2013 Pediatric Subspecialty Boot Camp_US Fundamentals
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  • Can decrease overall resolution
  • Remember high frequency give you better resolution (images) but has poor penetrationinto the tissue (need to focus on superficial structures).
  • If you apply enough pressure you WILL compress an artery (but less than the nearby vein)
  • Remember: The carotid is medial to the IJ. The probe marker is to YOUR left for venous access. If this is the right side of the neck then the carotid will be the small round structure slightly left and inferior to the large round IJ
  • Why is this important? This is important because if you are too far below the inguinal ligament the femoral artery will likely partially overlap the vein in at least half of the population

2013 Pediatric Subspecialty Boot Camp_US Fundamentals 2013 Pediatric Subspecialty Boot Camp_US Fundamentals Presentation Transcript

  • Pediatrics Kiyetta Alade, M.D., RDMS Assistant Professor Director, Pediatric Emergency Ultrasound Section of Emergency Medicine Department of Pediatrics Baylor College of Medicine Texas Children’s Hospital Ultrasound Fundamentals
  • Page 2 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Goals and Objectives •Describe and operate the basic functions of the ultrasound machine •Discuss the common pitfalls with ultrasound-guided vascular access •Integrate the “landmark technique” and dynamic ultrasound when performing central venous cannulation
  • Page 3 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Gain •Gain: Adjusts the intensity of returned echoes shown on display ‐Increasing gain makes picture brighter
  • Page 4 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Gain Gain will amplify all returning echoes equally
  • Page 5 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Gain
  • Page 6 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Ultrasound Fundamentals •Depth: Can be adjusted to ensure entire structure of interest is on the screen
  • Page 7 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Depth
  • Page 8 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Gain / Depth
  • Page 9 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Ultrasound Fundamentals •Axial resolution: US machines ability to differentiate objects in plane parallel to traveling wave ‐Increase frequency or decrease wavelength to improve •Lateral resolution: US machine’s ability to differentiate objects in plane perpendicular to traveling wave
  • Page 10 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Resolution Axial Lateral
  • Page 11 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Resolution •Low resolution (2-4 MHz) ‐Lower frequency ‐Deeper penetration •High resolution (8-14 MHz) ‐High frequency ‐Poor penetration (best to image superficial structures)
  • Page 12 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Probe Selection •High frequency ‐Linear Array •Low frequency ‐Curvilinear ‐Phased array
  • Page 13 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Ultrasound Fundamentals •Every probe has raised marker to correlate with the side of the screen with some type of identifier (dot, logo)
  • Page 14 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Probe Marker
  • Page 15 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics User Orientation •Remember the probe marker correlates with the symbol on the screen
  • Page 16 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics User Orientation
  • Page 17 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics User Orientation •Objects near the top of the screen correlate with structures CLOSEST to the probe on the patient •Objects near the bottom of the screen correlate with structures furthest away from the probe on the patient
  • Page 18 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics User Orientation Probe BED
  • Page 19 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Ultrasound Fundamentals •D (doppler) mode: Senses the movement of reflected US waves toward and away from the probe by color change or sound ‐Color represents flow toward or away from probe… NOT arterial vs venous flow ‐(Blue Away Red Toward)
  • Page 20 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Color Doppler
  • Page 21 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Procedural •Static ultrasound locates structure of interest but not used to guide procedure ‐LP ‐Thoracentesis ‐Paracentesis ‐I&D •Dynamic ultrasound is used to locate structure of interest AND allow direct visualization of procedure in real time ‐Vascular access
  • Page 22 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics The Agency for Health Care Research and Quality (AHRQ) •Supports the use of ultrasound guidance for the placement of central venous catheters as a way to improve success rates, reduce number of attempts and reduce complications associated with their placement (AHRQ) AfHCRaQ. Making Health Care Safer. A Critical Analysis of Patient Safety Practices. July 20, 2001.
  • Page 23 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Probe Selection •4-10 MHz frequency •Linear Array •Small to medium footprint
  • Page 24 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Vessel Selection Vein Artery •Thin walled •Compressible •May have transmitted pulsations from nearby arteries •Non compressible •Pulsating
  • Page 25 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Vessel Selection •Must be able to differentiate arteries from veins ‐Compression (veins more compressible) ‐Distal Augmentation ‐Color flow (look for pulsations)
  • Page 26 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Screening Ultrasound •Before preparing to cannulate a vessel you should ‐Screen the area of interest for a target ‐Evaluate the vessel size ‐Evaluate vessel compressibility
  • Page 27 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Screening Ultrasound •Before preparing to cannulate a vessel you should ‐Ensure you are targeting the correct vessel ‐Measure the depth
  • Page 28 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Compression IJ IJ CA CA
  • Page 29 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Distal Augmentation
  • Page 30 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Transverse Approach to Vessel
  • Page 31 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Transverse Approach •With a transverse approach to vessel puncture you should orient the probe with the marker to YOUR left and the US screen in FRONT of you ‐This allows for easy manipulation ‐If on the screen the needle looks like it is to the right of the vessel then you change direction more to the left
  • Page 32 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Transverse Approach •Locate target vessel in transverse plane •Pucture skin adjacent to probe, locate needle tip and follow it until it enters vessel ‐This requires you to move the probe as you advance the needle (following the needle tip)
  • Page 33 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Transverse Approach
  • Page 34 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Transverse Approach
  • Page 35 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Transverse Approach •Able to visualize surrounding structures •Have to locate needle tip through motion or comet artifact
  • Page 36 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Longitudinal Approach to Vessel
  • Page 37 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Longitudinal Approach •Locate target vessel in transverse approach •Turn probe longitudinal over selected vessel (probe marker to patients head) •Puncture skin adjacent to probe •Advance needle DO NOT move probe •Keep vessel in screen
  • Page 38 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Longitudinal Approach
  • Page 39 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Longitudinal Approach
  • Page 40 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Internal Jugular
  • Page 41 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Internal Jugular •Position the ultrasound screen in front of you •Orient the ultrasound probe with marker to YOUR left ‐This allows you to move the probe in the SAME direction as visualized on the screen
  • Page 42 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Internal Jugular Central Line carotid
  • Page 43 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Valsalva
  • Page 44 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Internal Jugular Central Line •US guided central line placement still with complications (fewer than landmark technique) ‐Puncture of posterior wall of vein ‐Cannulation of carotid artery
  • Page 45 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Femoral Vein •Complete overlap of femoral artery over vein 4 cm below inguinal ligament about half of the time •At least 50% overlap of femoral artery over vein in same location Hughes, et al. Brit J Anes. Ultrasonography of the femoral vessel in the groin: implications for vascular access. 2000:84(5):668-669
  • Page 46 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Femoral Vein
  • Page 47 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Femoral Vein •Position the ultrasound screen in front of you •Orient the ultrasound probe with marker to YOUR left ‐This allows you to move the probe in the SAME direction as visualized on the screen
  • Page 48 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Femoral Vein •Single operator: ‐Hold probe with hand on outside of leg •Left hand right leg •Right hand left leg ‐Use free hand to access vein using Seldinger technique
  • Page 49 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Femoral Vein •Locate target vessel in transverse plane •Measure depth of vessel •Puncture skin at a ~ 30° angle (too sharp will inhibit passing of guidewire)
  • Page 50 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Sonosite M-Turbo Series
  • Page 51 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Remember •ALWAYS ‐find potential puncture sight using landmark technique before evaluating with US •If time allows ‐Screen BOTH sides to determine the best site for needle puncture
  • Page 52 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics
  • Page 53 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Select your probe
  • Page 54 xxx00.#####.ppt 7/15/2013 7:19:50 PM Pediatrics Thank You