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Franco-Sadud R, Schnobrich D, Mathews BK, Candotti C, Abdel-Ghani S, Perez MG, Rodgers SC, Mader MJ, Haro EK, Dancel R, Cho J, Grikis L, Lucas BP, Soni NJ. Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine. J Hosp Med 2019; 14:E1-E22. [PMID: 31561287 DOI: 10.12788/jhm.3287] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 07/08/2019] [Accepted: 07/09/2019] [Indexed: 02/02/2023]
Abstract
PREPROCEDURE 1)We recommend that providers should be familiar with the operation of their specific ultrasound machine prior to initiation of a vascular access procedure. 2)We recommend that providers should use a high-frequency linear transducer with a sterile sheath and sterile gel to perform vascular access procedures. 3)We recommend that providers should use two-dimensional ultrasound to evaluate for anatomical variations and absence of vascular thrombosis during preprocedural site selection. 4)We recommend that providers should evaluate the target blood vessel size and depth during preprocedural ultrasound evaluation. TECHNIQUES General Techniques 5) We recommend that providers should avoid using static ultrasound alone to mark the needle insertion site for vascular access procedures. 6)We recommend that providers should use real-time (dynamic), two-dimensional ultrasound guidance with a high-frequency linear transducer for central venous catheter (CVC) insertion, regardless of the provider's level of experience. 7)We suggest using either a transverse (short-axis) or longitudinal (long-axis) approach when performing real-time ultrasound-guided vascular access procedures. 8)We recommend that providers should visualize the needle tip and guidewire in the target vein prior to vessel dilatation. 9)To increase the success rate of ultrasound-guided vascular access procedures, we recommend that providers should utilize echogenic needles, plastic needle guides, and/or ultrasound beam steering when available. Central Venous Access Techniques 10) We recommend that providers should use a standardized procedure checklist that includes the use of real-time ultrasound guidance to reduce the risk of central line-associated bloodstream infection (CLABSI) from CVC insertion. 11)We recommend that providers should use real-time ultrasound guidance, combined with aseptic technique and maximal sterile barrier precautions, to reduce the incidence of infectious complications from CVC insertion. 12)We recommend that providers should use real-time ultrasound guidance for internal jugular vein catheterization, which reduces the risk of mechanical and infectious complications, the number of needle passes, and time to cannulation and increases overall procedure success rates. 13)We recommend that providers who routinely insert subclavian vein CVCs should use real-time ultrasound guidance, which has been shown to reduce the risk of mechanical complications and number of needle passes and increase overall procedure success rates compared with landmark-based techniques. 14)We recommend that providers should use real-time ultrasound guidance for femoral venous access, which has been shown to reduce the risk of arterial punctures and total procedure time and increase overall procedure success rates. Peripheral Venous Access Techniques 15) We recommend that providers should use real-time ultrasound guidance for the insertion of peripherally inserted central catheters (PICCs), which is associated with higher procedure success rates and may be more cost effective compared with landmark-based techniques. 16)We recommend that providers should use real-time ultrasound guidance for the placement of peripheral intravenous lines (PIV) in patients with difficult peripheral venous access to reduce the total procedure time, needle insertion attempts, and needle redirections. Ultrasound-guided PIV insertion is also an effective alternative to CVC insertion in patients with difficult venous access. 17)We suggest using real-time ultrasound guidance to reduce the risk of vascular, infectious, and neurological complications during PIV insertion, particularly in patients with difficult venous access. Arterial Access Techniques 18)We recommend that providers should use real-time ultrasound guidance for arterial access, which has been shown to increase first-pass success rates, reduce the time to cannulation, and reduce the risk of hematoma development compared with landmark-based techniques. 19)We recommend that providers should use real-time ultrasound guidance for femoral arterial access, which has been shown to increase first-pass success rates and reduce the risk of vascular complications. 20)We recommend that providers should use real-time ultrasound guidance for radial arterial access, which has been shown to increase first-pass success rates, reduce the time to successful cannulation, and reduce the risk of complications compared with landmark-based techniques. POSTPROCEDURE 21) We recommend that post-procedure pneumothorax should be ruled out by the detection of bilateral lung sliding using a high-frequency linear transducer before and after insertion of internal jugular and subclavian vein CVCs. 22)We recommend that providers should use ultrasound with rapid infusion of agitated saline to visualize a right atrial swirl sign (RASS) for detecting catheter tip misplacement during CVC insertion. The use of RASS to detect the catheter tip may be considered an advanced skill that requires specific training and expertise. TRAINING 23) To reduce the risk of mechanical and infectious complications, we recommend that novice providers should complete a systematic training program that includes a combination of simulation-based practice, supervised insertion on patients, and evaluation by an expert operator before attempting ultrasound-guided CVC insertion independently on patients. 24)We recommend that cognitive training in ultrasound-guided CVC insertion should include basic anatomy, ultrasound physics, ultrasound machine knobology, fundamentals of image acquisition and interpretation, detection and management of procedural complications, infection prevention strategies, and pathways to attain competency. 25)We recommend that trainees should demonstrate minimal competence before placing ultrasound-guided CVCs independently. A minimum number of CVC insertions may inform this determination, but a proctored assessment of competence is most important. 26)We recommend that didactic and hands-on training for trainees should coincide with anticipated times of increased performance of vascular access procedures. Refresher training sessions should be offered periodically. 27)We recommend that competency assessments should include formal evaluation of knowledge and technical skills using standardized assessment tools. 28)We recommend that competency assessments should evaluate for proficiency in the following knowledge and skills of CVC insertion: (a) Knowledge of the target vein anatomy, proper vessel identification, and recognition of anatomical variants; (b) Demonstration of CVC insertion with no technical errors based on a procedural checklist; (c) Recognition and management of acute complications, including emergency management of life-threatening complications; (d) Real-time needle tip tracking with ultrasound and cannulation on the first attempt in at least five consecutive simulation. 29)We recommend a periodic proficiency assessment of all operators should be conducted to ensure maintenance of competency.
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Affiliation(s)
| | - Daniel Schnobrich
- Divisions of General Internal Medicine and Hospital Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Benji K Mathews
- Department of Hospital Medicine, Regions Hospital, Health Partners, St. Paul, Minnesota
| | - Carolina Candotti
- Division of Hospital Medicine, University of California Davis, Davis, California
| | - Saaid Abdel-Ghani
- Department of Hospital Medicine, Medical Subspecialties Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Martin G Perez
- Department of Hospital Medicine, Memorial Hermann Northeast Hospital, Humble, Texas
| | - Sophia Chu Rodgers
- Division of Pulmonary Critical Care Medicine, Lovelace Health Systems, Albuquerque, New Mexico
| | - Michael J Mader
- Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
| | - Elizabeth K Haro
- Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
| | - Ria Dancel
- Division of Hospital Medicine, University of North Carolina, Chapel Hill, North Carolina
- Division of General Pediatrics and Adolescent Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Joel Cho
- Department of Hospital Medicine, Kaiser Permanente Medical Center, San Francisco, California
| | - Loretta Grikis
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
| | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | | | - Nilam J Soni
- Division of General & Hospital Medicine, University of Texas Health San Antonio, San Antonio, Texas
- Section of Hospital Medicine, South Texas Veterans Health Care System, San Antonio, Texas
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Tanhehco YC, Zantek ND, Alsammak M, Chhibber V, Li Y, Becker J, Wu DW, Foster T, Wehrli G. Vascular access practices for therapeutic apheresis: Results of a survey. J Clin Apher 2019; 34:571-578. [DOI: 10.1002/jca.21726] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/07/2019] [Accepted: 06/11/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Yvette C. Tanhehco
- Columbia University Irving Medical Center and New York‐Presbyterian Hospital, Department of Pathology and Cell BiologyColumbia University Vagelos College of Physicians and Surgeons New York New York
| | - Nicole D. Zantek
- Department of Laboratory Medicine and PathologyUniversity of Minnesota Minneapolis Minnesota
| | - Mohamed Alsammak
- Blood Bank/Transfusion Medicine, Temple University Hospital and Department of Pathology and Laboratory MedicineLewis Katz School of Medicine at Temple University Philadelphia Pennsylvania
| | - Vishesh Chhibber
- Transfusion Medicine, Northwell Health and Pathology & Laboratory MedicineZucker School of Medicine at Hofstra/Northwell Hempstead New York
| | - Yanhua Li
- Department of PathologyNew York University School of Medicine New York New York
| | - Joanne Becker
- Department of Pathology and Laboratory Medicine; Blood Bank and Therapeutic Apheresis Unit, Roswell Park Comprehensive Cancer Center, and Pathology and Anatomical SciencesJacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo Buffalo New York
| | - Ding W. Wu
- Department of Pathology and LaboratoriesNYU‐Brooklyn, NYU Langone Medical Center New York New York
| | - Tisha Foster
- Scientific Medical Technical Department, OneBlood Lakeland Florida
| | - Gay Wehrli
