Name: the supraclavicular fossa ultrasound view for central venous catheter placement and catheter change over guidewire
Uploaded: 2014-12-23T14:00:00.000+00:00
Duration: 7 min 47 s
Description: Watch this Scientific Journal Video about The Supraclavicular Fossa Ultrasound View for Central Venous Catheter Placement and Catheter Change Over Guidewire at JoVE.com

NOTE: The following protocol follows our internal guidelines and standard operation procedures approved by the chair of our department. The same protocol was approved by our institutional review board and was used for studies published in a previous paper8.
1. Pre-ultrasound Scan Preparation
<ol>
	<li>Place the patient in a supine position with an optional elevated head of bed or stretcher for comfort if the patient is awake.</li>
	<li>Position the ultrasound machine in a line with operator&#180;s position and the puncture site to prevent operator&#180;s head or body twisting to see the display. Turn on the ultrasound machine and connect the micro-convex ultrasound probe.</li>
	<li>Choose a pre-set that allows deep tissue penetration, e.g., set probe to 8 MHz or lower. Use alcoholic disinfection on skin for acoustic coupling of the ultrasound probe.</li>
</ol>
2. Ultrasound Scan of the CVC Insertion Site and Superior Vena Cava
<ol>
	<li>Place the micro-convex ultrasound probe on the puncture site. 
	NOTE: A B(rightness)-mode short axis view and out of plane puncture technique is preferred. Adjust gain, depth and focus position for an optimal image.</li>
	<li>Confirm vein by applying pressure to test for compressibility and to exclude thrombus at puncture site. Use color flow doppler if there is uncertainty. Move ultrasound probe centrally to detect potential thrombus.</li>
</ol>
3. Supraclavicular Fossa Ultrasound View
<ol>
	<li>Place the ultrasound probe in the right supraclavicular fossa to obtain a view of the confluence of the internal jugular vein and subclavian vein to detect a potential thrombus. Change gain, depth and focus using knobs of the ultrasound machine. 
	NOTE: Set gain high enough to differentiate between hyperechoic vessel walls and hypoechoic vessel lumen. Set depth (10-12 cm) to have a full view of the SVC and right pulmonary artery (RPA). Set the Focus to the level of the RPA.</li>
	<li>Increase depth (4-6 cm) using the knob of the ultrasound machine to obtain a view of the confluence of the brachiocephalic veins. This will also correspond to the beginning of the upper superior vena cava. Adjust depth (10-12 cm) and angulation of the ultrasound probe to obtain a full longitudinal view of the superior vena cava, adjacent ascending aorta and right pulmonary artery. 
	NOTE: Probe frequency will be adjusted by the ultrasound machine depending on depth of imaging.</li>
	<li>Evaluate the brachiocephalic veins and the superior vena cava for intravenous thrombus. Turn the ultrasound probe 90&#176; clockwise to obtain a sagittal view of the superior vena cava. Observe the right pulmonary artery in short axis dorsal of the lower superior vena cava. Additionally, observe a short axis view of the pulmonary veins distal of the right pulmonary artery. Use optional Doppler to confirm superior vena cava.</li>
</ol>
4. Ultrasound Guided Venipuncture
<ol>
	<li>Prepare CVC kit and dress with sterile gown and gloves. Disinfect skin with alcohol wipes and apply sterile drapes. Insert ultrasound probe into a sterile cover. Ultrasound guided venipuncture can be performed in non-sedated as well as in anesthetized patients. 
	NOTE: For non-sedated patients a local infiltration anesthesia before venipuncture is highly recommended.</li>
	<li>Obtain an ultrasound view of the vein to be punctured. Right-handed operators use the needle attached to a syringe in the right hand and the ultrasound probe in the left hand.</li>
	<li>Perform a venipuncture under ultrasound guidance. 
	NOTE: Out of plane and in plane techniques are both appropriate.</li>
	<li>Following venipuncture, insert the guidewire through the needle. At this point, a long axis view of the vein can confirm the guidewire within the vein.</li>
</ol>
5. Ultrasound Guided Guidewire Advancement
<ol>
	<li>Switch ultrasound probe to the right hand. Obtain a view of the superior vena cava by adjusting depth and focus position of the ultrasound image (Figure 3A and supplemental video loop). 
