Vascular access is a core critical care procedure, and doing it safely and quickly is now demanded by all our patients.
The debate about whether central access can be done safely using the traditional landmark method has largely been debunked in the literature, and is prominent in most guidelines around the globe (such as NICE 2002, Am Collage of Emergency physicians 2012). Most literature has investigated internal jugular vein and femoral venous, although US guided subclavian vein access is also become more established.
The key steps laid out below are by no means exhaustive, but form the basis of a sensible and evidence based method.
1) Site and Prescan – Site is decided on risk of infection, and ease of entry. Risk is lowest in subclavian<internal jugular vein<femoral vein. The pre scan should be done before you wash your hands to identify side and anatomical variability.
2) Equipment – including sterile probe cover, dressings, and consideration of antibiotics coated CVC and Biopath, depending on baseline CLABSI rates.
3) Position – patient between you and US screen, and both in a comfortable position.
4) Image and Puncture
- Optimise image: gain, focus, depth.
- Keep needle tip in the field by manouvering both left and right hands
- Transverse gives good lateral perception, while longitudinal gives good depth perception
- Confirm wire using US scanner
5) Evaluate for complications – arterial puncture, pneumothorax, thrombus.
6) Document – depth, type, complications.
There are some limitations to US including subcutaneous emphysema, losing the needle tip from the image, desterilization of probe.
These can almost always be managed by plenty of practise and if necessary moving to another site. Soon you will be a Jedi with the US guided vascular access!