an assistant professor
of emergency Medicine at Thomas Jefferson University in
Philadelphia, Pennsylvania.
My lecture will cover the use of ultrasound
to obtain venous access.
I would be speaking about how to use ultrasound
to obtain venous access of the internal jugular vein
and the peripheral veins of the arm.

Internal Jugular Vein

Let's start first with the internal jugular vein.
In 2001, the Agency for Healthcare research
and quality published safety practice guidelines
with the greatest strength of evidence
regarding their impact and effectiveness.
The use of real time two dimensional ultrasound in the insertion
of central venous catheters in the internal
jugular vein, made the list.
The use of ultrasound for central venous catheters is also
the standard of care in other countries.
The National Institute for Clinical Excellence,
which provides guidance
to the National Health Service in the United Kingdom,
recommended the use of ultrasound
for central venous insertion in 2002.
But despite this being the standard of care,
many physicians have excuses for not using ultrasound.
Some of these are, it takes too much time
or they feel pretty confident within putting central lines in without an ultrasound or
they feel like they need to put in central lines blindly.
But it's been well documented that using ultrasound for central venous access reduces complications
and reduces the amount of sticks to cannulate the vein.

Technique

Let's go over the technique.
You want to use a linear array probe,
which has a high frequency range in about 10 megahertz,
and this allows optimal visualization of the veins,
arteries and nerves.
In order to maintain sterility,
you need both a sterile transducer cover
and sterile gel to be used on the outside
of the sheath cover sterile gel.
Here, here's a picture of sterile gel and the sterile transducer cover.
But you can use a non-sterile gel to place right on the transducer itself.
So if you don't have a sterile cover, you can simply use a sterile glove.
The patient positioning remains the same both for central venous access, whether
or not you're using the ultrasound,
but be mindful of where you place the ultrasound machine,
because you'll be using the ultrasound in real time.
You want to have a clear view of the screen while performing the central venous cannulation.

Sonographic Anatomy

We're gonna review the sonographic anatomy.
In order to identify the internal jugular vein, you want
to identify the heads of the sternocleidomastoid muscles, which are here.
But finding the internal jugular vein isn't always so obvious.
Even in a thin patient's visual inspection of the sternocleidomastoid muscle can be difficult as demonstrated here.
You can use either the longitudinal
or transverse approach to cannulate the internal jugular vein.
The main advantage of the longitudinal approach,
which is demonstrated here, is
that you can visualize a tip of the needle,
and here is the needle entering into the vein itself.
But the main disadvantage with the longitudinal approach is
that you really can't visualize the carotid artery in relationship to the internal jugular vein
because it's often lies outside of the plane of the internal jugular.
With the transverse approach, you can easily visualize the carotid artery next
to the internal jugular vein.
And so we're showing a transverse view here,
and then now we're switching to the longitudinal.
And as you can see, once you switch from the transverse longitudinal, the carotid artery falls out of the picture.
And it's because of this that we recommend using the transverse approach to cannulate the internal jugular vein in order
to avoid an inadvertent carotid artery puncture.

Identifying the Internal Jugular Vein

So, how do you identify the internal jugular vein?
The vein is easily compressible
and it's thinner walled when compared to the carotid.
And if your patient is able to, you can ask him
or her to Valsalva,
and you'll appreciate the internal jugular
vein increasing in size.
You can also use a color flow non pulsatile color flow.
We will confirm that the vessel is a vein and not a artery.
A pitfall is to rely on the pulsatility of the carotid artery to distinguish it from the internal jugular.
As you can see here, the internal jugular vein
is more pulsatile than the carotid
because it's thinner wall,
and the internal jugular vein is right above the carotid right there, and it's expanding its size
because the patient's valsalva.
But the easiest way to determine whether
or not the vessel is an artery vein is compressibility.
Unless you're using extreme force, you will not be able
to compress the carotid artery,
but you will be able to easily compress the vein
as demonstrated here.

Alignment and Preparation

Before you cannulate the vein, make sure you line the transducer marker to the screen indicator.
This is a crucial step
because if you don't align the probe marker
with a screen indicator, then your left
and right will be reversed.
This can get confusing when you're moving the needle
to the left, because it will look like you're actually
moving it to the right on the screen when you're doing the procedure.
If you forget to do this, then after you
and the probe are sterile, simply tap on the left side
of the transducer and see if it corresponds to tapping the left side of the screen.
Next, you want to center the vessel in the middle
of the screen and scan up and down the vein.
You wanna do this in order to find the optimal place
to cannulate the internal jugular.
Ideally, find the spot where the vein is adjacent to
and not on top of the carotid artery,
and where the vein has the greatest diameter.
Because you can't see the tip
of the needle in the transverse view, it's possible to penetrate the entire vein
and hit the carotid artery below it.
So you want to make sure you pay very special attention to
where the carotid artery is.

Cannulation Tips

Next, you want to align the needle to the center
of the probe with at least a 45 degree angle
as demonstrated in this clip here.
It's also important to be mindful of where the clavicle is because if you penetrate the internal jugular vein too close to the carotid, you can cause pneumothorax.
This is an example of a ring down artifact.
It is a type of reverberation artifact,
and it's a helpful determine whether your needle is in the
same plane as the vessel.
So, because you can't visualize a tip
of the needle in the transverse view, look for deformation
of the vein as the needle penetrates the wall
as demonstrated here.
And one more thing to keep in mind is the
depth of the vessel.
As you can see here, the internal jugular vein is only 0.5
centimeters below the skin surface.

Peripheral Venous Access

Okay, now going on to peripheral venous access.
Basically it's the same principles,
but much harder since the peripheral veins are smaller.
And this is becoming widely used in emergency departments.
So much so that it's not uncommon to have patients requesting the use of ultrasound to have their peripheral veins accessed.
I first look for veins distal to the elbow
because they're more superficial.
But if I can't find a vein distal to the elbow,
then I move up approximately,
and I look specifically at the basilic
and the cephalic veins
of note when accessing these veins.
They're often deeper. So you would have
to use a longer IV catheter.
As with the internal jugular vein,
I prefer using the transverse rather than the long approach.
And you want to track the course of the peripheral vein
and see if it's compressible.
Another thing to keep in mind is you want to avoid the nerve bundle as demonstrated right here.

Mental Checklist

TUI has recently written a book
that advocates the use of a checklist to reduce surgical errors.
And I like to keep in my mind
before cannulate a vein a mental checklist.
Certain questions I ask myself,
is this really a vein or an artery?
Do I have a clear view of the ultrasound machine?
Because you want to be doing this in real time,
and you want to make sure where your probe marker is, that it's aligned
to the screen indicator.
You wanna be mindful of how deep the vein is relative
to the skin surface, so you know how far
to penetrate with your needle.
You want to be able to be mindful
where your needle tip is
and look for deformation of the vessel
as the needle enters into it.
And you want to look for a neurovascular bundle
to make sure you don't inadvertently hit it,
pay attention to the clavicle to avoid causing a pneumothorax.
And finally, before you penetrate the vein, you wanna double check
for compressibility and make sure it's a vein
and not an artery.