	NOTE: This has to be done by an assisting person or by the operator himself if the ultrasound machine is operated with a sterile cover. Angulation of the ultrasound probe needs to be in a small angle in relation to neck.</li>
	<li>Advance the guidewire with the left hand. Do not introduce the guidewire too far into the superior vena cava because this will make it difficult to identify the guidewire tip. Visualize the guidewire J-tip during advancement and crossing of the upper wall of the right pulmonary artery (Figure 3B).</li>
	<li>If the ultrasound beam cannot be aligned with the J-tip and the right pulmonary artery, use the ascending aorta as a landmark. Turn the ultrasound probe 90&#176; clockwise to obtain a sagittal view of the superior vena cava. With this view, confirm the guidewire position relative to the right pulmonary artery observed in the short axis.</li>
</ol>
6. Measurement of Insertion Depth
<ol>
	<li>Use the central venous catheter to measure the insertion depth of the guidewire. In order to do so, align the 20 cm markings of the CVC and the guidewire and read the cm marking at the venipuncture site. 
	NOTE: The guidewire has markings at 10, 20 cm and at the position indicating that the J-tip leaves the distal lumen. These markings may be different depending on the manufacturer. Be careful not to move the guidewire. 
	NOTE: From this point on, complete placement according to standard hospital protocol, including dilation of skin and vein, insertion of the CVC over guidewire, aspiration and flushing and suture.</li>
</ol>
7. Lung Ultrasound
<ol>
	<li>In the perioperative setting, perform a lung ultrasound examination in the patient to exclude pneumothorax following CVC placement. 
	NOTE: This procedure has been described by Lichtenstein et al.11.</li>
	<li>Place the ultrasound probe in all four quadrants of the anterior chest bilaterally to obtain view in B-mode for lung sliding and M-mode for seashore sign. Preferably use a linear ultrasound probe. For obese patients, use an ultrasound probe with higher penetration, e.g., curved array or micro-convex probes.</li>
</ol>
8. Central Venous Catheter Change Over Guidewire
NOTE: CVC change over guidewire is a single contributor to catheter-related blood stream infection and should be avoided. In patients with a high risk of mechanical complication related to CVC insertion or limited venous access, CVC change over guidewire still can be considered12.
<ol>
	<li>In case of a misplaced central venous catheter (not using the ultrasound guided tip position method), obtain a supraclavicular view to advance the guidewire into the correct position. Under sterile conditions, introduce a guidewire into the distal lumen of the misplaced central venous catheter. Change of a CVC over a guidewire with ultrasound guidance works in non-sedated patients as well as in anesthetized patients.
	<ol>
		<li>Pull back the central venous catheter. Visualize the guidewire from thesupraclavicular fossa view.</li>
		<li>Advance the guidewire into the correct position in the superior vena cava. Introduce the new central venous catheter over the guidewire.</li>
		<li>From this point on, complete procedure according to standard hospital protocol.</li>
	</ol>
	</li>
</ol>

<ol>
	<li>Troianos, C. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Special+articles:+guidelines+for+performing+ultrasound+guided+vascular+cannulation:+recommendations+of+the+American+Society+of+Echocardiography+and+the+Society+Of+Cardiovascular+Anesthesiologists.">Special articles: guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society Of Cardiovascular Anesthesiologists.</a> Anesth Analg. 114 (1), 46-72 (2012).</li><li>Cavanna, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound-guided+central+venous+catheterization+in+cancer+patients+improves+the+success+rate+of+cannulation+and+reduces+mechanical+complications:+a+prospective+observational+study+of+1,978+consecutive+catheterizations.">Ultrasound-guided central venous catheterization in cancer patients improves the success rate of cannulation and reduces mechanical complications: a prospective observational study of 1,978 consecutive catheterizations.</a> World J Surg Oncol. 8 (91), (2010).