Ultrasound-guided Venous Access Research Articles

516 Ultrasound Cannulation Training: A Hit or a Miss

Abstract As a junior doctor, familiarisation with ultrasound skills can be very useful. This reduces stress for patients from multiple access attempts, as well as preserving venous access. In our District General Hospital (DGH), there was no teaching on ultrasound-guided venous access available. Our aim was to create a formal training programme on ultrasound-guided venous access for junior doctors. Discussions were held with the medical education team at our DGH in order to understand how to organise a formal teaching programme. The interest of junior doctors was gathered through informal discussion. Those interested were then asked to complete pre and post-course evaluation forms. Data was gathered on experience using ultrasound, confidence (out of 5) in performing ultrasound cannulation before and after the session, and usefulness of the session. Of the 16 participants, only 81% (n=13) filled in the pre-session form, therefore data was only analysed from these individuals. 54% of participants (n=7) had previous experience using an ultrasound machine. 100% (n=13) felt more confident performing ultrasound-guided venous access after attending the session. The average confidence score pre versus post-session was 1.69/5 vs 4.08/5. This programme has the potential to improve confidence in procedural skills amongst junior doctors whilst also minimising the stress for patients of multiple access attempts. Though the sample obtained was small, it is clear to see increased confidence in participants, regardless of prior experience. The results from this study will be critical in continuing this training programme in our hospital and hopeful roll out to a wider audience.

Teaching Module on Ultrasound-Guided Venous Access Using a Homemade Gel Model for Fourth-Year Medical Students.

IntroductionEvidence supports an ultrasound-guided approach in patients with difficult vascular access. Prior research on teaching ultrasound-guided intravenous access has included only small groups of first- and second-year medical students.MethodsWe enrolled fourth-year medical students in our teaching module. The module featured a 6-minute prelearning narrated lecture and 5-minute orientation, followed by ultrasound-guided IV placement on homemade gel models. Facilitators were emergency medicine (EM) residents with a prespecified level of procedural ultrasound skills according to EM milestones. Students completed pre- and postmodule surveys. Facilitators completed the Directly Observed Procedural Skills Evaluation. Primary outcomes included global rating, proficiency on six procedural skills, and perceived learning.ResultsOur module was completed by 150 fourth-year medical students (94% of the class); 84% cannulated the vein in one attempt. We used a global rating scale to describe the students' cannulation abilities; 59% were trusted to perform this procedure with direct supervision and coaching, 29% with indirect supervision, and 8% without supervision. There was no association between a student's order of attempting IV access within the group and global rating (p = .41). Students reported increased understanding of indications, antecubital anatomy, sonographic anatomy, and procedural comfort (12%, 29%, 38%, and 65% improvement pre- vs. postmodule, respectively; p < .001).DiscussionOur module enabled more than one-third of fourth-year medical students to achieve an indirect supervision or better level of proficiency in ultrasound-guided IV access, with significant improvements in perceived knowledge. This module may be useful for other educators facilitating the transition to residency.

A Practical Guide to Ultrasound-guided Venous Access During Implantation of Pacemakers and Defibrillators.

Ultrasound (US) guidance has been shown to be a safe and effective option for gaining access to the axillary vein during implantation of cardiovascular implantable electronic devices (CIEDs). However, US-based technique has not been universally adopted in CIED implantations performed in cardiac electrophysiology (EP) laboratories, despite potential advantages over other vascular access techniques. For this reason, not all cardiac electrophysiologists have been trained to use US guidance during CIED implantation. This review is intended to provide a practical guide to the use of US guidance to obtain axillary vein access in the EP laboratory setting.

Feasibility study of cumulative sum (CUSUM) analysis as a competency assessment tool for ultrasound-guided venous access procedures.

