Ultrasound guidance for procedures??

[cfdavid]

Hey dudes, hope all is well.

My question is, do you ever use ultrasound (not TEE) for procedures?? For example, for inserting a central line or any other "blind" puncture?

Any further elaboration regarding usefulness or potential applications would be great.

---

Members don't see this ad.

 

[2ndyear]

Yup, I use ultrasound for IJ central line placement. I was pretty excited about it when I started using it last year as a CA-1 and used it every time. This was coming off of an internship where all lines were done blind and I seemed to hunt around with that darn finder needle forever. The learning curve is increadibly short with ultrasound. Now I'm probably about 50-50 depending on what attending I'm working with. Some won't let us place a line without it, but most aren't that compulsive. We have had a couple of M&M's regarding blind carotid punctures now, though, so it's becoming more standard in my department. I want to focus on not using it now as wherever I go to practice may not have a machine. In people without good landmarks it makes it one stick and I'm faster with it in that situation. No finder needle, just go for it. If I have a case that turns south intraop it's usually quicker and easier just to do it without. In heart cases, our TEE machines all have a nice little probe on them so if we line up in the room it's just sitting behind me begging to be used. And I can project it on the overhead monitor so I don't even have to crank my head around to look at the machine.

Axillary blocks are nice with the ultrasound because the vascular anatomy is easy to find, and I can usually pick out all of the nerves. Still use a stim needle though. But an axillary block isn't all that hard in the first place. I'm still up in the air on whether it's really helpful for these. To do it right you need to be long axis so you can see the needle tip, so it's a shallow angle that feels really weird. Definately not helpful if you go transarterial anyways.

Interscalene blocks are interesting with the US because there aren't vascular structures to image in the immediate area, so you're looking at nerves and muscles. If you can find them... My images never come close to those on the nysora site. Again, interscalene shouldn't be that hard of a block anyways so the US gets in my way on this one. It just looks like mush on the screen.

I've tried it for infraclavicular with no luck. My probe just doesn't get a good image laying up on the clavicle.

Femoral blocks/lines are easy with the US. But this is yet another place where the anatomy blind is so predictable it's probably just a novelty to use US.

 

[cfdavid]

thanks 2ndyear, for the great response. i'm already more interested in learning this thing. didn't want it to just be a novelty.

 

[proman]

I've found US guided peripheral IVs to be more rewarding. It's an PIV that no one else can get, and you avoid the need for a central line (assuming no other need of course).

 

[chesterfield]

Hey dudes, hope all is well.

My question is, do you ever use ultrasound (not TEE) for procedures?? For example, for inserting a central line or any other "blind" puncture?

Any further elaboration regarding usefulness or potential applications would be great.

this from an EM thread.

From our Shop.

The Use of Ultrasound Reduces the Number of Failed Lumbar Punctures and Improves Ease of Performance of Lumbar Puncture in Obese Patients

Jason T. Nomura, Stephen J. Leech, Srikala Shenbagamurthi, Paul R. Sierzenski, Robert E. O'Connor, Melissa Bollinger, Margaret Humphrey and Jason A. Gukhool
Christiana Care Health System: Newark, DE

ABSTRACT

Background: While limited to case reports, ultrasound (US) has been described as a useful adjunct to lumbar puncture (LP). However, evidence demonstrating utility of US in LP in the emergency department is lacking. Objectives: We hypothesized that US-guided LP would increase success and ease of performing LP. Methods: This was an IRB-approved, randomized, prospective, blinded study conducted at an ED with an annual census of 92,000. A convenience sample of patients undergoing LP from January 2004 to December 2004 was enrolled. In addition to palpation landmarks (PL), all patients underwent US to identify the L3–L4 or L4–L5 interspinous space to establish the US landmark (UL). Patients were then randomized to have LP by PL or UL. Investigators identified the landmarks; however, operators were blinded to which landmark was to be used. Data collected included age, body mass index (BMI), number of attempts, ease of performance, and patient comfort on a 10-cm visual analog scale, procedure time, success, and traumatic LP, as defined by >400 RBCs in tube 1. Statistical analysis of data included 95% confidence interval (CI) and Student's t-test. Results: A total of 46 patients were enrolled. Twenty-two patients were randomized to PL and 24 to UL, with no baseline differences in age or BMI. Twelve patients had a BMI >30. Six of 22 attempts failed with PL vs. one of 24 with UL (p = 0.003). There was no difference in number of attempts, traumatic LPs, ease of procedure, patient comfort, or procedure length between groups. In 12 patients with a BMI >30, seven were randomized to PL, five to UL. Four of seven attempts failed with PL vs. 0/5 with UL (p = 0.03). Ease of procedure was significantly better with UL vs. PL, 2.66 (95% CI 2.53 to 2.79) vs. 6.86 (95% CI 6.38 to 7.34) (p = 0.01). There was no difference in number of attempts, traumatic LPs, patient comfort, or procedure length. Conclusions: The use of US for LP significantly reduced the number of failed LPs in all patients and significantly improved ease of procedure in patients with a BMI over 30.

 

[militarymd]

From our Shop.

The Use of Ultrasound Reduces the Number of Failed Lumbar Punctures and Improves Ease of Performance of Lumbar Puncture in Obese Patients

Jason T. Nomura, Stephen J. Leech, Srikala Shenbagamurthi, Paul R. Sierzenski, Robert E. O'Connor, Melissa Bollinger, Margaret Humphrey and Jason A. Gukhool
Christiana Care Health System: Newark, DE

ABSTRACT

Background: While limited to case reports, ultrasound (US) has been described as a useful adjunct to lumbar puncture (LP). However, evidence demonstrating utility of US in LP in the emergency department is lacking. Objectives: We hypothesized that US-guided LP would increase success and ease of performing LP. Methods: This was an IRB-approved, randomized, prospective, blinded study conducted at an ED with an annual census of 92,000. A convenience sample of patients undergoing LP from January 2004 to December 2004 was enrolled. In addition to palpation landmarks (PL), all patients underwent US to identify the L3–L4 or L4–L5 interspinous space to establish the US landmark (UL). Patients were then randomized to have LP by PL or UL. Investigators identified the landmarks; however, operators were blinded to which landmark was to be used. Data collected included age, body mass index (BMI), number of attempts, ease of performance, and patient comfort on a 10-cm visual analog scale, procedure time, success, and traumatic LP, as defined by >400 RBCs in tube 1. Statistical analysis of data included 95% confidence interval (CI) and Student's t-test. Results: A total of 46 patients were enrolled. Twenty-two patients were randomized to PL and 24 to UL, with no baseline differences in age or BMI. Twelve patients had a BMI >30. Six of 22 attempts failed with PL vs. one of 24 with UL (p = 0.003). There was no difference in number of attempts, traumatic LPs, ease of procedure, patient comfort, or procedure length between groups. In 12 patients with a BMI >30, seven were randomized to PL, five to UL. Four of seven attempts failed with PL vs. 0/5 with UL (p = 0.03). Ease of procedure was significantly better with UL vs. PL, 2.66 (95% CI 2.53 to 2.79) vs. 6.86 (95% CI 6.38 to 7.34) (p = 0.01). There was no difference in number of attempts, traumatic LPs, patient comfort, or procedure length. Conclusions: The use of US for LP significantly reduced the number of failed LPs in all patients and significantly improved ease of procedure in patients with a BMI over 30.

although the data is interesting...the study is flawed in that the operators were folks who do not know how to perform LPs.

The control group had a failure rate of almost 30%!!!!

How many anesthesiologists have a failure rate of 1 in 3 when performing LP.

Interesting data, but this only applies to folks who don't know how to perform LP's.....

 

[jtheater]

I've found US guided peripheral IVs to be more rewarding. It's an PIV that no one else can get, and you avoid the need for a central line (assuming no other need of course).

Totally agree. When you can give someone a 3 day line holiday--that's a good thing. I had no issue using US during my ICU Sub-I for this. Getting a PIV that others can't (US or blind) is a great feeling and great for the patient.

 

[Noyac]

although the data is interesting...the study is flawed in that the operators were folks who do not know how to perform LPs.

The control group had a failure rate of almost 30%!!!!

How many anesthesiologists have a failure rate of 1 in 3 when performing LP.

Interesting data, but this only applies to folks who don't know how to perform LP's.....

How can one not know how to perform an LP? That is truely baffling.

 

[Planktonmd]

How can one not know how to perform an LP? That is truely baffling.

Why do we need to make simple procedures more complicated?
Next thing you will see Lawyers arguing that Ultrasound is the standard of care for central lines!!!

 

[jetproppilot]

Why do we need to make simple procedures more complicated?
Next thing you will see Lawyers arguing that Ultrasound is the standard of care for central lines!!!

 

[Noyac]

Why do we need to make simple procedures more complicated?
Next thing you will see Lawyers arguing that Ultrasound is the standard of care for central lines!!!

They will argue anything to win a case. And then it became the standard of care.

 

[cfdavid]

o.k. so, from the perspective of the attendings on the board, are there ANY procedures you use US for?

 

[Planktonmd]

o.k. so, from the perspective of the attendings on the board, are there ANY procedures you use US for?

Hmmm.. let's see... NO

 

[militarymd]

o.k. so, from the perspective of the attendings on the board, are there ANY procedures you use US for?

I use ultrasound for:

- paracentesis
- thoracentesis
- DIFFICULT nerve blocks.

 

[jetproppilot]

o.k. so, from the perspective of the attendings on the board, are there ANY procedures you use US for?

if I cant find the IJ.

Happened once so far this year.

 

[Noyac]

I've been out 5yrs and haven't needed it.