Ultrasound-guided vascular access in critical illness

Abstract

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.

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Correspondence to G. A. Schmidt.

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Conflicts of interest

Dr. Blaivas consults for and receives consulting fees from EchoNous, Inc. Dr. Lamperti is a scientific advisor of MEDTRONIC, received travel support from Fesenius Kabi and VYGON and honoraria from Draeger, Masimo, and MEDTRONIC. None of these relationships presents conflicts with regards to the content of this manuscript.

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134_2019_5564_MOESM3_ESM.avi

Supplementary material 3 (AVI 4698 kb) Epigastric and subcostal acoustic windows along the short heart axis focusing on superior cava vein outflow tract in the right atrium allow to confirm the correct catheter placement with the visualization of numerous microbubbles indistinguishable separately with linear flow coming from superior vena cava

134_2019_5564_MOESM4_ESM.avi

Supplementary material 4 (AVI 1747 kb) Malposition with clear direct visualization of catheter tip into the right atrium and numerous microbubbles indistinguishable separately with turbulent flow coming from atrium

134_2019_5564_MOESM5_ESM.avi

Supplementary material 5 (AVI 2849 kb) B-mode ultrasound through the epigastric and subcostal acoustic windows along the short heart axis allowing us to see both cava veins and right atrium at the same time confirming correct catheter placement

Supplementary material 6 (MP4 4897 kb) PIV insertion using a long-axis, in-plane approach using a manikin trainer

Supplementary material 7 (MP4 4898 kb) PIV insertion using a long-axis, in-plane approach and modified Seldinger technique with wire insertion using a manikin trainer

Supplementary material 8 (MP4 54,261 kb) Operator inserting IO into himself: Here a clinician is placing an IO into his own tibia using a commercially available drill. Pain is minimal and the procedure can be performed rapidly. The operator confirms proper placement with aspiration and flush. (Courtesy Mark Piehl, MD)

Supplementary material 9 (MP4 1032 kb) IO failure with flow above cortex: blood flow is seen on color Doppler above the bony cortex in this failed IO placement

Supplementary material 1 (DOCX 11 kb)

Supplementary material 2 (DOCX 13 kb)

Supplementary material 3 (AVI 4698 kb) Epigastric and subcostal acoustic windows along the short heart axis focusing on superior cava vein outflow tract in the right atrium allow to confirm the correct catheter placement with the visualization of numerous microbubbles indistinguishable separately with linear flow coming from superior vena cava

Supplementary material 4 (AVI 1747 kb) Malposition with clear direct visualization of catheter tip into the right atrium and numerous microbubbles indistinguishable separately with turbulent flow coming from atrium

Supplementary material 5 (AVI 2849 kb) B-mode ultrasound through the epigastric and subcostal acoustic windows along the short heart axis allowing us to see both cava veins and right atrium at the same time confirming correct catheter placement

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Schmidt, G.A., Blaivas, M., Conrad, S.A. et al. Ultrasound-guided vascular access in critical illness. Intensive Care Med 45, 434–446 (2019). https://doi.org/10.1007/s00134-019-05564-7

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Keywords

  • Central venous catheter
  • Vascular access
  • Ultrasound
  • Education
  • Complications