Typically, physician training programs use a self-reported case-log competency assessment that does not measure procedure success or objectively assess competency. Cumulative sum (CUSUM) analysis could provide objective assessments of competency and progress over the training period. Our study objective was to determine the feasibility of CUSUM analysis to assess competency of ultrasound-guided peripheral intravenous (USG-PIV) line placement in pediatric anesthesiology fellows. We applied a CUSUM analysis to assess competency in USG-PIV placement in three consecutive pediatric anesthesia fellowship classes. After a didactic and hands-on training session, fellows placed a USG-PIV line and self-reported the outcomes via a web-based application. Fellows were deemed competent if the CUSUM curve crossed two consecutive boundary lines from above. Twenty-nine fellows reported 1,388 USG-PIV attempts, with 74% success. Most fellows (26/29; 90%) achieved competency by the end of the fellowship. Two fellows identified in the mid-year CUSUM as not progressing towards competency achieved competency after targeted interventions. Fellows achieving competency (11/29 vs 25/29; odds ratio, 15; 95% confidence interval [CI], 1.98 to 113.56; P = 0.01) and attempts needed to achieve competency (19 vs 11; mean difference, 8.5; 95% CI, 3.3 to 13.7; P = 0.002) were significantly lower in younger patients and significantly higher in older patients. Our study showed that CUSUM can be used to assess competence in USG-PIV procedures performed by pediatric anesthesia fellows and to identify learners not progressing toward competency in procedural skills. Ultrasound-guided venous access required more attempts to achieve competency in younger patients.

Safety and feasibility of upper limb vascular access for cardiac catheterization in anticoagulated and non-anticoagulated patients.

The upper limb approach utilizing transradial access for combined left and right heart catheterization (CLRHC) and ultrasound-guided antecubital venous access for isolated right heart catheterization (IRHC) are strategies that may reduce risks, especially in anticoagulated patients. combined left and right heart catheterization. To assess safety and feasibility of upper limb approach for IRHC or CLRHC in anticoagulated versus non-anticoagulated patients. Ninety-three patients who underwent IRHC or CLRHC with ultrasound-guided antecubital venous access and transradial arterial access were prospectively enrolled. The primary outcome was a composite of procedure failure and incidence of immediate vascular complications. Of the 93 patients, 44 (47%) were on anticoagulation and 49 (53%) were not. Mean age was 54 ± 17 and 53 ± 15 years, respectively. Atrial fibrillation (39% vs 15%) and chronic kidney disease (21% vs 6%) were more common in anticoagulated patients. The main indication for anticoagulation was deep vein thrombosis/pulmonary thromboembolism in 22 patients (50%). The primary outcome occurred in 4 (8%) patients in the non-anticoagulated group as compared with 0 in the anticoagulated group (p = 0.12). Procedure failure occurred in two patients (4%) and immediate vascular complications in two patients (4%) in the non-anticoagulated group (p = 0.3 for all). There was no difference between groups regarding duration of the procedure, radiation dose, fluoroscopy time, post-procedure recovery room time and median time to venous or arterial hemostasis. The upper limb approach for heart catheterization had similar rates of procedure failure and immediate vascular complications in anticoagulated patients when compared to non-anticoagulated patients.

Die ultraschallgesteuerte periphere Venenpunktion bei schlechtem Venenstatus

In the case of a poor peripheral venous status the use of conventional approaches is associated with several failed attempts, delay of treatment, increased pain and escalation to more invasive techniques. Ultrasound-guided venous access has become increasingly popular for difficult venous access; however, in German-speaking countries it has not yet become as popular as in English-speaking countries. First attempt success rates are high, but the factors contributing to the time needed for ultrasound-guided venous access are not well investigated. It is hypothesized that body mass index (BMI), vein diameter and depth contribute to the time needed for successfully establishing aperipheral vein access in patients with a difficult venous status. This study included 68patients with a poor venous status. After written consent was obtained patient characteristics were documented and upper extremity veins eligible for access were scanned with ultrasound with the aim of performing an ultrasound-guided venous access. The following time periods were documented: 1) first skin contact with the ultrasound probe, 2) time to identify an accessible vein, 3) time for venous access. Of the patients 67 were successfully punctured by ultrasound-guided venous access, 65 at the first attempt and 2 at the second attempt. In one patient conventional venous access was obtained at the same time. Ahigher BMI was associated with asignificantly shorter total puncture time (+1BMI point ≙ -2.25 s) and ashorter vein identification time (+1BMI point ≙ -1.82 s). Agreater vein diameter correlated with ashorter total time (-14.23 s/mm) and agreater depth correlated with an increased total time (+1.65 s/mm). Agreater vein diameter and ahigher BMI contribute to ashorter time period for ultrasound-guided venous access. Obese patients with difficult venous access may benefit from ultrasound-guided venous access, which could be explained by the imaging contrast with a higher proportion of subcutaneous fatty tissue.

Ultrasound‑guided venous access facilitated by the Valsalva maneuver during invasive electrophysiological procedures.

Data on the feasibility of an ultrasound‑guided venous access (USGVA) for catheter ablation (CA) and electrophysiological studies (EPS) in large cohorts are scarce. The impact of the Valsalva maneuver (VM), which can increase the diameter of the femoral vein (FV), on the USGVA is unknown. The study aimed to determine the impact of the VM on FV diameters during establishing the USGVA and overall safety and effectiveness profile of the USGVA in a large cohort. Consecutive patients undergoing CA and/ or EPS with the USGVA were included, and those with anatomical landmark–guided VA were recruited as controls. In a subgroup of USGVA patients, a VM‑facilitated FV puncture was performed. The measurements obtained before and during the VM were used to calculate the estimated access area (EAA) of the FV A total of 1564 ultrasound-guided FV accesses in 876 patients and 172 FV accesses in 105 patients in the anatomical‑VA group were performed. We observed no major complications associated with the USGVA. Minor adverse events related with VA were less common in the USGVA group than in controls (1.5% vs 6.7%, respectively; P = 0.001), resulting in a 4‑fold decrease in VA‑related complications. In 204 consecutive patients who underwent the VM‑facilitated USGVA, the FV diameters increased during VM in both vertical (mean [SD], 10.1 [3] mm vs 14.4 [3.2] mm; P <0.001) and horizontal axes (10.6 [2.9] mm vs 14.5 [3.2] mm; P <0.001). This led to the mean (SD) increase in EAA of 38%: from 0.8 (0.2)cm2 at baseline to 1.1 (0.2) cm2 during VM (P <0.001). The USGVA for EPS and/ or CA is feasible. Complication rates for the USGVA are low and result in minor events. The Valsalva maneuver is a simple way to remarkably increase the femoral vein EAA and it can be helpful in performing the USGVA in difficult cases.

IP173. Development of Simulators for Realistic Training: Simulator for Ultrasound-Guided Venous Access

IP173. Development of Simulators for Realistic Training: Simulator for Ultrasound-Guided Venous Access

Ultrasound-guided venous access: “Wire-loaded puncture” technique for paediatric cancer patients

Ultrasound-guided venous access is becoming a standard technique in many centers worldwide. In small veins and in the pediatric population, successful venous puncture is sometimes followed by resistance in passing the wire. The needle seems to miss the small vein during syringe dismounting, wire mounting and wire advancement through the needle.This work describes a “wire-loaded puncture” technique as a solution for this problem. Patients and methodsPaediatric cancer patients who needed venous access for different indications were included in the study.The wire-loaded technique is described in detail, with special emphasis on the pitfalls of needle guidance under ultrasound in the “out of plane” technique. One-hundred and thirty-nine (139) procedures were initially included using different ultrasound and different access sets. Different operators have participated in the work.Data of patients were retrospectively collected. ResultsOne-hundred and thirty-nine (139) paediatric cancer patients were initially included in the study. After exclusion of patients with inaccurate data registration, the number of patients decreased to 132.The most common primary pathology was leukemia, 47 cases (33.8%), and Porta-cath was the most commonly used catheter in 70 (50.3%) cases. The right internal jugular vein (IJV) was the most commonly used vein for access in 111 (79.8%) cases.The access was feasible in 130 out of 132 cases from a single puncture. No procedure related complications were recorded. ConclusionThe “wire-loaded puncture” technique is a useful technique, particularly in small veins overcoming the relatively common problem of “resisting wire” after a successful vein entry. The technique has a reasonable learning curve and has shown to be reproducible by different operators, machines and venous access sets. A high resolution ultrasound machine is recommended.

