In a sick neonate where peripheral venous access is not possible, placement of an umbilical venous catheter (UVC) may be lifesaving!
The umbilical vein may remain patent for up to 10 days after birth.
- Emergency resuscitation and stabilization of neonates (to give volume or medications, such as epinephrine
- Abdomen doesn’t look normal (omphalocele, gastroschisis, omphalitis, peritonitis, necrotizing enterocolitis)
- Vascular compromise of the lower limbs
Umbilical Vessel Anatomy:
From Robert and Hedge’s Clinical Procedures in Emergency Medicine
- Umbilical cord has 2 arteries and 1 vein
- Vein is thin-walled, usually at 12 o’clock
- Arteries are smaller and thick-walled
- Neonatal blood flow:
- Umbilical vein –> ductus venosus –> IVC –> RA –> PA –> ductus arteriosus –> aortic arch
- Umbilical arteries –> internal iliac arteries
Finding your Materials:
- In Hasbro ED:
- Locate UVC Tray and UVC lines in Hasbro Trauma Bay
- Other materials not in kit:
- 3-0 silk suture on a curved needle
- Infusion solution (usually NS or D10W)
- Three-way stopcock
- Tegaderm and tape
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?
- 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
|Anatomical Landmarks Method
(OR vs LM)
|Avg # of Attempts
|Avg Total Sec
- 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
- 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.
- 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.
- 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
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!
a monthly blog series on procedures
Take your LP skills to Eleven: this is spinal tap!
Last week we discussed the basics of the adult LP. This week we will guide you through some difficult scenarios and their solutions.
THE SPOOKED PATIENT
Your patient is nervous and squirmy
- Consider having an assistant hold and position the patient.
- Steady the shaft of the needle with your non-dominant hand.
- Talk to the patient. Here are some examples of what you can say prior to the procedure:
- “I will numb up your back, and that should be the only part that hurts.”
- “Most of the procedure is just setting up my materials.”
- During the procedure, the patient cannot see you, which can be anxiety provoking. Describe each step of the procedure in a calm manner. And try to avoid THIS.
- If necessary, administer an anxiolytic such as a benzodiazepine.
Your patient is very sensitive to pain
- First, lidocaine!
- Did you inject enough volume into the deeper structures of the back? As Dr. Whit Fisher mentioned in the comments of the previous post, make sure you gather extra lidocaine (only 5ml in the LP tray). In a sterile fashion, draw up an extra 5-10 ml with the help of an assistant.
- Note: if trying a new interspace, make sure this area is also anesthetized.
- Patient still in pain? Consider administration of an analgesic such as an opioid.
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.
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
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:
Nasty Fish Hook stuck in your patient? Here’s how to get it out!
And if the fish hook is superficial, there’s also the advance and cut technique: