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Ultrasound for avscular access last microsoft power point
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  • An important proportion of intensivist consider Us as no use for vacular access
  • However who can answer yes to these three questions
  • Soem explanatiosn are obvious
  • Some other reasons are located under teh skin
  • So to conclude
  • The major problem is to visualize the neddle
  • Specpfoc device guide the needle pathway and aloows a perfct visulation o fteh progression
  • It is even possibel ti use US to improve succes rate od f artrai cnnaulatioj

Transcript

  • 1. In the emergency roomUltrasound for vascular access Eric Maury Medical ICU Saint-Antoine Hospital Paris 6 Medical University eric.maury@sat.aphp.fr
  • 2. Ultrasound for vascular access• « Not a problem for me »• « It is time consuming »• « I have always used the anatomical land marks «
  • 3. Ultrasound for vascular access• Who has never accidentally punctured artery during a venous cannulation attempt ?• Who has never induced a pneumothorax after insertion of a venous sub clavian catheter?• Who always reaches the vein at first pass?• If I was a critically ill patient, I would like this procedure to be performed with an optimal mastery.
  • 4. To see or not…
  • 5. IJV
  • 6. Anatomical landmarks are sufficient Complications McGee, Gould, NEJM 2003; 348: 1123
  • 7. Carotid artery puncture inocuity?
  • 8. Why such a rate of complications?
  • 9. Anatomical variabilityThe carotid artery and the internal jugular vein Gordon et.al., JVIR 1998; 9:333
  • 10. • « Unequal size »: – 80 patients • Right IJV major in 2/3 cases • IJV diameter < 0.4cm2 25% cases Lichtenstein, Intensive Care Med 2001 – Compression:
  • 11. 100 90 80 70 Success on first 60 attempt 50 Sucessful 40 30 Access time (sec) 20 10 0 Ultrasound LandmarkInternal jugular vein cannulation1230 patients
  • 12. Hind BMJ 2003;327:361.
  • 13. Landmark Ultrasonography Static/skin mark Dynamic
  • 14. US-guided IJV access• Safe• Feasible• Decreases failure rate• Decreases complications rateCVC US guidance subsidiary questions All sites? Emergency? Static vs dynamic? Which device?
  • 15. Jugular and femoral
  • 16. 411 pts vs 410 ptsNo effet of static US on catheterization failure RR (0.75-1.50) 1994
  • 17. Sus clavicular access
  • 18. US and femoral access? US and femoral access :YES Kwong, Nephro Dial Transpl 1997
  • 19. 20 patients presenting to ED with cardiopulmonary arrest Two venous femoral accessone inserted using the landmark and the other one US guidance
  • 20. Static <dynamic
  • 21. Device?• In plane:• Out of plane:
  • 22. Ultrasound Needle source I do not see the needle I see part of the needle I see the entire needle pathway pathway
  • 23. « Take Home Messages »• US guidance• Easier• More prompt• Decreases complications• Jugular femoral > sub clavian
  • 24. Sensitivity: 100%; feasibility 99%, training 2 hours,time required for the procedure: 6.8 mn vs 80.3 mn
  • 25. Catheter tip visualisation?The correct place
  • 26. Feasability 90%
  • 27. CVC in the SVC
  • 28. Peripheral vein• Six months retrospective study• 148 impossible peripheral access  147 success US guided (71% at first attempt) Gregg, Journal of Critical Care 2010
  • 29. 45 minutes trainingHands on an inanimate deep peripheral arm 2 blind IV sticks US guided cannulation Succes rate 87%
  • 30. Radial artery Levin Crit Care med 2003
  • 31. Shiloh, Chest 2011