Tricks of the Trade: Vascular Access - UCSF CME · Tricks of the Trade: Vascular Access Michelle Lin, MD UCSF Academy Endowed Chair of EM Education UCSF Associate Professor of Emergency

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

[email protected]

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