This week, we have a post from regular contributor Nick Mancuso on how to excel when performing a procedure common in the ED as well as upstairs: ultrasound guided central line placement.
The three most common veins used in central line placement are the internal jugular (IJ), subclavian (SV), and femoral (FV). I will focus on IJ placement and the use of dynamic ultrasound.
- Sterile technique is paramount (if time permits).
- Linear array probe is used with a sterile probe cover, and sterile gel. A CVC kit is obviously required, along with sterile personal protective equipment. This procedure can be done with one person, but two can be helpful especially during training.
- Operator on the isiplateral side of the pt, pt in Trendelenburg, probe indicator to the left of operator, in transverse position.
- Place probe superior to clavicle, IJV usually larger, lateral to carotid artery.
- The IJV will compress with pressure, vs. the artery. If hypotensive or dehydrated, may disappear with inspiration.
- Center vein on screen, lidocaine can be used to anesthetize pt. Use center of probe as guide, while not looking at monitor, stick pt skin with entry needle.
- Look at monitor after puncture. Visualize needle or tissue compression. Puncture vein looking at monitor.
- If needle can’t be visualized, a long-axis (longitudinal) view can help
- It is extremely important to visualize the needle tip and not proceed with advancement of the needle without visualization of the tip. The tip can be followed with slow fanning or sliding of the probe distally as you advance. The most common mistake is not following the tip of the needle and letting the needle get “ahead of” the probe. This leads to visualization of the proximal portion of the needle while the tip is in a different location in the neck, possibly causing complication.
In emergency medicine, central lines (central venous catheters) are commonly placed in patients. In the few times I have been in the ED so far for my ultrasound in emergency medicine elective with the pro Dr. Matt Dawson, I have seen two IJ catheters placed using the sterile (vs. unsterile) method. Both times ultrasound was utilized, vs. when we briefly learned about using the anatomical landmarks in our Anatomy class. Why not just use the anatomical lankmarks?
Several papers give the answer: in one, unadjusted success rates were 98%, 82%, and 64% for using dynamic ultrasound, static ultrasound, and land marks, respectively, for first-attempt success1. In a separate review of 18 trials, the conclusion was that ultrasound improved outcomes most convincingly using external probes, for internal jugular vein cannulation, and when used by clinicians less experienced at line placement. No difference was found in time to insertion of catheter2. There are several more quality studies showing better outcomes with fewer complications than the traditional method.
Indications for central line (central venous catheter-CVC) placement include: Peripheral venous access is unobtainable, drugs causing phlebitis are to be administered (amiodarone, vasopressors such as epi and dopamine), central venous pressure monitoring needed, rapid administration of blood products required, frequent blood draws, etc.
Contraindications to CVCs include infection at the insertion site, venous thrombosis, anticoagulation therapy, morbid obesity (ultrasound can improve this), atypical anatomy, and things like a C-spine collar, pt compliance etc.
Complications can include arterial puncture, infection, bleeding, thrombosis, pneumothorax, nerve injury, guidewire embolism4 . Ultrasound can decrease some of these considerably3.
For entire step by step placement instructions, great pics and videos, check out Introduction to Bedside Ultrasound: Volume 1 in iBooks, Chapter 9.
With ultrasound guidance becoming/being the standard of care in placement of central venous catheters, many complications can be avoided. This is one of many areas in emergency medicine that bedside ultrasound use is improving patient care, outcomes, and reducing costs for providers.
Submitter: Nick Mancuso
1. Sznajder JI, Zveibil FR, Bitterman H, Weiner P, Bursztein S. Central vein catheterization. Failure and complication rates by three percutaneous approaches. Arch Intern Med. Feb 1986;146(2):259-61. [Medline].
2. Keenan SP. Use of ultrasound to place central lines. J Crit Care. 2002 Jun;17(2):126-37. [Medline].
3. Sekiguchi H, Tokita JE, Minami T, Eisen LA, Mayo PH, Narasimhan M. A prerotational, simulation-based workshop improves the safety of central venous catheter insertion: results of a successful internal medicine house staff training program. Chest. Sep 2011;140(3):652-8. [Medline].
4. Pigott, MD, RDMS, FACEP. David , and Gowthaman Gunabushanam, MD, FRCR, eds. “Ultrasonography Assisted Central Line Placement.” Medscape Reference. Web. 19 Mar 2013. http://emedicine.medscape.com/article/110152-overview
5. Dawson MD, Matt. Mallin MD, Mike. Introduction to Bedside Ultrasound: Volume 1. iBook
6. Stanton MD, Ryan. “Central Lines, Chapter 9”. pgs. 167-182. Introduction to Bedside Ultrasound: Volume 1. iBook
7. Blogpost on Central Venous Cannulation http://lifeinthefastlane.com/education/procedures/central-line