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POCUS for Vascular Access

Morgan Morrow, DNAP, CRNA

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Objectives

  • Explain the use of point-of-care-ultrasound in identifying vasculature
  • Demonstrate use of ultrasound to identify vasculature appropriate for cannulation

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How is Vascular Access POCUS?

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Less hocus, more POCUS!

Traditional vascular access

“Going in blind”

Palpating

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US can determine�

Best location for venipuncture

Depth of vascular use

Real time needle position tracking

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Benefits of US for Vascular Access

Increases safety

Effectiveness

Efficiency

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Benefits of US

Lower rates of cannulation failure (venipuncture)

First time failure rates can be as high as 39%

Second time failure rates can be as high as 22%

Lower risk of hematoma

Increase patient comfort (1 stick)

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Benefits of US

Meta analysis of 5,108 patients undergoing CVC of IJV:

4% complications with US guided CVC

13.5% complications with landmark CVC

97.6% success with US guided CVC

87.6% success with landmark CVC

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Difficulty with vascular access

Body habits

Anatomical variations

Cutaneous edema

Multiple previous failed attempts

IV drug abuse

Volume depletion

Chronic comorbidities

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Drawbacks of US in vascular access

Skepticism from providers

Lack of standardized training

Lack of equipment (?)

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Successful vascular access

Patient anatomy

Comorbidities

Operator skill

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Set yourself up for success!

Target vessels at depths between 0.3 cm and 1.5 cm

Success rates decrease when depth >1.6 cm

Target vessel diameter >0.4 cm

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What am I looking at?

Arteries

Veins

Non-compressible (with light pressure)

Compressible (with light pressure)

Thick walls

Thinner walls

Round shape

Round to variable shaped

Pulsatile

Not pulsatile but may appear pulsatile depending on reflection

Color flow unchanged with distal compression

Color flow changes with distal compression (augmented)

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Transverse approach

Short axis, out-of-plane

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Longitudinal approach

Long axis, in-plane

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Systematic Approach to Access

Identify target vessel

1

Confirm patency

    • Compressibility excludes presence of thrombis

2

Real time needle tracking

3

Confirm needle tip within the lumen of the vessel

4

Confirm wire

5

Confirm catheter

6

Pat yourself on the back

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PICC vs CVC

Significantly lower risk of infection

Low risk of contamination

Secure

Increased patient comfort

Low mobility

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A-line placement

RECOMMENDED TO USE US

EASE OF USE

RAPID ACCESS

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Complications

Arterial punctures

Nerve injury

Hematoma

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References

  • Lamperti, M., Bodenham, A. R., Pittiruit, M., et al. (2012). International evidence-based recommendations on ultra-sound guided vascular access. Intensive Care Med, 38, 1105-1117.
  • Mallios, A. (2020, Feb 17). Pioneering best practice in vascular access with point-of-care ultrasound. Sonosite. Sonosite.com
  • Saugel, B., Scheeren, T.W.L. & Teboul, JL. (2017). Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Critical Care, 21, 225. https://doi.org/10.1186/s13054-017-1814-y
  • Soni, N.J., Arntfield, R., & Kory, P. (2020). Point of Care Ultrasound. Elsevier.
  • Weiner, M. M., Geldard, P., & Mittnacht, A. (2013). Ultrasound-guided vascular access: A comprehensive Review. Journal of Cardiothroacic and Vascular Anesthesia, 27(2), 345-360.