Annoyed by Sonosite ad campaign

[gtb]

Went to news website today, and a Sonosite commercial played ending with the words, "And if they were not using ultrasound, I would find another doctor”.

This reminds me of the early days of Aspect Medical advertisements for BIS, and it seems that Sonosite is also pandering to patient's fears. I use ultrasound for 99% of my IJ lines, and our machines are Sonosite, but I have never used u/s for a subclavian line. To me, this ad seemed completely outrageous in giving the impression that placing a line without ultrasound is malpractice. Looking for other opinions on this.

http://www.youtube.com/watch?feature=player_embedded&v=Y13YBHHEEpM

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Members don't see this ad.

 

[PMPMD]

Went to news website today, and a Sonosite commercial played ending with the words, "And if they were not using ultrasound, I would find another doctor”.

This reminds me of the early days of Aspect Medical advertisements for BIS, and it seems that Sonosite is also pandering to patient's fears. I use ultrasound for 99% of my IJ lines, and our machines are Sonosite, but I have never used u/s for a subclavian line. To me, this ad seemed completely outrageous in giving the impression that placing a line without ultrasound is malpractice. Looking for other opinions on this.

http://www.youtube.com/watch?feature=player_embedded&v=Y13YBHHEEpM

For me, the jury's still out on US-guided SC lines. The article in CCM this summer was intriguing, but as I recall, their complication rate in the landmark group was sky high. It made me question their technique. There was an accompanying editorial that implied (or even stated outright) that US should e used for EVERY site, and that to even do studies of other sites (SC, fem, etc) would be unethical because US is SO safe that to not ise it would be harmful. I am just not seeing this personally. I think it's great for IJs. But I feel like it's conparing apples and oranges to study landmark SCs vs USG axillary lines. Because you have to go way lateral to get the view.

And yes, an ad that suggests US for non IJ lines is standard of care Is unfounded IMO.

 

[Bertelman]

I'm not at all convinced U/S is the standard of care for any central line. To make that claim insists that anyone NOT using U/S is breaching the standard. I just don't see it. Is it an improvement? Yes, probably, if the training is adequate. Am I reckless if I don't use it? Nope.

In 4 months at an academic powerhouse I have personally witnessed more IJ -> carotid sticks by residents under direct ultrasound guidance than I saw in my 3 years in residency where practically no one used ultrasound. It's basically occurring once a week in just the 2-3 ORs that i inhabit. Probably an incidence of like 5-10%

Frankly, I too am disgusted by these ads that use cheap emotional comparisons like "Using an ultrasound to place a central line is like the difference between driving down the highway with your eyes wide open and closed shut." Um, no, it's actually nothing at all like that, and I don't appreciate you oversimplifying a medical procedure just to make a few extra bucks on your machines.

 

[TrustMe]

Agree that U/S is not "standard" but if I have time and it is available I feel like it should be used. I also use it on IJ's in the ICU. I feel like if a pt. is sick enough to be in the ICU they don't need a complication from a line placement on top of their illness. That said, I don't think it is always indicated for femoral or SC lines. I only use it for femoral lines if the pt. is really fat or if they are coagulopathic. I have started using it more for SC lines but still prefer landmarks for those. I have used it for SC lines if I can see the chest pulsating under the clavicle or if I feel a prominent pulse when I palpate the landmarks. I still feel like everyone should be comfortable with U/S and landmark techniques for IJ's. U/S for when you have time and landmarks for urgent or emergent lines.

 

[seinfeld]

I hope you all realize that the ASA is putting language forward that US should be standard of care.

I you feel strongly i would send a message to the ASA.

 

[Frank Rizzo]

Was flipping back and fourth between a couple of college football games a week or two ago, and caught the very very end of a commercial that had the word "sonosite" on it. I almost doubted actually seeing it. "Are they actually advertising," I thought? I guess they are.

