Central lines, routinely with or without ultrasound?

[secretasianman]

Hi everyone, when you guys put in your lines, do you use ultrasound, or go purely by landmarks? As an intern in the unit I've only done them with ultrasound. I recently asked this to one of the anesthesia residents at the hospital I work in, who said their attendings prefer they always use ultrasound. Is this the norm?

---

Members don't see this ad.

 

[Mman]

While knowing how to put in lines rather deftly without ultrasound, I confess to always using it for IJs. It adds about 30 seconds of extra setup time with opening the sterile probe cover/gel and covering up the probe, but I think in the fewer needle passes that I make that the time is ultimately not an issue.

I also think that at some point in the not too distant future that it will be considered standard of care. Whether or not it should is open for debate, but most people do not deny that is the way it seems to be heading.

 

[Dejavu]

Our institution, a relatively well known Clinic in Rochester Minnesota, is about to mandate live US use for IJ central lines placed anywhere in the institution.

 

[sevoflurane]

It is also THE WAY TO GO if you are putting in awake lines for any reason. IMHO. I was doing one last friday where the caliber of the IJ went from reasonable to literally nothing with spontaneous ventilation (patient was dry).

I think that if patients knew your options, they would always ask for USD guidence. I certainly would rather get one vs. two or three or four sticks.

That being said, in an urgent situation, you gottsta be able to throw one in quick w/o USD.

 

[aneftp]

Our institution, a relatively well known Clinic in Rochester Minnesota, is about to mandate live US use for IJ central lines placed anywhere in the institution.

When I finished in 2004 with my training, routine U/S just started being used.

With that said, it will become extremely dangerous if residents are not taught the tried and true method. They need to learn how to use basic anatomical skills.

While U/S has proven to be much more successful, what happens in an emergency situation when no ultrasound is available? If you were never taught how to how to do IJ's without U/S, how are going to do it in an emergency situation?

So teach U/S for central lines, but residents need to be taught how to use their basic anatomy skills to place IJ's. You never know what situations/institutions where U/S isn't routinely available or the devices are available to someone else is using it at the same time you need it.

 

[UTSouthwestern]

Have never used ultrasound for lines and I've put in few thousand in private practice. It is useful to have, but for us, wastes time especially if you know your landmarks and have 2 or more lines to put in on top of TEE and positioning. Good tool but as previous poster said, become the expert without it first.

 

[seinfeld]

Agree with aneftp on this one. I think in anesthesia where you are more likely to be doing them emergently than most knowing how to do them blind is important. I basic rule is that when i am working in ICU everyone is done with US live guidance. In the OR anyone with coaguopathy, or in whom i hit the carotid more than once with a finder (rare) gets real time US guidance.

 

[tucker27705]

Things transitioned during my training from not using U/S to always using U/S unless you were with an attending who really wanted you to do it without.
I got very good at both methods.
Now in PP, and honestly, in 2 years I've done prob less than 10 central lines. All but one was without U/S and they all went in on 1 or 2 sticks. The one time I asked for U/S was when the wire would not pass despite good flow from both the R and L IJ sticks. Ended up doing a subclav.
I would say I wish I had done more sub clavian lines as a resident. They seem to be the norm here, but 98% of my lines were IJ's as a resident so I don't feel that comfortable doing the SC's.
I think that for training, I can see the benefit of U/S. It is way safer, and when you are supervising it has to put your heart at rest to be able to see what your resident is actually doing on his/her first several central lines.
That being said, I'm going to keep doing the rare central line without U/S unless there seems to be some trouble brewing or I anticipate difficulty for some reason.
Tuck

 

[jdh71]

I also think that at some point in the not too distant future that it will be considered standard of care.

Wether or not U/S was used is part of the central line "bundle" these days, as in, if you don't use it, you have to say explain why. Sounds like it's SOC as far as anyone important is concerned.

 

[Noyac]

Have never used ultrasound for lines and I've put in few thousand in private practice. It is useful to have, but for us, wastes time especially if you know your landmarks and have 2 or more lines to put in on top of TEE and positioning. Good tool but as previous poster said, become the expert without it first.