- Department of PathologyUniversity of Virginia Health Charlottesville Virginia
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Gillman LM, Blaivas M, Lord J, Al-Kadi A, Kirkpatrick AW. Ultrasound confirmation of guidewire position may eliminate accidental arterial dilatation during central venous cannulation. Scand J Trauma Resusc Emerg Med 2010; 18:39. [PMID: 20626896 PMCID: PMC2912234 DOI: 10.1186/1757-7241-18-39] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Accepted: 07/13/2010] [Indexed: 11/30/2022] Open
Abstract
Background Ultrasound guidance during central line insertion has significantly reduced complications associated with this procedure and has led to it being incorporated as standard of care in many institutions. However, inadvertent arterial penetration and dilation remains a problem despite ultrasound guidance and can result in significant morbidity and even mortality. Dynamic ultrasound confirmation of guidewire position within the vein prior to dilation may help to prevent and even eliminate this feared complication. Methods A prospectively collected database of central line insertions for one author utilizing this novel technique was retrospectively reviewed for all incidents of arterial dilation over a period from September 2008 to January 2010. Results During the study period 53 central lines were inserted with no incidents of arterial dilation. Conclusions Ultrasound confirmation of guidewire position has the potential to reduce or eliminate the morbidity and mortality of arterial dilation during central line placement.
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Affiliation(s)
- Lawrence M Gillman
- Department of Critical Care Medicine, University of Calgary, 1403 - 29 Street NW, Calgary, T2N 2T9, Canada.
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Use of hand-held ultrasonography to confirm the correct placement of a central venous catheter tip. J Med Ultrason (2001) 2007; 34:69-72. [PMID: 27278184 DOI: 10.1007/s10396-006-0120-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2006] [Accepted: 08/10/2006] [Indexed: 10/23/2022]
Abstract
To avoid severe complications resulting from malpositioning of a central venous catheter, removal and recannulation of the catheter may be necessary, thus wasting medical equipment and increasing stress on the patient. Therefore, central venous catheters should be inserted correctly the first time. We tested whether real-time hand-held ultrasound-guided confirmation of the location of the tip of a central venous catheter inserted from the femoral vein could reduce the rate of malpositioning. Catheters were inserted using conventional methods for 65 patients, and using ultrasound guidance for 29 patients. For the latter group, when a central venous catheter was inserted, the ultrasound examiner first identified its tip located dorsal to the liver in the inferior vena cava and then fixed the catheter in position. We considered a central venous catheter to be malpositioned when its tip appeared in neither the inferior vena cava nor the right atrium-inferior vena cava junction in X-rays. Flexed or inverted catheters were also considered to be malpositioned. We compared the malpositioning rates for the ultrasound and conventional groups. Malpositioning was identified for two (6.9%) patients in the ultrasound group and 19 (29.2%) patients in the conventional group. The relative risk of ultrasound-guided versus conventional catheter insertion was 0.23 (95% confidence interval, 0.09-0.62). Our data suggest that real-time ultrasound monitoring is useful for avoiding malpositioning of central venous catheters inserted from the femoral vein.
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Senzolo M, Burra P, Cholongitas E, Lodato F, Marelli L, Manousou P, Patch D, Sturniolo GC, Burroughs AK. The transjugular route: the key hole to the liver world. Dig Liver Dis 2007; 39:105-16. [PMID: 17196894 DOI: 10.1016/j.dld.2006.06.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2006] [Revised: 06/20/2006] [Accepted: 06/27/2006] [Indexed: 02/07/2023]
Abstract
Portal hypertensive complications are major causes of morbidity and mortality in patients with liver cirrhosis. The advent of the transjugular route with its minimal access allows non-surgical management of portal hypertension, therapy of venous complications of liver transplantation, monitoring of therapy for portal hypertension, hepatic venous pressure gradient and is also the major route to treat hepatic venous obstruction syndromes. In addition, the transjugular route is a safe route to perform a liver biopsy (transjugular liver biopsy) and allows retrograde evaluation of the portal vein. All these procedures can be combined in the same session. These hepatic interventional radiological skills should be incorporated into the expertise of the liver team in specialised hepatological centres, particularly in liver transplant centres as they are especially useful in improving outcomes of cirrhotic patients on the liver transplantation waiting list. A limitation in achieving this goal, could be the number of experienced radiologists, but hepatologists can be trained, at least for the most simple procedures (transjugular liver biopsy and hepatic venous pressure gradient). This would allow wider applicability and use of these diagnostic and therapeutic techniques, all through a 2 mm hole in the neck--the key hole to the liver world.
