Ultrasound-guided Central Lines

[DrRobert]

Do any of you train at institutions where ultrasound is the standard when placing central lines either in the OR or the ICU?

If not, does anyone see this as becoming the standard of care in the near future?

Also, what about you private practice docs? Ultrasound or not?

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[UTSouthwestern]

Do any of you train at institutions where ultrasound is the standard when placing central lines either in the OR or the ICU?

If not, does anyone see this as becoming the standard of care in the near future?

Also, what about you private practice docs? Ultrasound or not?

Never have needed to use it, so can't comment on it, and I put in an average of 8-12 central lines a week for my hearts (actually 16-24 since I put in a right IJ and right SC line for each heart).

 

[militarymd]

There is a push by certain groups to make u/s guided procedures standard of care.,....perceived improved safety.

I've trained with u/s guided central lines....I've self-trained doing u/s guided nerve blocks..

but using it on every patient is really overkill....although insurance companies will reimburse you more units for using it.

To be honest, I only use u/s when I've spent more than 5 minutes trying to do a procedure.

 

[cchoukal]

The university of chicago has them available in the ICUs, encouraged in the MICU, and not available in the ORs. In the MICU, we were presented with some evidence for improved success, fewer attempts, etc., but I'm having a hard time finding the reference. One thing that is mandatory in the MICU is transducing a manual CVP in some IV tubing prior to passing the dilator. When I tried to do that at the community hospital where we rotate part time, they looked at me like I was an alien, so I suspect this is not standard of care yet.

 

[Noyac]

We have an U/S machine for central lines but I personally don't know where it is and have not seen any of my partners use it either. The only ones that use it in our hospital that I have seen are the surgeons. Go figure.

 

[proman]

I think the data supports the use of US for those without much experience. After a fair number of lines it doesn't appear to help with time/complications/success rate. On my home rotation (private practice) there was one attending (25 years of practice) who would mark the landmarks with the US in holding. That seemed to work well.

 

[MDEntropy]

What do people use more - catheter over needle, or needle alone? Do those not using US always use a finder then and keep pressure on the carotid?

Does everyone hang a column before dliating the vessel?

When the IR guys put in an IJ, they look with US (but don't use it for live guidance), puncture with a large needle (unlike the small one the cardiac ep guys use) but with no syringe attached, and then pass the wire.

UT, why do you place 2 CVC's in each heart? Am I correct that you DON'T float a PA? Are either of your lines, or perhaps both an introducer? Hmmm.

 

[sevoflurane]

I find the use of USD time consuming and annoying in the filed. I don't like to rely on a piece of electronic equipment to do something that has been done a billion times in the past without such equipment. What happens to the guy who only does USD guided central lines and suddenly finds himself in a fast paced group that doesn't have an USD?

I have, however, been thankful for it on the thick necked 500 pounder. This is rare though, even the large individuals can be done w/o such equipment.

My 2 cents

 

[medgator]

I did my IM internship at UPMC Presby in Pittsburgh and during my MICU month, we were mandated to use U/S for all IJs. They felt pretty strongly about it as reducing M&M. After seeing some funky anatomy with it, I couldn't help but agree with them.

 

[UTSouthwestern]

UT, why do you place 2 CVC's in each heart? Am I correct that you DON'T float a PA? Are either of your lines, or perhaps both an introducer? Hmmm.

One of the lines is always an introducer. Use a PA about 50% of the time, usually only if the surgeon requests one for postop management, if a patient is extremely sick with preexisting severe pulmonary HTN, or if I'm at a hospital where I know the ICU nurses are somewhat less trained than others and having a PA helps them accurately convey information to myself or the surgeon after we have left the hospital.

Otherwise, I use TEE to measure PA pressures if necessary.

 

[militarymd]

One of the lines is always an introducer. Use a PA about 50% of the time, usually only if the surgeon requests one for postop management, if a patient is extremely sick with preexisting severe pulmonary HTN, or if I'm at a hospital where I know the ICU nurses are somewhat less trained than others and having a PA helps them accurately convey information to myself or the surgeon after we have left the hospital.

Otherwise, I use TEE to measure PA pressures if necessary.

