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May 2008
By Phillips Perera, MD, RMDS, and Diku Mandavia, MD, FACEP, FRCPC
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Presentation:
A 72-year-old man presents to your emergency department complaining of generalized weakness and fever for the past two days. The patient appears ill and is diaphoretic and confused. Vital signs are: heart rate, 120; blood pressure, 70/50; temperature, 102ºF; respirations, 20. Multiple attempts at obtaining peripheral access by the nursing staff are unsuccessful. You enter the room and also attempt to place an intravenous line, but you can’t see or palpate a vein in his arms, legs, or neck. This patient needs immediate resuscitation with intravenous fluids, antibiotics for presumed sepsis, and possibly vasopressors for blood pressure support.
If needed, an ultrasound machine is available to assist with vascular access. How should you proceed with this patient?
Click for diagnosis and discussion
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Diagnosis and discussion:
Immediate central venous access is indicated as multiple attempts to place a peripheral line have failed. Studies have shown ultrasound-guided placement of central venous catheters to be faster, more accurate, and associated with a decreased complication rate when compared to the standard landmark technique. Using ultrasonography to assist in central venous access is becoming the standard of care in the emergency department and in intensive care units.
The ultrasound image on the first page shows the internal jugular vein and carotid artery of the neck in the short- or transverse-axis view. This image can easily be obtained by placing a high-frequency probe (7.5 to 10 MHz range, linear array type) on the patient’s neck with the marker dot facing left. Once the vein has been located, the vascular access procedure can begin.
A sterile probe cover is placed over the ultrasound catheter, which can then be guided by observing its movement in relation to the vein. The ultrasound probe can be placed in both short- and long-axis configurations to aid in catheter placement. Most clinicians begin in the side-to-side, or short-axis, view to mark the correct needle puncture site on the neck. The long-axis plane can then be used to observe the anatomy of the vein in a superior-to-inferior plane, allowing the physician to plot the correct direction of the needle once it passes beneath the skin. The long-axis view also provides useful information on the depth of the needle, allowing for more accurate placement of its tip into the lumen of the vein (see image above). Once the needle is in the vein, ultrasound can ensure that the guide wire passes easily into the lumen without obstruction. |
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Dr. Perera is an assistant clinical professor of emergency medicine at Columbia University College of Physicians and Surgeons and Weill Cornell Medical College and director of emergency ultrasound at New York Presbyterian Hospital in New York City. Dr. Mandavia is a clinical associate professor of emergency medicine and director of emergency ultrasound at Los Angeles County-USC Medical Center and an attending staff physician at Cedars-Sinai Medical Center in Los Angeles.
Emerg Med 40(5):13-4, 2008
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