tricks of the trade: vascular access - ucsf cme · tricks of the trade: vascular access michelle...
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Tricks of the Trade:Vascular Access
Michelle Lin, MDUCSF Academy Endowed Chair of EM Education
UCSF Associate Professor of Emergency MedicineSan Francisco General Hospital and Trauma Center
Bedside ultrasound has revolutionized vascular access procedures
External Jugular Vein
The mandible keeps getting in the way of your IV.
You are attempting a peripheral EJ line.
Thanks to Dr. Caitlin Bilotti (Kaiser Oakland)
The mandible keeps getting in the way of your IV.
You are attempting a peripheral EJ line.
Central Line Tips
The guidewire doesn’t want to feed through the needle.
You are attempting a central line.The guidewire doesn’t want to feed through the needle.
You are attempting a central line.
Re-aspirate for blood
The guidewire doesn’t want to feed through the needle.
You are attempting a central line.
Flatten needle angle and
twirl guidewire
How can I reinsert the guidewire?
I lost the guidewire introducer!
Wire coiled with an outer wire
How can I reinsert the guidewire?
I lost the guidewire introducer!
Can temporarily straighten J-tip by stretching guidewire
How can I reinsert the guidewire?
I lost the guidewire introducer!
Safest way to dispose of the guidewire?
Bryant:
Bryant:
Safest way to dispose of the guidewire?
Thanks to Dr. Rob Bryant (Utah Emergency Physicians)
Safest way to dispose of the guidewire?
Safest way to use straight-needle in suturing?
Use needle cap as “thimble” protector
Safest way to use straight-needle in suturing?
Thanks to Dr. Bret Nelson (Mount Sinai)
How do you find the femoral vein in a pulseless patient?
Femoral lineHow do you find the femoral vein in a pulseless patient?
Femoral line
V-Technique
Why can’t I feed the guidewire?
Femoral line
Incorrect approximation of inguinal ligament Don’t cannulate the inferior greater saphenous vein
Why can’t I feed the guidewire?
Femoral line
How to maximize IJ vein diameter if a patient can not tolerate being in Trendelenburg position?
Internal jugular line
Valsalva manuevers
Valsalva maneuvers
Hum it out.
Lewin MJ et al. Ann Emerg Med, 2007.
Smith G, Boyle MJ. Emerg Med Australas. 2009 Dec;21(6):449-54.
Valsalva maneuvers
Blow into a syringe
Thanks to Dr. David Johnson (Stanford EM resident)
Valsalva maneuvers
Push against provider’s hands, which are deeply palpating abdomen
How to minimize the risk of malpositioning the subclavian catheter into the IJ vein?
Subclavian lineHow to minimize the risk of malpositioning the
subclavian catheter into the IJ vein?
Place finger over IJ in supraclavicular fossa during guidewire insertion.
Ambesh et al, Anesth, 2002
Subclavian line
Where can I get rapid vascular access?
BP
HR
O2 sat
T
70/30
160
90% RA
36.7 C
Where can I get rapid vascular access?
Teismann et al. J Emerg Med. 2012.
Temporize with ultrasound-guided “peripheral IJ”
• Proximal tibia• Proximal humerus• Distal tibia (just superior to medial malleolus)
EZ-IO Drill
Where can I get rapid vascular access?
Intraosseous line
Intraosseous Line
Video
How do you interpret IO blood?
Discard first 2 mL blood return
Correlates well with peripheral blood draw:• Albumen, total protein• BUN, creatinine• Glucose• Hematocrit, hemoglobin
IO blood may result in lower numbers: • CO2• Platelets
IO blood may result in higher numbers:• WBC
Miller et al, Arch Pathol Lab Med, 2010.
Tricks of the Trade in Vascular Access
1. Know your equipment
2. Avoid complications by anticipating them