 

[jwk]

Agree that U/S is not "standard" but if I have time and it is available I feel like it should be used. I also use it on IJ's in the ICU. I feel like if a pt. is sick enough to be in the ICU they don't need a complication from a line placement on top of their illness. That said, I don't think it is always indicated for femoral or SC lines. I only use it for femoral lines if the pt. is really fat or if they are coagulopathic. I have started using it more for SC lines but still prefer landmarks for those. I have used it for SC lines if I can see the chest pulsating under the clavicle or if I feel a prominent pulse when I palpate the landmarks. I still feel like everyone should be comfortable with U/S and landmark techniques for IJ's. U/S for when you have time and landmarks for urgent or emergent lines.

This is going to be an issue in intubating as well. US for ALL central lines, glidescopes for ALL intubations. Stupid, stupid, stupid.

 

[Multifidus]

In 4 months at an academic powerhouse I have personally witnessed more IJ -> carotid sticks by residents under direct ultrasound guidance than I saw in my 3 years in residency where practically no one used ultrasound. It's basically occurring once a week in just the 2-3 ORs that i inhabit. Probably an incidence of like 5-10%.

That sounds crazy. Don't mean to offend, but perhaps they aren't being taught or supervised appropriately.

 

[foxtrot]

That sounds crazy. Don't mean to offend, but perhaps they aren't being taught or supervised appropriately.

Exactly. As someone who trained with U/S, I don't see how that is possible. And if you are unsure, put color on the doppler and you can easily see which is which. I personally love U/S. It just depends on how you trained. I think I am faster with U/S than I would be just poking around. But there are some people who have been doing it for decades without US and they feel U/S slows them down, and it probably does. All depends how you were trained. Maybe if I had trained on skinny patients, I would have been better without U/S, but since most of the patients I take care of have a BMI >40, U/S is a God send.

 

[Bertelman]

That sounds crazy. Don't mean to offend, but perhaps they aren't being taught or supervised appropriately.

No offense taken

Exactly. As someone who trained with U/S, I don't see how that is possible. And if you are unsure, put color on the doppler and you can easily see which is which. I personally love U/S. It just depends on how you trained. I think I am faster with U/S than I would be just poking around. But there are some people who have been doing it for decades without US and they feel U/S slows them down, and it probably does. All depends how you were trained. Maybe if I had trained on skinny patients, I would have been better without U/S, but since most of the patients I take care of have a BMI >40, U/S is a God send.

It's not a question of identifying which vessel is which. If you don't know what you are looking at, you shouldn't be sticking. Besides, our dopplers don't have color, so that's not really an option. It's a question of following the needle, which they don't appear to do very well. I agree it is a matter of training, but unfortunately I'm not exactly responsible for that. Maybe that needs to change.

 

[epidural man]

Went to news website today, and a Sonosite commercial played ending with the words, "And if they were not using ultrasound, I would find another doctor”.

This reminds me of the early days of Aspect Medical advertisements for BIS, and it seems that Sonosite is also pandering to patient's fears. I use ultrasound for 99% of my IJ lines, and our machines are Sonosite, but I have never used u/s for a subclavian line. To me, this ad seemed completely outrageous in giving the impression that placing a line without ultrasound is malpractice. Looking for other opinions on this.

http://www.youtube.com/watch?feature=player_embedded&v=Y13YBHHEEpM

You would think that the huge backlash that BIS got (followed by intense hatred for the product despite its obvious advantages) would have taught other companies how to behave......apparently not. Sonosite my pay for this the way BIS makers did.

It is too bad, since they make a great product.

 

[foxtrot]

It's not a question of identifying which vessel is which. If you don't know what you are looking at, you shouldn't be sticking. Besides, our dopplers don't have color, so that's not really an option. It's a question of following the needle, which they don't appear to do very well. I agree it is a matter of training, but unfortunately I'm not exactly responsible for that. Maybe that needs to change.[/QUOTE]

Aren't any of the staff teaching them what the vessels look like? Even if you don't have dopplers, you can still identify the vessels (arteries are not compressible). But you are right, someone does need to teach you those things. That is a shame. Do you do any resident teaching?