Agreed.

I will use it for the awake lines on occasion, however. But I rarely place lines in awake pts.

 

[Noyac]

Wether or not U/S was used is part of the central line "bundle" these days, as in, if you don't use it, you have to say explain why. Sounds like it's SOC as far as anyone important is concerned.

Really?
Be careful what you call SOC.

 

[aneftp]

Really?
Be careful what you call SOC.

I agree. There are very few "standards of care" in anesthesia.

Just ask any of your colleagues what's considered a standard of care in anesthesia. Short of the basic monitoring for anesthesia cases, I can't think of any other standard of care.

Everything we go by is a "guideline" which is completely different than a standard of care.

 

[jdh71]

Really?
Be careful what you call SOC.

*I* didn't call anything SOC. What I'm saying is that these "line bundles" that are all part of the joint commision folks' idea of what should be done with any central line, include a questionaire (apparently replaces the procedure note), which asks if you've use the U/S, and if not, why. If that does not mean it ends up being de facto SOC, then I'm willing to hear how I'm wrong in my thinking about this.

I would also imagine documented: "emergent line needed, no time for U/S" would be a legitimate reason not to use it.

 

[gaspasser2004]

During my residency (2005-2008), there was a transition in my institution from landmarks to ultrasound when placing IJ's. Towards the end of my residency, I used ultrasound exclusively when placing IJ lines.

Unfortunately, I think there is a cowboy mentality in anesthesia that leads people to abandon practices that are safer for patients. There is clear evidence that ultrasound is safer and ultimately quicker than landmarks for IJ placement (A. Kumar, A. Chuan / Best Practice & Research Clinical Anaesthesiology 23 (2009) 299–311. sorry, no link to free PDF version).

Hospitals that do not have ultrasound machines should not be taking care of a patient population that requires IJ access. In an emergency, there are alternative sites for central access (subclavian, femoral) that are safer to perform without ultrasound. I don't think it is ethical to subject a real, live patient to an inferior technique so someone can learn how to do IJ's without ultrasound.

I understand that there are many posters on this forum who have done thousands of IJ lines without ultrasound. This doesn't mean that their technique is ultimately better than using ultrasound.

 

[sevoflurane]

Have never used ultrasound for lines and I've put in few thousand in private practice. It is useful to have, but for us, wastes time especially if you know your landmarks and have 2 or more lines to put in on top of TEE and positioning. Good tool but as previous poster said, become the expert without it first.

I know you are da bomb UT and you have far more experience than I do. 😎

Here is how I see it:

It depends on your set up. By the time I'm done placing TEE/gown/glove and get back to the head of the bed, the scrub nurse has draped and placed the USD probe over the IJ in sterile fashion. Absolutely no time wasted. Not a second. I have gained a little bit of safety.

If your resources are such that this is not possible, then it can delay your placement of central access. But not by much. If you have another subclavian to place for the ICU, then that is two central lines and an a-line + TEE to place and read. I fully understand your position. It will probably just get in the way. Fact is, you were in residency when I was a medical student and training is different now days.

I see parallels to regional anesthesia. By the end of residency my colleagues and I really had to present a good reason why NOT to use USD with regional blocks.

I bet there are some residents that are graduating who do not feel comfortable with their skills when doing an interscalene w/o USD. It's becoming a lost art in some institutions that are firm believers in USD guided regional anesthesia.

Personally, I'm all for it. I think it's fun to use USD. If you do enough of them, it will pay for your sonosite and add a margin of safety.

I think it's a good idea to know and practice with both techniques and not to discount one way over the other.

I also think that those who have placed thousands of central lines can do it with their hands tied behind their backs. 🙂

 

[urge]

Have never used ultrasound for lines and I've put in few thousand in private practice. It is useful to have, but for us, wastes time especially if you know your landmarks and have 2 or more lines to put in on top of TEE and positioning. Good tool but as previous poster said, become the expert without it first.

