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
  • Ultrasound for avscular access last microsoft power point

    1. 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. 2. Ultrasound for vascular access• « Not a problem for me »• « It is time consuming »• « I have always used the anatomical land marks «
    3. 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. 4. To see or not…
    5. 5. IJV
    6. 6. Anatomical landmarks are sufficient Complications McGee, Gould, NEJM 2003; 348: 1123
    7. 7. Carotid artery puncture inocuity?
    8. 8. Why such a rate of complications?
    9. 9. Anatomical variabilityThe carotid artery and the internal jugular vein Gordon et.al., JVIR 1998; 9:333
    10. 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. 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. 12. Hind BMJ 2003;327:361.
    13. 13. Landmark Ultrasonography Static/skin mark Dynamic
    14. 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. 15. Jugular and femoral
    16. 16. 411 pts vs 410 ptsNo effet of static US on catheterization failure RR (0.75-1.50) 1994
    17. 17. Sus clavicular access
    18. 18. US and femoral access? US and femoral access :YES Kwong, Nephro Dial Transpl 1997
    19. 19. 20 patients presenting to ED with cardiopulmonary arrest Two venous femoral accessone inserted using the landmark and the other one US guidance
    20. 20. Static <dynamic
    21. 21. Device?• In plane:• Out of plane:
    22. 22. Ultrasound Needle source I do not see the needle I see part of the needle I see the entire needle pathway pathway
    23. 23. « Take Home Messages »• US guidance• Easier• More prompt• Decreases complications• Jugular femoral > sub clavian
    24. 24. Sensitivity: 100%; feasibility 99%, training 2 hours,time required for the procedure: 6.8 mn vs 80.3 mn
    25. 25. Catheter tip visualisation?The correct place
    26. 26. Feasability 90%
    27. 27. CVC in the SVC
    28. 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. 29. 45 minutes trainingHands on an inanimate deep peripheral arm 2 blind IV sticks US guided cannulation Succes rate 87%
    30. 30. Radial artery Levin Crit Care med 2003
    31. 31. Shiloh, Chest 2011

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