What view do you use to measure PA pressures. I find that the angles just aren't quite right with a TEE to accurately measure the TR jet.

Surface probes, on the other hand, are pretty easy.

 

[UTSouthwestern]

What view do you use to measure PA pressures. I find that the angles just aren't quite right with a TEE to accurately measure the TR jet.

Surface probes, on the other hand, are pretty easy.

I use the midesophageal bicaval view with the probe slightly advanced further until the tricuspid valve just comes in to view. Typically, the TR jet is oriented directly toward the probe or less than 20 degrees off axis.

I also use the upper esophageal aortic short axis view to get a direct main pulmonary artery view from which I can usually get a very clean doppler flow profile and calculate peak pulmonary systolic pressure by the modified Bernoulli equation as well.

 

[Noyac]

What do people use more - catheter over needle, or needle alone? Do those not using US always use a finder then and keep pressure on the carotid?

Does everyone hang a column before dliating the vessel?

When the IR guys put in an IJ, they look with US (but don't use it for live guidance), puncture with a large needle (unlike the small one the cardiac ep guys use) but with no syringe attached, and then pass the wire.

UT, why do you place 2 CVC's in each heart? Am I correct that you DON'T float a PA? Are either of your lines, or perhaps both an introducer? Hmmm.

I use the catheter over needle for the IJ and the needle alone for SC and femoral. I never use a finder needle and I never hang a column.
When placing the catheter over needle, I slide the catheter down and remove the needle. If it is arterial then it will pump right out of the catheter. Now you are hands free and can easily guide a wire without having to hold a needle in place. I use the Needle only for the SC b/c of teh depth and angle of the SC approach. In the femoral it really doesn't matter to me which way.

 

[militarymd]

I use the midesophageal bicaval view with the probe slightly advanced further until the tricuspid valve just comes in to view. Typically, the TR jet is oriented directly toward the probe or less than 20 degrees off axis.

I also use the upper esophageal aortic short axis view to get a direct main pulmonary artery view from which I can usually get a very clean doppler flow profile and calculate peak pulmonary systolic pressure by the modified Bernoulli equation as well.

When I'm measuring the TR velocity with a surface probe, I have found that the TR jet shoots between 20 and 30 degree towards the right of midline (your left if facing the patient)..and agnled slightly cephalad.

Or slightly lateral to the esophagus.

I have always found the jet to be angled in the views that you describe.

My initial training in u/s was solely transthoracic.....for a long time...before moving to transesophageal views....perhaps its the purist in me (as drilled by the cardiologists that trained me) that has me unhappy with the tr jets as measured through a esophageal probe.

 

[12R34Y]

Two academic ED's with residency's put virtually all lines in with US guidance.

Very common in the ED as best I can tell.

Not very common anywhere else. (in my locale).

later

 

[bubalus]

I typically use US, at least to mark the course of the IJ, and use it real-time if it looks like it would be beneficial. If I'm doing a peds case then I use it real-time.

 

[UTSouthwestern]

When I'm measuring the TR velocity with a surface probe, I have found that the TR jet shoots between 20 and 30 degree towards the right of midline (your left if facing the patient)..and agnled slightly cephalad.

Or slightly lateral to the esophagus.

I have always found the jet to be angled in the views that you describe.

My initial training in u/s was solely transthoracic.....for a long time...before moving to transesophageal views....perhaps its the purist in me (as drilled by the cardiologists that trained me) that has me unhappy with the tr jets as measured through a esophageal probe.

The reason I trust my measurements is that I have been able to reproduce them and when I have both a TEE and PAC in, my calculated PA pressures almost exactly match the PAC's reading.

 

[kmurp]

In our private practice we always use the Sonosite. it seems to make things safer. I like it because i don't do that many central lines- it seems to help. The purchase of our machine and it's routine use in our group was driven by the guys who do cardiac in our group. They feel that it helps.

 

[Noyac]

In our private practice we always use the Sonosite. it seems to make things safer. I like it because i don't do that many central lines- it seems to help. The purchase of our machine and it's routine use in our group was driven by the guys who do cardiac in our group. They feel that it helps.

Thats a good point Kmurp. I could see a use for US in groups that do very little central lines.