The ASA is getting ready to put out a practice guideline where they basically say not using live ultrasound is bad medicine, no questions asked. They are aware many groups don't have that many ultrasound machines but they don't care. Their reply is "they are going to have to buy them".

Is the ASA really representing you?

Everybody should write them an email about this.

 

[starsop93]

Started practice around 4 yrs ago, having rarely used US except in difficult situations in residency and fellowship. I have done a LOT of lines and for over 2 yrs I rarely used it. Unfortunately, when I needed it, it took several minutes to find the damn Sonosite and usually a hell of a lot of talking with the nurses to explain what they needed to do so I could use it. After an 2nd accidental carotid stick in a 3 month period (not dilation mind you) after not having one since training, I decided I would use it routinely for a month or so to make sure I didn't do it again. It became so routine and simple to just have it in there every morning, that, while it ultimately took 30 sec to a minute longer with each line, I never had those 5-10 minute periods to look for it and set it up when I struggled. Having used it pretty much exclusively since then, I can tell you the variation in the Rt IJ is pretty large. I'm frequently amazed how small some can be, how lateral, or how often they lie practically on top of the carotid. I'm shocked I didn't have more trouble than I did, before I used it routinely. I will say, on the downside, when I have to put one in without the US now, it doesn't seem as easy as it used to be...

Bottom line: US use is safer and easier, takes a non-significantly longer time per patient, and probably should be standard of care.

 

[gaspasser2004]

I think it's a good idea to know and practice with both techniques and not to discount one way over the other.

I also think that those who have placed thousands of central lines can do it with their hands tied behind their backs. 🙂

But the evidence clearly shows that using ultrasound for IJ lines is superior. Why would you want to use an inferior technique? Just to prove that you can?

As I stated before, there are many posters on this forum who have done thousands of IJ's without ultrasound - this doesn't mean they are doing it right. There were a lot of really good practitioners who scoffed at the seldinger technique because they were deft at doing cutdowns. There were a lot of general surgeons who thought laparoscopic anything would never be as good as their open technique.

I believe that the evolving evidence will soon make ultrasound guidance for IJ's standard of care.

 

[Sergio99]

I think that if patients knew your options, they would always ask for USD guidance.

Yes, and they do ask for it. "Don't you have an ultrasound?" "Why don't you use ultrasound?" "I have never had this done without ultrasound," "...at my other hospital they always used ultrasound," etc.

It is also THE WAY TO GO if you are putting in awake lines for any reason.

It is the way to go whether the patient is awake or not. At my hospital they do thousands of lines, and most of them without ultrasound, but some people are learning to use it routinely after some big disasters. Why wait for disaster to strike before you decide to do it right?

Starsop93 said it eloquently:

Started practice around 4 yrs ago, having rarely used US except in difficult situations in residency and fellowship. I have done a LOT of lines and for over 2 yrs I rarely used it. Unfortunately, when I needed it, it took several minutes to find the damn Sonosite and usually a hell of a lot of talking with the nurses to explain what they needed to do so I could use it. After an 2nd accidental carotid stick in a 3 month period (not dilation mind you) after not having one since training, I decided I would use it routinely for a month or so to make sure I didn't do it again. It became so routine and simple to just have it in there every morning, that, while it ultimately took 30 sec to a minute longer with each line, I never had those 5-10 minute periods to look for it and set it up when I struggled. Having used it pretty much exclusively since then, I can tell you the variation in the Rt IJ is pretty large. I'm frequently amazed how small some can be, how lateral, or how often they lie practically on top of the carotid. I'm shocked I didn't have more trouble than I did, before I used it routinely. I will say, on the downside, when I have to put one in without the US now, it doesn't seem as easy as it used to be...

Bottom line: US use is safer and easier, takes a non-significantly longer time per patient, and probably should be standard of care.

Starsop93's post reminds me of my experience with epidural steroid injections. When I started doing them routinely with fluoroscopy and epidurograms I was amazed to see how often they seem to be in the right place and they are not.

Greetings

 

[Mman]

As far as I can tell, there are only 2 possible downsides against routinely using an ultrasound for placement of an IJ line.

1) Time. If you aren't facile with the ultrasound, it takes longer to get it all set up and put a probe cover on and what not. With a little practice you can get that time down to almost nothing with some planning. How many lines do you put in that are truly emergent without seconds to spare? Maybe slamming one in the middle of a case if they just ripped the aorta in half unintentionally, but that's pretty rare. Even for major traumas, you know the patient is coming at least 5 minutes ahead of time. For anything that I'm planning ahead of time, I just go track down the ultrasound, wheel it into the room in a good location for me and plug it in and turn it on. Then when I'm opening the central line kit I just drop on the packet with the sterile probe cover and gel and it adds maybe 10 seconds to the process to put the probe cover on. If I'm shorthanded, I can even do it unassisted by leaving the ultrasound probe in the holder facing up and dropping nonsterile gel on it before I get sterile and then picking it up with the probe cover by dropping it down on to the probe.

The bottom line is that time doesn't really factor into it 99% of the time.

2) Cost. Ultrasound machines are expensive. No denying that. The good ones are even pricier. However, in the longrun the cost is probably at least balanced out by the reduced number of complications and the slight bump in reimbursement.

$$$ are important to everybody and I won't deny that.

I just like the fact that we have ultrasound machines and that it decreases my chances of poking a hole in the carotid without slowing me down.

 

[dhb]

Honestly most IJ's are straightforward one stick procedures. For lines under GA i don't use US although i have a low threshold for popping the machine in the room after one try at the IJ and the SC.

For awake patients (we put the central lines for the patients from the wards) i'll do a US scan since they are frequently hypovolemic or have had multiple lines. If it looks like a hard stick i'll use US or else not.

Everything has it's indication, mandatory US for lines is dumb except for the "less skilled" providers.

 

[sevoflurane]

Why would you want to use an inferior technique? Just to prove that you can?

I don’t think so. I do it to maintain my versatility as an anesthesiologist. I don't ever want to rely on a machine in order to perform my job (exception anesthesia machine 😉). If I go to a new hospital that can' fork out 40K for a sonosite, then I transition easily. As, I said: I like using USD, and I use it all the time. However, I don't ever want it to be my achilles heel.

Why wait for disaster to strike before you decide to do it right?

I hear you Sergio. It can be very advantageous in the disaster case. No quesiton. I would prefer to place a line with USD in disaster cases.
Here is my point, however: Not preparing is preparing to fall. Land mark technique is my contingency plan in case a sonosite is not available to me for whatever reason.

Had a GSW come in about a month and a half ago. Too unstable to transfer. Roll through the ED door, systolics in the 40’s. Sonosite upstairs in the OR “on it’s way down”. First unit half way in before the Sonosite arrived. Yes, I could have waited, but maybe my patient couldn't.

I still do 85% of my neck lines with USD. But until it is standard of care, I don’t mind doing it the "old fashioned" way from time to time. A finder needle is not that invasive and often you can see venous pulsations that will home you in on your target.

I find that it’s biggest utility is in obtaining central access in pediatric hearts where you need a CVP and have small targets that you don’t want to muck up even on the first pass. Getting a femoral a-line in this population can be trying. I clocked like 30 pedi hearts during residency and found that USD is a must for these cases. I don’t know how anesthesiologists used to do it in the old days. They did get it done however. 🙄

I think that teaching institutions that are teaching USD only techniques are doing a diservice to their residents.
You can make an argument that regional anesthesia should be done with USD only. The brachial plexus has a lot of dangerous territory to be injecting 20cc's of .5% marcaine, yet most people still use traditional landmark techniques. I see a double standard here.

Again, I do nearly all my blocks with USD. I think it's safer and easier. But, I will do landmark techniques from time to time.

 

[IN2B8R]

Hi everyone, when you guys put in your lines, do you use ultrasound, or go purely by landmarks? As an intern in the unit I've only done them with ultrasound. I recently asked this to one of the anesthesia residents at the hospital I work in, who said their attendings prefer they always use ultrasound. Is this the norm?

