Over the past two decades, ultrasound (US) has become widely accepted to guide safe and accurate insertion of vascular devices in critically ill patients. We emphasize central venous catheter ...insertion, given its broad application in critically ill patients, but also review the use of US for accessing peripheral veins, arteries, the medullary canal, and vessels for institution of extracorporeal life support. To ensure procedural safety and high cannulation success rates we recommend using a systematic protocolized approach for US-guided vascular access in elective clinical situations. A standardized approach minimizes variability in clinical practice, provides a framework for education and training, facilitates implementation, and enables quality analysis. This review will address the state of US-guided vascular access, including current practice and future directions.
Real-time ultrasound (US) in central venous catheterization is superior to pre-procedure US. However, moving real-time US into routine practice is impeded by its perceived expense and difficulty. ...Currently, pre-procedure US and landmark (LM) methods are most widely used. We investigated these techniques in internal jugular vein (IJV) catheterization in respect of operator experience, complications, and risk factors.
In an observational non-randomized study, we investigated 606 of ∼1300 procedures, that is, 200 patients were treated under pre-procedure US and 406 under LM pathfinder (PF) n=202, direct cannulation (DC) n=204. We recorded first needle pass success rate, success rate after the third attempt, and the cannulation time. Procedures were performed by inexperienced (<100) or experienced (>100 catheterizations) operators.
Pre-procedure US was associated with more successful attempts and shorter cannulation times. Under pre-procedure US, 88% of first attempts were successful and 100% of third attempts. The median (range) cannulation time was 39 (10-330) s. Under PF, only 56% of first, and 87% of third, attempts were successful with a median (range) cannulation time of 100 (25-3600) s. Under DC, 61% of first and 89% of third attempts were successful; the median (range) cannulation time was 70 (10-3600) s. Remarkably, inexperienced operators using pre-procedure US (n=38) were significantly faster than experienced operators using PF or DC (n=343) (cannulation time: median 60 s, range 12-330, for inexperienced; 60 s, range 10-3600, for experienced). First puncture success rates were higher (pre-procedure US, inexperienced 84%, PF or DC, experienced 57%).
Pre-procedure US for IJV catheterization is safe, quick, and superior to LM.
Dynamic variables, for example, systolic pressure variation (SPV), are superior to filling pressures for assessing fluid responsiveness. We analysed the effects of SPV-guided intraoperative fluid ...management on organ function and perfusion when compared with routine care.
Eighty patients (44 female and 36 male) undergoing elective major abdominal surgery were randomly assigned to a control group n=40, mean age 66 (sd 10), range 40–84 yr or SPV group n=40, age 61 (16), range 26–100 yr in which intraoperative fluid management was guided by SPV (trigger: SPV>10%). Central venous O2 saturation (ScvO2), lactate and bilirubin, creatinine, indocyanine green plasma disappearance rate (ICG-PDR), and gastric mucosal CO2 tension were measured after induction of anaesthesia, after 3, 6, 12, and 24 h.
Patient characteristics, duration of surgery 5.8 (2.5) vs 5.4 (2.5) h, and infusion volumes (median 4865 vs 4330 ml) were comparable between the groups. At 3 and 6 h, SPV (P=0.04, P=0.01) and Δdown (P=0.005, P=0.01) were significantly higher in the control group. Oxygen transport and organ function were comparable: baseline and 24 h values for ICG-PDR: 28.5 (7.9) and 22.7 (7.8) vs 23.9 (6.9) and 26.1 (5.9)% min−1, 77.7 (6.6) and 72.6 (5.5) vs 79.3 (7.1) and 72.8 (6.7)% for ScvO2 and 1.0 (0.4) and 1.2 (0.6) vs 0.9 (0.2) and 1.3 (0.5) mmol litre−1 for lactate. Length of mechanical ventilation, ICU stay, and mortality were comparable.
In comparison with routine care, intraoperative SPV-guided treatment was associated with slightly increased fluid adminstration whereas organ perfusion and function was similar.
Central venous catheter (CVC) placement under ECG guidance in the left thoracocervical area can lead to catheter misplacement. The aim of this study was to identify the cause and quantify the ...magnitude of this error.
CVCs were sited in either the left or right internal jugular (IJ), subclavian (SC), or innominate (brachiocephalic) vein using the Seldinger technique and a total of 227 insertions were studied. The position of the catheter tip was confirmed with two different intra-atrial ECG monitoring methods (Seldinger's wire vs 10% saline solution). Measurements were compared between the two methods and correlated to the different access sites.
All right-sided CVC had the line tip in the optimal position and both intra-atrial ECG recording by Seldinger's wire or 10% saline delivered correct results. For left-sided lines, however, the two methods gave significantly different results regarding the position of the line tip for each insertion site. When using the Seldinger wire as intravascular ECG lead, the results differed from the saline method by a mean of 21 mm for the IJ and 10 mm for the SC.
CVC placement under ECG guidance is a reliable method to site the line tip at the optimal position. However, when using a left-sided thoracocervical access point, the Seldinger wire-conducted ECG delivered a constant error. This could be adjusted for by advancing the CVC 20 mm in addition to the wire-based measurement of the insertion depth at the left IJ vein and 10 mm at the left SC vein.
This article presents the case of a 43 year old woman with right-sided lung cancer. She underwent transpericardial pneumonectomy. After an uneventfull surgery, the patient was transferred to the ...intensive care unit for postoperative monitoring. She was hemodynamically stable and had already been extubated in the OR.On postoperative chest X‑ray a mediastinal shift to the operated side as well as a herniation of the heart into the right chest cavity was detected. While the patient remained hemodynamically stable a computed tomography of the chest was performed which confirmed the diagnosis of cardiac herniation and torsion. The lady underwent rethoracotomy the following day where the heart was repositioned and the pericardial defect was closed. She made an uneventfull recovery.Five years after the pneumonectomy she remains well and is without relapse of lung cancer.Mechanism for cardiac herniation and torsion, the clinical presentation and the typical radiologic signs are discussed. However, the clue to early diagnosis is a high index of clinical suspicion.It is highlighted that a hemodynamically unstable patient under these circumstances demands urgent rethoracotomy.
Loss of the guide wire: mishap or blunder? Schummer, W.; Schummer, C.; Gaser, E. ...
British journal of anaesthesia : BJA,
January 2002, 20020101, 2002, 2002-Jan, 2002-01-00, Letnik:
88, Številka:
1
Journal Article
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We describe four cases of lost guide wires during central venous catheterization. Although percutaneous catheterization of central veins is a routine technique, it is a procedure requiring advanced ...operating skills, expert supervision, and attention to detail in order to prevent adverse effects.
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