 

[sevoflurane]

OMG. Really? 5-10%? They need better supervision. Tell 'em to go slow the first 10 times... And guide them in as they tent the skin with their needle.... You can see if your vector is on the right tract this way. Heck, hold the USD for them the first couple of times.

In 100 sticks, I might use color in one of them. It is not hard to tell what is artery (pulsating thingy) and Vein (squishy-squishy).

USD is Faaaaaaaaar superior to land mark/blind stick (IMHO).

No question.... unless you need it supa fast... in which case it is still nice to have if things don't go smoothly.

As for sonosties remarks.... Unprofessional and untrue. You still need to know how to place one if it breaks down.

USD machines for regional/vascular access is huge compared to 10 years ago and more and more anesthesia departments realize it's usefulness, safety and efficiency.

Definitely NOT standard of care. That is just silly.

 

[periopdoc]

In 4 months at an academic powerhouse I have personally witnessed more IJ -> carotid sticks by residents under direct ultrasound guidance than I saw in my 3 years in residency where practically no one used ultrasound. It's basically occurring once a week in just the 2-3 ORs that i inhabit. Probably an incidence of like 5-10%

That is ridiculously high. In 4 years residency and 1 year fellowship our (rather large) program had less than a half dozen of these. Sadly, it was almost entirely predictable which residents were going to have the complication.

I suspect it is not a case of mis-identifying the IJV/Carotid and more of going through and through the IJV and into the Carotid.

Maybe you could suggest to your PD that a formal educational curriculum should be established for placement of U/S guided central lines. (sounds like a qualifying academic project to me).

- pod

 

[Bertelman]

Aren't any of the staff teaching them what the vessels look like? Even if you don't have dopplers, you can still identify the vessels (arteries are not compressible). But you are right, someone does need to teach you those things. That is a shame. Do you do any resident teaching?

The vessels are being identified, but at some point between identification and flash, things go wrong. I do resident teaching when I can, but I am often second in command.

 

[Bertelman]

That is ridiculously high. In 4 years residency and 1 year fellowship our (rather large) program had less than a half dozen of these. Sadly, it was almost entirely predictable which residents were going to have the complication.

I suspect it is not a case of mis-identifying the IJV/Carotid and more of going through and through the IJV and into the Carotid.

Maybe you could suggest to your PD that a formal educational curriculum should be established for placement of U/S guided central lines. (sounds like a qualifying academic project to me).

- pod

Agree with pretty much everything here. Let me qualify this by stating these are carotid sticks, not cannulations or wires. If you are talking about 5 years at your program with <6 incidences of people finding the carotid, I find that hard to believe, but I guess it could be the case with excellent training. I may be overstating the 10% incidence where I am, but it's not far off from 5%. Either way, it occurs a couple times per month just in the three rooms that I haunt.

 

[BobBarker]

Have them find the vessels in cross section, then tilt the probe 45 degrees as if the probe is pointing at the heart. Gain access with lateral entry, keeping the needle in plain. View will be similar to cross section view but the entire needle will be visualized.

 

[periopdoc]

I am talking cannulations and that would be a combination of U/S guided and anatomic non- U/S guided, I just don't remember how many of each.

In terms of just sticks, I can only speak to the rooms where I was in attendance as a resident/fellow/attending and I have never seen a needle or wire placed into the carotid (I am sure it happened in other rooms).

I did help one of my residents place the wire into the IJ and then I left the room to help start another room and the attending took over. During placement of the cordis, it ended up in the subclavian artery. The tip of the wire was still in the IJ, but the resident bent the mid-portion of the wire as he was placing the line and took a path parallel to the IJ. (big fat floppy neck tissue)

It sounds to me like some basic U/S training is in order. Cross section. Identify vessels. Move head to get carotid away from IJ if possible. IJ in middle of screen. Look at hands and place needle tip right in the middle of the probe. Insert through skin. +/- long axis view. Watch needle tip tent superficial wall of IJ then jab. Aspirate. Withdraw slightly while watching deep wall of IJ. If the deep wall "tents" as you start to withdraw, withdraw until the deep wall pops back into place then flatten out the needle and advance 1-2 cm. Withdraw slightly and watch posterior wall of IJ. Repeat until posterior wall no longer tents on withdrawal then pass wire. Confirm wire placement in IJ in SAX/LAX prior to dilating.

