ROCKstars – Case 1: US-Guided Central Venous Access (CIV)

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An elderly patient is in the RIH Critical Care bay with severe sepsis and needs central access.  Luckily, Drs. Adam “Hyperechoic” Haag and Eddie “Rule ‘Em Out” Ruhland are on shift.  They settle on the right Internal Jugular vein, but traditional sternocleidomastoid muscle (SCM) and clavicular bone landmarks are not apparent.  So a linear-array probe is correctly placed transversely over the triangle formed by the bifurcation of the SCM, to where the IJ and Carotid are seen in parallel…but there is some sort of hyperechoic, noncompressible mass…

They identify the thrombus, and instead find the Femoral vein, where CIV access is successfully achieved on the first attempt with no immediate complications.  The use of US to guide this procedure changed this patient’s course and potentially saved a complication.  

But exactly how much safer, faster, and more reliable is US-guided CIV placement?

THE ISSUE

  • Vascular access is critical in emergent situations
  • Body habitus, dehydration, poor perfusion, anatomical abnormalities, or history of IVDU can cause difficulties and delays when using landmark-based techniques
  • Complications of CIV placement include arterial puncture, excessive bleeding, vessel laceration, pneumothorax, hemothorax, and necessitation of multiple attempts
  • US guidance was identified in 2001 by United States Agency for Healthcare Research and Quality as one of the top 11 means of increasing patient safety, but this was based on one study of subclavian lines at one large urban center (1)

The “SOAP-3” Trial (2005)

  • A concealed, randomized, controlled study of 201 patients
  • Studies dating back to the 1990s in EM and Anesthesia (4) had demonstrated the efficacy of ultrasound-guidance, but this was the first study in the ED setting comparing the anatomical landmark method, the static “quick look” US-guided method, and dynamic “real time” US-guided method
  • In the “quick look” group, US was used to identify landmarks, the skin was marked, and the catheter was placed without real-time US guidance
  • EM residents and Attendings passed a 1h training course, then placed 10 CIVs with dynamic US guidance to qualify to participate

RESULTS

Dynamic

US Guidance

Static

US Guidance

Anatomical Landmarks Method
Overall Success 98% 82% 64%
First-Attempt Success

(OR vs LM)

5.8 3.4
Avg # of Attempts 1.7 1.6 3.2
Avg Total Sec 30 20 150
Complications 2 2 8

DISCUSSION

  • Dynamic guidance is superior but requires the most training
  • Static guidance is vastly superior to Landmark, and while slightly inferior to Dynamic, it requires less training
  • 10% of the study patients had “extremely narrow” (<5mm) IJs bilaterally, which could explain the inferior performance of the LM technique, even with experienced practitioners
  • All the complications were arterial punctures, and these were not statistically significant

References

  1. Agency for Health Care Research and Quality (AHRQ). Evidence Report/Technology Assessment: Number 43. Making Health Care Safer. A Critical Analysis of Patient Safety Practices: Summary 2001. 2007.
  1. Milling, et al. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial.  Critical Care Medicine, 2005, Aug;33(8); 1764-9.
  1. Sulek et al.  A Randomized Study of Left versus Right Internal Jugular Vein Cannulation in Adults.  J Clin Anesth, 2000, Mar; 12(2): 142-5
  1. www.sonoguide.com/line_placement.html

Nerve Blocks Rule

Jon and I did this awesome ultrasound-guided superficial cervical plexus nerve block the other day for a R IJ central line placement– taught to us by none other than the amazing Dr. Otto Liebmann.

It was so neat we made a video about it. Check it out!

 

Lumbar Puncture Part 1: The Basics

a monthly blog series on procedures


Hunting & Gathering

Find a Workstation on Wheels (WOW) with a functioning Topaz to obtain informed consent.

Place Epic orders for CSF. Print the stickers and sign each with your initials.

Locate an LP tray,  its contents, sterile gloves, eye protection, facemask.

Gather these optional supplies:

  • Extra spinal needles:
    • 20 gauge, 3.5 in Quincke = cutting needle (1 included in tray).
    • 22 gauge, 3.5 in Whitacre = atraumatic needle.
    • 20 gauge, 6 in “Harpoon” = longer needle.
  • Extra 1% Lidocaine (5ml in tray).
  • Extra Povidone-Iodine.
  • Non-sterile marking pen.

Optional: Tech or RN for positioning assistance during procedure.

Timeout!

Perform the LP (see below).

Collect CSF in 4 tubes and send to lab.

Choosing the right needle

The Whitacre needle (aka a type of pencil point needle, or “atraumatic” needle) contains side ports, and theoretically causes less damage to tissue fibers upon entry. They are more difficult to use for skin entry. However, studies have shown that atraumatic needles decrease the incidence of post-LP headache (1 and 2). As an aside, there is no evidence that lying supine for any fixed period time is helpful in the prevention of post-LP headache(3). Continue reading

Crack the Chest

Part of our recurring ’52 Articles’ series exploring landmark articles in Emergency Medicine, inspired by the ALiEM blog’s index project, 

Main Points:

  1. Over 23 years 950 patients underwent post injury thoracotomy at Denver Health Medical Center and overall survival was noted to be 4.4 percent with 3.9 percent surviving functionally intact.
  1. Using various assumptions for cost analysis the authors concluded that “the benefit-charge ratio was strongly in favor of performing EDT [emergency department thoracotomy] at 5.6:1, it was 1.8:1 if adjusted for the cost of maintaining all neurologically injured survivors throughout their lifetime.”

Background:

Emergency department thoracotomy remains a hotly debated procedure within the scope of emergency medicine.  Not only is it a resource intense process that potentially places providers at increased risk for blood borne infections, but it is also one whose utility has been questioned given the limited success rate of meaningful patient outcomes. The authors of this study reviewed a cohort of consecutive trauma patients presenting to a level I hospital in Denver, CO in hopes of clarifying not only the costs as well as the utility of the procedure. The authors in this study reported “neurologically intact survival at time of discharge” as one of the study outcomes; however, it does not appear that any patients had post-hospitalization follow up to evaluate for any future changes. Continue reading

Simple pneumothorax? Try a pigtail!

Why the 32 French?! It’s not 1970 anymore. Next time you’ve got a simple pneumothorax, consider the pigtail! Chana Rich and Kat Farmer will show you how:

For a more detailed, step by step process, see another great post by Dr. Jay Diamond:

http://blogs.brown.edu/emergency-medicine-residency/pigtail-catheter-placement-for-pneumothorax/