TCT-195 Real Time Ultrasound-Guided Venous Access of the Arm for Right Heart Catheterization

TCT-195 Real Time Ultrasound-Guided Venous Access of the Arm for Right Heart Catheterization

An experimental study on the impact of clinical interruptions on simulated trainee performances of central venous catheterization

BackgroundInterruptions are common in the healthcare setting. This experimental study compares the effects of interruptions on simulated performances of central venous catheterization during a highly versus minimally complex portion of the task.MethodsTwenty-six residents were assigned to interruptions during tasks that are (1) highly complex: establishing ultrasound-guided venous access (experimental group, n = 15) or (2) minimally complex: skin cleansing (control group, n = 11). Primary outcomes were (a) performance scores at three time points measured with a validated checklist, (b) time spent on the respective tasks, and (c) number of attempts to establish venous access.ResultsRepeated measure analyses of variances of performance scores over time indicated no main effect of time or group. The interaction between time and group was significant: F (2, 44) = 4.28, p = 0.02, and partial eta2 = 0.16, indicating a large effect size. The experimental group scores decreased steadily over time, while the control group scores increased with time. The experimental group required longer to access the vein (148 s; interquartile range (IQR) 60 to 361 vs. 44 s; IQR 27 to 133 s; p = 0.034). Median number of attempts to establish venous access was higher in the experimental group (2, IQR 1–7 vs. 1, IQR 1–2; p = 0.03).ConclusionsInterruptions during a highly complex task resulted in a consistent decrement in performance scores, longer time required to perform the task, and a higher number of venous access attempts than interruptions during a minimally complex tasks. We recommend avoiding interrupting trainees performing bedside procedures.

How to achieve ultrasound-guided femoral venous access: the new standard of care in the electrophysiology laboratory.

Bedside vascular ultrasound machines are increasingly available. They are used to facilitate safer vascular access across a number of different specialties. In the electrophysiology laboratory however, where patients are frequently anticoagulated and require the insertion of multiple venous sheaths, anatomical landmark techniques predominate. Despite the high number of vascular complications associated with electrophysiological procedures and the increasing evidence to support its use in electrophysiology, ultrasound remains underutilised. A new standard of care is required. A comprehensive technical report, providing a detailed explanation of this important technique, will provide other electrophysiology centres with the knowledge and justification for adopting ultrasound guidance as their standard practice. We review the increasing body of evidence which demonstrates that routine ultrasound usage can substantially improve the safety of femoral venous access in the electrophysiology laboratory. We offer a comprehensive technical report to guide operators through the process of ultrasound-guided venous access, with a specific focus on the electrophysiology laboratory. Additionally, we detail a novel technique which utilises real-time colour Doppler ultrasound to accurately identify needle tip location during venous puncture. The use of vascular ultrasound to guide femoral venous cannulation is rapid, inexpensive and easily learnt. Ultrasound is readily available and offers the potential to significantly reduce vascular complications in the unique setting of the electrophysiology laboratory. Ultrasound guidance to achieve femoral venous access should be the new standard of care in electrophysiology.