U/S allows visualization, while other techniques utilize "anatomical" landmarks. Problem is, there is not a standard "anatomical patient." Nevermind all the pathology that exists out there: thrombosed IJ's, etc.... Use the U/S if you have it. Be safe.

 

[Noyac]

*I* didn't call anything SOC. What I'm saying is that these "line bundles" that are all part of the joint commision folks' idea of what should be done with any central line, include a questionaire (apparently replaces the procedure note), which asks if you've use the U/S, and if not, why. If that does not mean it ends up being de facto SOC, then I'm willing to hear how I'm wrong in my thinking about this.

I would also imagine documented: "emergent line needed, no time for U/S" would be a legitimate reason not to use it.

Don't get too fired up. I just read the comment you posted "Sounds like it's SOC as far as anyone important is concerned." And thought you were agreeing that it was SOC.

 

[Noyac]

Unfortunately, I think there is a cowboy mentality in anesthesia that leads people to abandon practices that are safer for patients. There is clear evidence that ultrasound is safer and ultimately quicker than landmarks for IJ placement (A. Kumar, A. Chuan / Best Practice & Research Clinical Anaesthesiology 23 (2009) 299–311. sorry, no link to free PDF version).

What is FANCAZ? I read it as an anesthetist in New Zealand and Australia. Are they doctors?

Either way, they are in training at the facility that published this article. You need to be careful calling an article that comes from training facility SOC. US may be safer in the hands of trainees but is it safer in the hands of seasoned veteran physicians?

 

[pgg]

If getting the u/s wasn't such an ordeal at one of my hospitals (at that place we have to borrow the machine from the OB clinic fer chrissakes) I'd probably use it every time.


I rarely place IJs in awake patients these days, but when I do I make a point of at least scouting the anatomy with u/s beforehand. Unless something is aberrant I won't do the sterile sleeve real-time placement thing - just a mark on the neck where the IJ is, prep/drape/etc, needle, angiocath, transduce, dilate, etc.

Ultrasound wasn't routinely available when I was learning to place lines and easily 90%+ of the IJs I've done have been without it. I was taught to always transduce before dilating. A carotid stick with a 22g finder needle isn't something to be happy about, but it's not the disaster a dilated carotid is. Transducing is easy and takes seconds; a poor-man's CVP with a length of tubing doesn't even need a monitor.

The two carotid dilations I've witnessed were done by people who didn't use u/s and didn't transduce. I know there are some experienced guys who are comfortable looking at dark non-pulsatile blood and then dilating, but I'm not.

 

[Jay K]

ExCellent discussion. I trained first in anatomical landmark placement then ultrasound. Currently I place all my CVL and nerve blocks under real time u/s. Since I already have it for my CVL in cardiac cases, I've even begun using it for my Aline first (it's very handy for Afib-ing pts with diff palpable pulses). It's amazing the amount of anatomical variation, size and clotted or stenosed vessels I've seen which likely would have resulted in bad lines or non-threading difficulties. My partners for the most part seldom use the u/s, which is good because I have it at my disposal more often. I really should promote it less. The only unfortunate thing is I haven't been billing for u/s guidance bc we don't have the print photo documentation setup.

 

[sevoflurane]

ExCellent discussion. I trained first in anatomical landmark placement then ultrasound. Currently I place all my CVL and nerve blocks under real time u/s. Since I already have it for my CVL in cardiac cases, I've even begun using it for my Aline first (it's very handy for Afib-ing pts with diff palpable pulses). It's amazing the amount of anatomical variation, size and clotted or stenosed vessels I've seen which likely would have resulted in bad lines or non-threading difficulties. My partners for the most part seldom use the u/s, which is good because I have it at my disposal more often. I really should promote it less. The only unfortunate thing is I haven't been billing for u/s guidance bc we don't have the print photo documentation setup.

You can actually have it stored on your Sonosite and have it trasmitted electronically to your hospital imaging service (WiFi). No paperwork/photo to staple to the chart. Have your crew enter the patients name and MRN into your machine, get a post block or line view, freeze, save and voila, you are done. Much easier than printing and stapling to the chart. I did the photo thingy during residency.... electronic is much better IMHO.

 

[Noyac]

ExCellent discussion. I trained first in anatomical landmark placement then ultrasound. Currently I place all my CVL and nerve blocks under real time u/s. Since I already have it for my CVL in cardiac cases, I've even begun using it for my Aline first (it's very handy for Afib-ing pts with diff palpable pulses). It's amazing the amount of anatomical variation, size and clotted or stenosed vessels I've seen which likely would have resulted in bad lines or non-threading difficulties. My partners for the most part seldom use the u/s, which is good because I have it at my disposal more often. I really should promote it less. The only unfortunate thing is I haven't been billing for u/s guidance bc we don't have the print photo documentation setup.

I didn't want to mention this earlier but I've seen some people (locums mostly who couldn't get an A-line in) use US for A-lines. What next, will it be considered SOC by even newer younger anesthesiologists to use US for A-lines?

 

[dhb]

I didn't want to mention this earlier but I've seen some people (locums mostly who couldn't get an A-line in) use US for A-lines. What next, will it be considered SOC by even newer younger anesthesiologists to use US for A-lines?

I was called to the ED last time on call to place an iv ina 5y/o with burns to one arm and both legs. Of course the AC was already blown and i had nothing in the hand so i took the US to get the AC distal to the initial puncture.

It was the first time i use US to get an iv but it was the right time.

 

[Noyac]

I was called to the ED last time on call to place an iv ina 5y/o with burns to one arm and both legs. Of course the AC was already blown and i had nothing in the hand so i took the US to get the AC distal to the initial puncture.

It was the first time i use US to get an iv but it was the right time.

Great, now it will be SOC for PIV's.

 

[Sergio99]

Hello,

Great, now it will be SOC for PIV's.

Don't laugh, patients are already asking for it.

What is FANCAZ? I read it as an anesthetist in New Zealand and Australia. Are they doctors?

It is not FANCAZ, but FANZCA, Fellow of the Australian and New Zealand College of Anaesthestists, and yes, they are physicians, very good ones, very well trained, UK style. As far as I know, the United States is the only country in the world that has non-physicians practicing medicine.


Greetings

 

[Planktonmd]

Ultrasound guided IJ access is safer only in the hands of inexperienced people and trainees.
Also I wouldn't go as far as saying that blind subclavians are safer than blind IJ's!
What makes you think that?

During my residency (2005-2008), there was a transition in my institution from landmarks to ultrasound when placing IJ's. Towards the end of my residency, I used ultrasound exclusively when placing IJ lines.

Unfortunately, I think there is a cowboy mentality in anesthesia that leads people to abandon practices that are safer for patients. There is clear evidence that ultrasound is safer and ultimately quicker than landmarks for IJ placement (A. Kumar, A. Chuan / Best Practice & Research Clinical Anaesthesiology 23 (2009) 299–311. sorry, no link to free PDF version).

Hospitals that do not have ultrasound machines should not be taking care of a patient population that requires IJ access. In an emergency, there are alternative sites for central access (subclavian, femoral) that are safer to perform without ultrasound. I don't think it is ethical to subject a real, live patient to an inferior technique so someone can learn how to do IJ's without ultrasound.

I understand that there are many posters on this forum who have done thousands of IJ lines without ultrasound. This doesn't mean that their technique is ultimately better than using ultrasound.

 

[urge]

I put the eye tape under ultrasound guidance. Eyelashes must be aligned 40 degrees lateral to the line between the epicantal fold and the color signal from the retinal artery. I found that my patients wake up with less nausea and the chance of awareness is nearly zero.

 

[Mman]

While I believe that ultrasound is safer than landmark based techniques, the evidence is a bit lacking at this point for many reasons. The last time I seriously reviewed the literature in this area was at least 6-12 months ago, so take anything I say with a grain of salt.

There are few if any large studies comparing the 2 techniques amongst providers that are experienced. The problem with the majority of studies is that, thankfully, complications are very rare regardless of what technique you use. What is the incidence of carotid puncture with the 25 g seeker needle? Varies from about 0.5% to 5% depending on the study. Now even if you poke a hole in the carotid with the 25 g needle, the incidence of stroke or mega-sized hematoma is still miniscule. The chances of an experienced provider passing the dilator into the carotid are likely < 1/1000 regardless of the technique used and even if you do, it isn't a given that the patient will have serious morbidity or mortality.

That's why you need huge studies to show a statistically significant difference in a meaningful outcome in this area.

Another problem that can arise is highlighted in the following example:

Take your average 50 yo anesthesiologist that has been in practice for 15-20 years and has placed thousands of central lines. They've probably had a few minor complications, maybe even one big one, along the way but those are very few and very far between. Now if I wanted to start forcing them to use ultrasound for all their line placements, I'm essentially putting them back at the beginning of a learning curve. They know how to put in a line like a champ, but I'm opening them up to the possibility of making errors related to the ultrasound that they couldn't have made before. Maybe they got medial and lateral sides confused on the screen and aimed way too medial with their needle. Maybe they just kept the probe stationary and didn't realize the vessels can be tortuous in the neck and while they started out above the IJ, their needle path ended up placing them over the carotid more distally.


Now don't get me wrong. I think using the ultrasound is a superior method. I'm just aware that the actual outcome differences between one or the other are miniscule at best. I spend lots of time teaching senior partners how to use the ultrasound for blocks and line placements, but it does take quite a bit of practice to become facile.

 

[secretasianman]

The ASA is getting ready to put out a practice guideline where they basically say not using live ultrasound is bad medicine, no questions asked. They are aware many groups don't have that many ultrasound machines but they don't care. Their reply is "they are going to have to buy them".

Is the ASA really representing you?

Everybody should write them an email about this.

Hopefully this does not include femoral lines or lines placed in emergent situations?

I put the eye tape under ultrasound guidance. Eyelashes must be aligned 40 degrees lateral to the line between the epicantal fold and the color signal from the retinal artery. I found that my patients wake up with less nausea and the chance of awareness is nearly zero.

Most awesome response in the thread.

 

[Noyac]

How many of you are using US for your epidurals?

 

[periopdoc]

I am struck by the probability that these arguments are likely quite similar to the arguments that were fielded after the introduction of pulse oximetry.

Eventually there will be very few young anesthesiologists capable of safely placing IJ's without U/S guidance and the whole discussion will be moot.

With the ongoing development of smaller and cheaper ultrasound equipment the arguments against using them will continue to lose weight.


- pod

 

[Noyac]

I am struck by the probability that these arguments are likely quite similar to the arguments that were fielded after the introduction of pulse oximetry.
- pod

Your probably right.

Unfortunately, that means I am just showing my age.

But to give a little perspective. I watched someone use the US today for what was a very easy block and I could have done 4 blocks by the time he was done. I still don't get it.

 

[kraphtymac]

I do all of my awake Foley catheters under ultrasound guidance. You just never know... it may LOOK like a urethra, SMELL like a urethra, and FEEL like a urethra, but unless you are using an ultrasound, you're just never quite sure you're in the bladder even if you taste the returned urine and transduce an abdominal pressure.

 

[2win]

I am struck by the probability that these arguments are likely quite similar to the arguments that were fielded after the introduction of pulse oximetry.

Eventually there will be very few young anesthesiologists capable of safely placing IJ's without U/S guidance and the whole discussion will be moot.

With the ongoing development of smaller and cheaper ultrasound equipment the arguments against using them will continue to lose weight.


- pod

👍👍👍

 

[drccw]

When I started residency, the teaching was based on anatomical landmarks. Many lines, often in coagulopathic liver patients without difficulty. My last year of residency was when the ultrasound really started making an appearance. Since I've left residency I've been using the ultrasound more and more. One of the main driving forces is that we have two surgeons that want lines a lot for the patients for post op and also want them to be placed under active US guidance. So I've learned. Some of my partners tell the surgeons to place the line themselves if they want US, which they are fine to do.