(Sure you don't need that Bert, but thought I would toss it in for any new folks who happen across this thread)

- pod

 

[proman]

My residents really struggle with US guided lines (mostly because I'm one of the few who has them use US). I had a resident successfully cannulate the IJ (we did poor man CVP pressure transduction). Then I had him visualize the wire in the vein. Sure enough it was in and out the IJ and into the carotid. I really regret not taking a picture of that.

 

[periopdoc]

Classic, I wish you had a picture of that too. That is what I love about cardiac cases where I am using TEE. Throw in the probe before doing the IJ cannulation then watch for the wire in the right atrium.

- pod

 

[Bertelman]

I am talking cannulations and that would be a combination of U/S guided and anatomic non- U/S guided, I just don't remember how many of each.

That makes more sense. During my 3 years of residency, Exactly 2 people (n=15) in ANY class advanced a guidewire or dilator into carotid territory. I imagine your residency classes were 3-4 times the size of mine, so our numbers tend to agree. However, I trained at a place where U/S was used only rarely. We didn't even have a machine dedicated to the purpose. We would borrow vascular's machine, or the block team.

 

[Bertelman]

It sounds to me like some basic U/S training is in order. Cross section. Identify vessels. Move head to get carotid away from IJ if possible. IJ in middle of screen. Look at hands and place needle tip right in the middle of the probe. Insert through skin. +/- long axis view. Watch needle tip tent superficial wall of IJ then jab. Aspirate. Withdraw slightly while watching deep wall of IJ. If the deep wall "tents" as you start to withdraw, withdraw until the deep wall pops back into place then flatten out the needle and advance 1-2 cm. Withdraw slightly and watch posterior wall of IJ. Repeat until posterior wall no longer tents on withdrawal then pass wire. Confirm wire placement in IJ in SAX/LAX prior to dilating.

(Sure you don't need that Bert, but thought I would toss it in for any new folks who happen across this thread)

- pod

Exactly.

 

[PMPMD]

I am talking cannulations and that would be a combination of U/S guided and anatomic non- U/S guided, I just don't remember how many of each.

In terms of just sticks, I can only speak to the rooms where I was in attendance as a resident/fellow/attending and I have never seen a needle or wire placed into the carotid (I am sure it happened in other rooms).

I did help one of my residents place the wire into the IJ and then I left the room to help start another room and the attending took over. During placement of the cordis, it ended up in the subclavian artery. The tip of the wire was still in the IJ, but the resident bent the mid-portion of the wire as he was placing the line and took a path parallel to the IJ. (big fat floppy neck tissue)

It sounds to me like some basic U/S training is in order. Cross section. Identify vessels. Move head to get carotid away from IJ if possible. IJ in middle of screen. Look at hands and place needle tip right in the middle of the probe. Insert through skin. +/- long axis view. Watch needle tip tent superficial wall of IJ then jab. Aspirate. Withdraw slightly while watching deep wall of IJ. If the deep wall "tents" as you start to withdraw, withdraw until the deep wall pops back into place then flatten out the needle and advance 1-2 cm. Withdraw slightly and watch posterior wall of IJ. Repeat until posterior wall no longer tents on withdrawal then pass wire. Confirm wire placement in IJ in SAX/LAX prior to dilating.

(Sure you don't need that Bert, but thought I would toss it in for any new folks who happen across this thread)

- pod

Agree, especially w/ bold

 

[Multifidus]

Does anybody have any good references on how to place subclavians using the U/S? As a fan of U/S, I would love to learn how to do this because I seem to be particularly lucky at sticking the subclavian artery from time to time...

 

[PMPMD]

Does anybody have any good references on how to place subclavians using the U/S? As a fan of U/S, I would love to learn how to do this because I seem to be particularly lucky at sticking the subclavian artery from time to time...

