Is it a routine in your intensive care unit to perform ultrasound-guided central venous catheterization?
It is. We consider it the standard of care. Landmark-based techniques may be used in extreme circumstances, i.e. femoral venous access in crash-situations. However, some would favor an I.O. access.
Same in the UK. US guided central venous cannulation is now considered the gold standard, and it would be difficult to defend doing otherwise.
Many intensivists, anaesetists and paediatric surgeons use u/s to place central lines in our institution. I believe it will become the standard of care.
In our MICU, it's the daily technique used to place venous central lines. I think, today, for experts, it could be judged as a medical error if a complication occurs during the placement of a CVL without ultrasound.
In our ICCU is not routine to perform ultrasound guided CV L, however I agree that it helps. I am not sure that a complication occuring during placement of a CVL without ultrasound could be judged a medical error ; to my Knowledge there are no studies showing that CVL placement with ultrasound reduce complications more than without the use of ultrasound.
In the UK there has been national guidance issues that suggests that US should be used when placing CVC in non-emergent settings, when available. This makes it very hard to defend any complications that might arise if you are inserting a CVC without US whilst working on a unit that has access to US as most UK ICU's do.
Has been in the UK & our unit for may years. Practiced it as a standard from the start of my 10 year as a ICU Consultant - a no-brainer!
Yes, we use US guidance for all Internal Jugular vein central venous catheters. We use it for some femoral vein catheters, but not all. We do not generally use it for subclavian catheter placement.
No, only in thrombopenic, coagulopathy, history of complications or extraordinary anatomic conditions. The reason is that the doctors might lose skills with landmark method and the young ones would never learn it. Imagine what happens in emergency condition when the ultrasound device is suprisingly down.....
It is routinely used for jugular and femoral vein catheterization and considered standard of care (beginning with NICE guideline in 2002...). Few other colleagues and myself use it also for subclavian access but others still consider it to be more difficult. Actually I'd like to do some practical investigation on this topic.
http://www.nice.org.uk/guidance/ta49/resources/guidance-guidance-on-the-use-of-ultrasound-locating-devices-for-placing-central-venous-catheters-pdf
no,only for educational purposes and sometimes when coaggulation abnormalities are present
Yes, now it is routine practice, and unthinkable to do Central line in any patient without ultrasound. I have used landmark in emergencies but I would prefer ultrasound.
No we do not use ultrasound routinely for central venous catheterisation. The residents are encouraged to do without as the ultrasound may not always be available in the ICU in a developing country and also in dire emergencies ultrasound may delay its insertion
At our ICU we do all insertions with ultrasound. I suppose few doctors would be able to do it without, as they already learn to do it ultrasound-guided.
No. This makes for sometimes long procedures in less experienced doctors. In special cases (failed earlier attempt) ultrasound is used to support insertion of a central venous line.
There is adequate evidence that ULS speeds up the insertion procedure, not slowing it as Dr. Van Berkom suggests.
Routine use of ULS actually helps performing landmark punctures, as you get an anatomy course for every procedure.
It is becoming standard of care (at least in the United States). Ultrasound is found in almost every ED and ICU I have worked in. Although I agree it does not allow for competence in finding landmarks, the iatrogenic complication rates are extremely and hard to argue should you have a bad outcome form a blind stick when ultrasound was available.
I encourage all my residents to use US for venous and sometimes arterial punctures. Why ? We have a US machine so why not use it ? Procedure times go down even in emergencies, Patients with long ICU stay often show jugular vein thrombosis, so its better to see it before puncture. The only arguments against a routinely usage of ultrasound is the absence of an ultrasound device or the fact you never tried it before. After 2-3 supervised procedures residents can safely use it.
Yes I do. I started the use of the desvice in the year 2000 with patients for liver transplantation without any complications afterwards I use the ultrasound in each patient in anesthesia and intesive care the best results are for yugular internal vein and femoral catheterization
Yes, a good thing except when the patient might benefit from a subclavian. If one has a complication, like a pneumothorax, the first question will be "why didn't you just do an US guided IJ." So I worry, now that we are at the point at which pigtail catheters reduce the morbidity of pneumothraces, and reasonable data that subclavians are not more prone to Ptx, and maybe less prone to line infection, that US guided IJ's are placing the clinician who decides to place a subclavian for appropriate reasons, at greater liability risk.
The observation is correct, but I dispute the conclusion: If you judge a subclavian line to be beneficial (and I agree that this may often be the case), inform the patient and document it in the records.
You might also want to use the alternative method, where you cannulate the IJV and tunnel the exit to the usual subclavian puncture site. With loop technique, this takes additional 3-4 minutes that may be well spent: Make a 1cm incision at the IJV puncure site. Tunnel the guidewire to the subclavian region, leaving a wire loop at the IJV puncture site. Thread the catheter from the thorax and around the wire loop into the IJV, then remove the wire and straighten the loop.
A very interesting technique I have never performed. Often we do subclavians when we worry about erythema at the IJ site. We often use axillary arterial lines, ultrasound guided. I have often wondered why not a right axillary to subclavian line.
The axillary vein can be UL visualized and cannulated. It is very slender, but it can be done.
Yes, I agree with Sven. The axillary vein can be visualized and cannulated with ultrasound very easly (infraclavicular approach). It is very elegant technique and useful in many clinical circumstances (tracheostomy, facial trauma, neck infection...)
Do you guys know if there is any data on line infection or upper extremity DVT with an axillary approach to the subclavian?
No, we don't usually perform ultrasound-guided central venous catheterization because we didn't have the US machine. From january 2015, we have a US machine and we started to use it for the ultra-sound guided central venous catheterization. In my hospital, even whitout US guided help , the incidence of complications associated with central venous catheterization (most of them subclavicular approach) is very low.
Of course, the recommandation is to always perform the US central venous catheterization and we try to do this.
We usually perform US guided central venous catheterization, but is important to keep in mind that could be time consuming in emergencies
Seth, data on long term complications associated with the axillary vein cannulation are lacking, no significant RCTs or observational studies. This technique is not very popular among intensivists (especially landmark technique). Recently It gained popularity because of the ultrasonography.
Mauricio, I do not think that ultrasound guided central vein cannulation is time consuming. It could be done rapidly by a skilled operator and even faster than a landmark technique.
Tomaste, thanks for the reply. My axillary arterial lines are US guided and the vein looks like a decent sized vessel, but hard to do in the US without data. I'm guessing someone will look at this, as double lumen piccs are threaded from the arm into the central circulation.
I had 13 years of landmark experience before I started to use US. My personal experience, for what it is worth, is that US saves time. And arterial punctures, by the way. And I am quite certain that I can back it up with trial data.
Tomasz: my auto-correct thought your name was the past tense of the informal second person Spanish verb "tomar", to drink or to take. My apologies. I haven't figured out how to easily make the auto-correct figure out what language I am writing in.
Seth, you can edit your posts if so desired. Hold your cursor over the post, and an upper right corner arrow appears.
Yes we do. Is it helpful in all cases? Depends on intensivist expertise. When you have practiced a lot without ultrasounds it may be a bit less easy.
We have not used ultrasound, but have tried to use handy transilluminator. At Mercy Hospital, central lines (PICC lines) are done by nurses and they have not found transilluminator to be much helpful. They have tried transilluminator for difficult peripheral IV lines. My guess is that with enthusiasm to try new techniques, with little experience and experience backed by evidence based data, anything is possible. I wonder if anyone else has used transilluminator with success.
Funnily enough our anestesiologists perform landmark twchnique whereas we emergency physicians perform US-guided technique. Obviously we teach and encourage ultrasound-guided technique.
We use ultrasound in patient with platelet alteration or in patient with multiple puncture.
But we believe that the resident, must to learn the tradicional tecnique before use the ultrasound.
I have answered already.
Ithink it better to know the traditional tecnique,and then to learn US-guided catherisation.
In our ICU we use US only when coaggulation abbnormalities occur.
For sure, we always use US nowadays, but I am concerned how the new generation of colleagues will perform when no machine is available and there is a hurry to get a line in.
It is a valid point, Mats. I think supervision of colleagues skilled in landmark technique will be the answer. They will be able to point out the position of the vein as shown on-screen and, using the UL scanner, give technical advice of blind technique should the equipment be unavailable.
Do you meen Sven that we first try to identify vein location by landmarks and put two or three marks with a sterile pen at points we believe in and then confirm (if lucky) with US? That could be good pedagogy!
New technology kills old ways but we should not stop progress for that reason. It is upto individuals to train according to needs. Landmark technique should be learnt and taught but latest technique should not be not denied in the process. we must be able perform at the highest level, adapt to the local needs and improvise where needed.
I have learnt this in my many charity outings to remote parts of the world.
yes, Mats, if you wait with your puncture attempt till you have used US, it could be a valuable lesson!
@ Giannis and Juan Eduardo: if you use US guidance only in patients with expected difficulties the yield will be disastrous in patients with an unexpectable abnormality (great vessel anomaly, jugular DVT, etc...)
It is a standard practice in UK. It is routinely used for all central line insertions in my unit. It helps to insert the cannula quicker and safer. The US machine is available in all areas where central venous cannulation is performed.
An easy question . Yes the use of ultrasound has become common practice here as the machine is now readily available. Appears to save time and complication .
I am responding to this question 6 years later.
The cebtre i work, in Sri Lanka, we routinely use ultrasound during central line placements.
Majority are Internal jugular lines.
Only when the Ultrasound is occupied elsewhere, we go for land mark guided technique.
Practically,subclavian line insertions under Uss guidance is bit difficult, but for that too, the USS is of great help and improves safety profile....
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