I find that I have gotten just as quick with US. Bear in mind it took some time. But, I've developed little tricks to get slick at it, and to be able to place a line quickly without any additional help. There are a couple things one has to learn to do:
1) before you gown and glove, turn the machine on. Make sure the probe is assecible easily
2) I then gown, glove, prep and drape the patient. With one hand holding the sterile sheath (pre-jellied), I use the other hand with one of the sterile pieces of paper to grab the US probe and drop it in.
3) Pop line in. One stick. One thing that's handy is visualizing the long axis of the vein with the wire in it.

Honestly the whole process adds 15 secs to the line. and I never use a small finder needle. I figure if you average all the lines out I am quicker with US then without. The anesthesia techs tell me I am one of the fastest at putting lines in in the group.

I do try to do a couple lines a month based on anatomy. I can still do it in a pinch. Honestly though, I prefer US. It's probably the lazy way to do lines, but it's quick and easy for me.

drccw

 

[2win]

How many of you are using US for your epidurals?

I tried it one or two times - doesn't work for me...
I do use sometimes fluoro ...

 

[dhb]

How many of you are using US for your epidurals?

As i've said every technique has it's limits (and i believe this is one of them) although it could be useful to judge the epidural space depth in the beached whales.

 

[Intensivist]

I do all of my awake Foley catheters under ultrasound guidance. You just never know... it may LOOK like a urethra, SMELL like a urethra, and FEEL like a urethra, but unless you are using an ultrasound, you're just never quite sure you're in the bladder even if you taste the returned urine and transduce an abdominal pressure.

👍👍👍

 

[Frank Rizzo]

I use U/S for the majority of my IJ's. Not for any good reason, I just do. Still do by landmarks every once in a awhile. Interestingly enough, I do all of my interscalene blocks without it. I suppose that the same arguments people use for U/S guided lines can be applied to U/S guided interscalene blocks. Guess I'm a walking paradox.

 

[cfdavid]

I am struck by the probability that these arguments are likely quite similar to the arguments that were fielded after the introduction of pulse oximetry.

Eventually there will be very few young anesthesiologists capable of safely placing IJ's without U/S guidance and the whole discussion will be moot.

With the ongoing development of smaller and cheaper ultrasound equipment the arguments against using them will continue to lose weight.


- pod

My last rotation of 4th year was in the MICU at a pretty large hybrid academic/community hospital. One of the residents (who's word I trust) told me that it was the hospital system's standard of care to use US for IJ's in all settings.

I AM a little concerned about not doing them anatomically, in the future. You just never know.... That being said, one could always just brush up on the anatomy and "shoot from the hip" in an emergent situation in which an US machine was unavailable... But, your point on safety is well noted..

cf

 

[Noyac]

My last rotation of 4th year was in the MICU at a pretty large hybrid academic/community hospital. One of the residents (who's word I trust) told me that it was the hospital system's standard of care to use US for IJ's in all settings.

That's BS, it's not the SOC. In order for it to be SOC it must be available to everyone.

 

[Mman]

That's BS, it's not the SOC. In order for it to be SOC it must be available to everyone.

Not true. I believe standard of care is more a legal definition that is restricted both geographically and by the type of setting you are in.

If you are working in a small hospital in Wyoming, your standard of care is not the same as somebody working in a huge academic level 1 trauma center. You are held to what physicians in your geographic area and your practice setting would do in the same situation.

 

[rsgillmd]

How many of you are using US for your epidurals?

On my previous attempts during residency, I was only able to successfully identify the anatomy once, and that was with the aid of an experienced pain physician.

I took the U/S workshop at the SOAP meeting this month. I feel more comfortable having seen the structures on a real person at the workshop and will try to use it again. Only if I use it on normal people will I be likely to recognize the anatomy on a morbidly obese patient. The problem is going to be finding a time when the ultrasound is not being used by OB.

But, yes, at this point I am certainly likely to be faster placing an epidural in my usual manner.