To be technically correct, it's an axillary vein line, not a subclavian. To get the US view, you end up going much more laterally than a landmark SC.

-------------------------------------------------------------------------------

Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: A prospective randomized study*

Mariantina Fragou, MD; Andreas Gravvanis, MD, PhD; Vasilios Dimitriou, MD, PhD; Apostolos Papalois, MD, PhD; Gregorios Kouraklis, MD, PhD; Andreas Karabinis, MD, PhD; Theodosios Saranteas, MD, DDS, PhD; John Poularas, MD; John Papanikolaou, MD; Periklis Davlouros, MD, PhD; Nicos Labropoulos, MD, PhD; Dimitrios Karakitsos, MD, PhD

Objective: Subclavian vein catheterization may cause various complications. We compared the real-time ultrasound-guided subclavian vein cannulation vs. the landmark method in critical care patients.

Design: Prospective randomized study.

Setting: Medical intensive care unit of a tertiary medical center. Patients: Four hundred sixty-three mechanically ventilated pa-
tients enrolled in a randomized controlled ISRCTN-registered trial (ISRCTN-61258470).

Interventions: We compared the ultrasound-guided subclavian vein cannulation (200 patients) vs. the landmark method (201 pa- tients) using an infraclavicular needle insertion point in all cases. Catheterization was performed under nonemergency conditions in the intensive care unit. Randomization was performed by means of a computer-generated random-numbers table and patients were strat- ified with regard to age, gender, and body mass index.
Measurements and Main Results: No significant differences in the presence of risk factors for difficult cannulation between the two groups of patients were recorded. Subclavian vein cannulation was
achieved in 100% of patients in the ultrasound group as compared with 87.5% in the landmark one (p < .05). Average access time and number of attempts were significantly reduced in the ultrasound group of patients compared with the landmark group (p < .05). In the landmark group, artery puncture and hematoma occurred in 5.4% of patients, respectively, hemothorax in 4.4%, pneumothorax in 4.9%, brachial plexus injury in 2.9%, phrenic nerve injury in 1.5%, and cardiac tamponade in 0.5%, which were all increased compared with the ultrasound group (p < .05). Catheter misplacements did not differ between groups. In this study, the real-time ultrasound method was rated on a semiquantitative scale as technically difficult by the participating physicians.

Conclusions: The present data suggested that ultrasound- guided cannulation of the subclavian vein in critical care patients is superior to the landmark method and should be the method of choice in these patients. (Crit Care Med 2011; 39:1607–1612)

KEY WORDS: subclavian vein cannulation; technique; ultrasound; critical care

 

[dhb]

In the landmark group, artery puncture and hematoma occurred in 5.4% of patients, respectively, hemothorax in 4.4%, pneumothorax in 4.9%, brachial plexus injury in 2.9%, phrenic nerve injury in 1.5%, and cardiac tamponade in 0.5%

I think this study is trying to tell us that monkeys should not place subclavian lines

 

[PMPMD]

I think this study is trying to tell us that monkeys should not place subclavian lines

Yes this was a huge point that was brought up when we discussed this article in journal club.

 

[OB1🤙]

LOL @ tamponade from a subclavian.

 

[Socrates25]

Why are Dr Myron Shabot and Dr Mayank Patel of Cedars-Sinai and UT Memorial Herman whoring thsemselves out for an ultrasound company? How many thousands of dollars did they get paid to make this silly commercial?

I'm gonna dig up their emails and ask them if they tell their patients that they are hookers for Sono-Site and thats why their residents will use it as part of the central line placement process.

 

[MTGas2B]

I don't have a gray hair yet, but ultrasound for subclavians seems not very helpful. The few times I've tried to visualize the subclavian on u/s the view isn't that good. I've done a fair number of subclavian, all I did this summer. The landmarks are so much more consistant than IJs I don't really see advantage.

Looking at that paper I echo the above, their complications seem crazy high. Was this the Helen Keller center for medical education? I can buy the 87.5% success rate. I also can't buy the time savings. If you can get a subclavian by landmarks you can get wire in way faster.

I guess I'm already becoming an old timer.