Ultrasound-Guided Infraclavicular Axillary Vein Cannulation

Background and Objective: Percutaneous central venous cannulation is a common invasive procedure. In comparison with an external landmark technique, the advantages of ultrasound-guided venous access include direct visualization of the anatomy and in vivo visualization of venous cannulation. Methods: We evaluated an ultrasound-guided technique for infraclavicular axillary vein cannulation, focusing on its ease of use, success rate and complications rate. One hundred and twenty patients who submitted to central venous catheter placement were punctured using our technique. The patients were positioned so that their ipsilateral upper limb was abducted at 90° to the longitudinal axis, which makes it possible to visualize the infraclavicular vessels due to the elevation of the clavicle, thereby improving accessibility. Results: Cannulation was successful in all patients. The median time from the start of the first puncture (of the skin) until the aspiration of blood was 15 s (range 7 - 135 s). Both infraclavicular axillary veins were cannulated, and the vein was punctured successfully at the first attempt in 95% of the patients, without complications during the procedure. Conclusion: We propose an ultrasound-guided infraclavicular approach of the axillary vein, with a high success rate and no complications in the present cohort.

Ultrasound-Guided Vascular Access Simulator for Medical Training: Proposal of a Simple, Economic and Effective Model.

To present a simple and affordable model able to properly simulate an ultrasound-guided venous access. The simulation was made using a latex balloon tube filled with water and dye solution implanted in a thawed chicken breast with bones. The presented model allows the simulation of all implant stages of a central catheter. The obtained echogenicity is similar to that observed in human tissue, and the ultrasound identification of the tissues, balloon, needle, wire guide and catheter is feasible and reproducible. The proposed model is simple, economical, easy to manufacture and capable of realistically and effectively simulating an ultrasound-guided venous access.

The "L-shaped tunneling technique": a modified technique facilitating a more discreet implantable port positioning.

Venous port catheters, also known as "totally implantable venous access devices" (TIVADs), are now the standard of care in patients requiring long-term intermittent intravenous drug administration. We describe a modification of the implantation technique that we use in our department in order to improve the cosmetic result of a TIVAD. After ultrasound-guided venous access in the internal jugular vein (IJV) or another appropriate vein has been obtained, we create a port pocket in the deltopectoral groove, in the upper-lateral chest wall, in a "far-lateral-oblique" orientation, respecting the individual patient's relaxed skin tension lines. Then we create a subcutaneous tunnel using a straight metal tunneler in two steps: first tunneling cranially and perpendicular to the port incision for a small distance, and then, after turning the tunneler at a right angle continuing in a straight line until we exit at the venous access site. This configuration not only prevents catheter kinking, to ensure uninhibited flow, but also allows us to place the port pocket in a more discreet position, in order to offer a better cosmetic result to our patients. Adoption of a "far-lateral-oblique" port implantation site along with the "L-shaped tunneling technique" will offer doctors who are implanting TIVADs a useful alternative for a better cosmetic result.

Getting the most from ultrasound guidance for CVC insertion

Ultrasound is an imaging technique that uses ultra-high frequency sound waves. The interaction of the sound waves with body tissue enables an image to be produced. Following guidance from the National Institute for Health and Care Excellence (NICE) (2002), the use of two-dimensional ultrasound imaging for central venous catheter (CVC) insertion has increased. Ultrasound provides the nurse with visualisation of the target vein as well as any other surrounding structures. It also demonstrates any variation in anatomy that the patient may have. Increased first-time puncture rates and decreased complications are among the benefits of ultrasound use for CVC placement described in the literature. However, NICE (2002) guidance recommended that education and training be sought by those using this technology. The aim of this article, therefore, is to provide useful information regarding ultrasound-guided venous access and to describe some techniques to improve image quality.