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Affiliation(s)
- M Senzolo
- Liver Transplantation and Hepatobiliary Unit, Royal Free Hospital, London, Pond Street, London NW3 2QG, UK
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Suarez T, Baerwald JP, Kraus C. Central venous access: the effects of approach, position, and head rotation on internal jugular vein cross-sectional area. Anesth Analg 2002; 95:1519-24, table of contents. [PMID: 12456410 DOI: 10.1097/00000539-200212000-00010] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED We investigated the effects of approach (lateral versus anterior), position (supine versus Trendelenburg), and head rotation (0 degrees, 20 degrees, and maximum) during central venous catheterization on the area of the right internal jugular vein. Twenty-four patients were placed in supine position, followed by 25 degrees of Trendelenburg position. In each position, measurement of the anterior and lateral right internal jugular vein cross-sectional areas was obtained by using planimetry with the patient's head oriented at 0 degrees, 20 degrees, and maximum rotation. The largest cross-sectional areas were achieved in the lateral approach with the Trendelenburg position. In this position, no differences were detected among head rotation conditions. Data suggest that for those patients who tolerate the Trendelenburg position, the lateral access approach yields the statistically largest target area regardless of head rotation. When the Trendelenburg position is contraindicated, the results of this study suggest other approaches, e.g., the anterior approach, for central venous catheter placement that maximize the internal jugular vein area. IMPLICATIONS Central venous catheter insertion is commonly performed in the neck by using the right internal jugular vein. This study assesses factors affecting the cross-sectional area of this vein during central venous catheterization.
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Affiliation(s)
- Thomas Suarez
- Sinai Hospital of Baltimore, Johns Hopkins University, Maryland, USA.
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Harned RK, Kelly SS, Foreman NK, Giller RH. Peripheral placement of apheresis catheters in children: feasibility, safety, and efficacy in the collection of blood stem cells--initial experience. Radiology 2001; 218:294-8. [PMID: 11152818 DOI: 10.1148/radiology.218.1.r01ja21294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
An 8-F 24-cm-long apheresis catheter was placed in the basilic vein with imaging-guided percutaneous technique in 15 children undergoing leukapheresis for collection of autologous peripheral blood stem cells. There were no immediate or long-term complications. This is a low-morbidity procedure requiring minimal sedation that results in successful collection of peripheral blood stem cells and allows flow rates comparable to those with surgically placed central catheters.
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Affiliation(s)
- R K Harned
- Department of Radiology, University of Colorado Health Sciences Center and the Children's Hospital, 1056 E 19th Ave, Denver, CO 80218, USA.
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Sadler DJ, McCarthy M, Saliken JC, So CB, Klassen J, Selinger S, Gray RR. Image-guided central venous catheter placement for apheresis in allogeneic stem cell donors. J Clin Apher 2000; 15:173-5. [PMID: 10962469 DOI: 10.1002/1098-1101(2000)15:3<173::aid-jca3>3.0.co;2-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Peripheral blood stem cell harvest by apheresis is an increasingly important procedure utilized in the treatment of many malignancies. Whether autologous or allogeneic, it is frequently performed via peripheral access because of concern over major complications associated with central venous catheter placement. This study was to determine the safety and success, complications and premature failure rates for radiolocally placed ultrasound-guided non-tunneled central venous catheters placed for apheresis in a donor (allogeneic) population. One hundred central venous catheters were placed in ninety-one individuals for allogeneic stem cell harvest. Procedural success and complications relating to placement were noted in all. In 97 cases the number of needle passes required for venous cannulation and whether this was achieved with a single wall puncture was noted. Duration of catheterization and reason for removal were recorded in all cases. All catheters were placed by a right transjugular route. Venous cannulation and functioning line placement was achieved in every case; 92/97 (95%) required only a single needle pass and 84/97 (87%) only a single wall puncture. There were no placement related complications; 94 catheters were removed the same day with the remainder removed within 48 hr. All completed apheresis. Our study demonstrates the safe use of central venous catheters for apheresis in normal donors if ultrasound guidance is used for the puncture and the duration of catheterization is short.
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Affiliation(s)
- D J Sadler
- Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada.
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