A comparison of longitudinal and transverse approaches to ultrasound-guided axillary vein cannulation

ObjectiveThe axillary vein is an easily accessible vessel that can be used for ultrasound-guided central vascular access and offers an alternative to the internal jugular and subclavian veins. The objective of this study was to identify which transducer orientation, longitudinal or transverse, is better for imaging the axillary vein with ultrasound. MethodsEmergency medicine physicians at an inner-city academic medical center were asked to cannulate the axillary vein in a torso phantom model. They were randomized to start with either the longitudinal or transverse approach and completed both sequentially. Participants answered questionnaires before and after the cannulation attempts. Measurements were taken regarding time to completion, success, skin punctures, needle redirections, and complications. ResultsFifty-seven operators with a median experience of 85 ultrasound procedures (interquartile range, 26-120) participated. The frequency of first-attempt success was 39 (0.69) of 57 for the longitudinal method and 21 (0.37) of 57 for the transverse method (difference, 0.32; 95% confidence interval [CI], 0.12-0.51 [P = .001]); this difference was similar regardless of operator experience. The longitudinal method was associated with fewer redirections (difference, 1.8; 95% CI, 0.8-2.7 [P = .0002]) and skin punctures (difference, 0.3; 95% CI, −2 to +0.7 [P = .07]). Arterial puncture occurred in 2 of 57 longitudinal and 7 of 57 transverse attempts; no pleural punctures occurred. For successful attempts, the time spent was 24 seconds less for the longitudinal method (95% CI, 3-45 [P = .02]). ConclusionsThe longitudinal method of visualizing the axillary vein during ultrasound-guided venous access is associated with greater first-attempt success, fewer needle redirections, and a trend of fewer arterial punctures compared with the transverse orientation.

The effect of nitroglycerin ointment on great saphenous vein targeted venous access site diameter with endovenous laser treatment

To assess the effect of topically applied nitroglycerin (NTG) ointment (2%) on preoperative targeted venous access site great saphenous vein (GSV) diameter in patients undergoing endovenous laser treatment (ELT). In this double-blinded randomized study design, 75 patients received either (A) treadmill ambulation only, (B) topically applied NTG ointment only, or (C) topically applied NTG ointment + treadmill ambulation. Targeted venous access vein diameters were measured before therapeutic intervention and then repeated after approximately 30 min following pretreatment intervention. Presence of venospasm and the number of ultrasound-guided venous access attempts during each ELT procedure were assessed during the study. The mean pretreatment vein diameter was 2.6 mm (range 0.9-4.9 mm). The post-treatment percentage change in vein diameter for group A (treadmill ambulation only) was +2.7% (P = 0.403), whereas group B (NTG only) and group C (NTG + treadmill ambulation) demonstrated significant venodilatation of +69.0% (P < 0.0001) and +51.7% (P < 0.0001), respectively. Statistical analysis of variances and multivariate linear regression model revealed topically applied NTG ointment and 'C' classification of clinical, aetiological, anatomical and pathological elements (CEAP) were each significant predictors for venodilatation percentage change (P < 0.001 and = 0.028, respectively). Pretreatment with topically applied NTG ointment (2%) produced a statistically significant, as well as subjective clinically significant venodilatation change in the targeted venous access site diameter of patients undergoing ELT of the GSV in this study.

Portable ultrasound for difficult central venous access

Central venous catheterization can be difficult and can cause serious complications. Ultrasound-guided venous access is increasingly used but reports concern only routine cases. We performed a prospective observational study in 'difficult' or 'failed' procedures to assess the usefulness of ultrasound guidance. We used the technique in 33 patients; 23 had previous failed attempts or had suffered complications from such attempts. Ultrasound provided an anatomical reason for failure in 16 patients. Ten other patients were expected to be difficult before catheterization. Ultrasound identified a suitable site for catheterization in all 33 patients. Real-time ultrasound was used to successfully catheterize 22 patients. In nine patients, a surface landmark technique was used, which failed in three patients. In these three patients, ultrasound guidance allowed successful cannulation. Ultrasound guidance is a useful technique to aid central venous access when difficulties or complications have been encountered or anticipated.