</li><li>Wirsing, M., Schummer, C., Neumann, R., Steenbeck, J., Schmidt, P., Schummer, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Is+traditional+reading+of+the+bedside+chest+radiograph+appropriate+to+detect+intraatrial+central+venous+catheter+position.">Is traditional reading of the bedside chest radiograph appropriate to detect intraatrial central venous catheter position.</a> Chest. 134 (3), 527-533 (2008).</li><li>Ender, J., Erdoes, G., Krohmer, E., Olthoff, D., Mukherjee, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transesophageal+echocardiography+for+verification+of+the+position+of+the+electrocardiographically-placed+central+venous+catheter.">Transesophageal echocardiography for verification of the position of the electrocardiographically-placed central venous catheter.</a> J Cardiothorac Vasc Anesth. 23 (4), 457-461 (2009).</li><li>Pittiruti, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+intracavitary+ECG+method+for+positioning+the+tip+of+central+venous+catheters:+results+of+an+Italian+multicenter+study.">The intracavitary ECG method for positioning the tip of central venous catheters: results of an Italian multicenter study.</a> J Vasc Access. 13 (3), 357-365 (2012).</li><li>Matsushima, K., Frankel, H. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bedside+ultrasound+can+safely+eliminate+the+need+for+chest+radiographs+after+central+venous+catheter+placement:+CVC+sono+in+the+surgical+ICU+(SICU).">Bedside ultrasound can safely eliminate the need for chest radiographs after central venous catheter placement: CVC sono in the surgical ICU (SICU).</a> J Surg Res. 163 (1), 155-161 (2010).</li><li>Matsushima, K., Frankel, H. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Detection+of+central+venous+catheter+insertion-related+complication+using+bedside+ultrasound:+the+CVC+sono.">Detection of central venous catheter insertion-related complication using bedside ultrasound: the CVC sono.</a> J Trauma. 70 (6), 1561-1563 (2011).</li><li>Kim, S. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound+confirmation+of+central+venous+catheter+position+via+a+right+supraclavicular+fossa+view+using+a+microconvex+probe:+A+observational+pilot+study.">Ultrasound confirmation of central venous catheter position via a right supraclavicular fossa view using a microconvex probe: A observational pilot study.</a> Eur J Anaesthesiol. , (2013).</li><li>Lanspa, M. J., Fair, J., Hirshberg, E. L., Grissom, C. K., Brown, S. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound-guided+Subclavian+Vein+Cannulation+Using+a+Micro-Convex+Ultrasound+Probe.">Ultrasound-guided Subclavian Vein Cannulation Using a Micro-Convex Ultrasound Probe.</a> Ann Am Thorac Soc. 11 (4), 583-586 (2014).</li><li>Weber, S. U., Kim, S. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+right+supraclavicular+ultrasound+view+for+real-time+ultrasound-guided+definite+placement+of+a+central+venous+catheter+with+a+microconvex+transducer.">The right supraclavicular ultrasound view for real-time ultrasound-guided definite placement of a central venous catheter with a microconvex transducer.</a> Eur J Anaesthesiol. 31 (3), 173-174 (2014).</li><li>Lichtenstein, D. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound+diagnosis+of+occult+pneumothorax.">Ultrasound diagnosis of occult pneumothorax.</a> Crit Care Med. 33 (6), 1231-1238 (2005).</li><li>Garnacho-Montero, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Risk+factors+and+prognosis+of+catheter-related+bloodstream+infection+in+critically+ill+patients:+a+multicenter+study.">Risk factors and prognosis of catheter-related bloodstream infection in critically ill patients: a multicenter study.</a> Intensive Care Med. 34 (12), 2185-2193 (2008).</li><li>Schummer, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intra-atrial+ECG+is+not+a+reliable+method+for+positioning+left+internal+jugular+vein+catheters.">Intra-atrial ECG is not a reliable method for positioning left internal jugular vein catheters.</a> Br J Anaesth. 91 (4), 481-486 (2003).</li></ol>

The authors declare that they have no competing financial interests.

This procedure allows for visualization of ultrasound guided venipuncture and central venous catheter tip position in real time via the right supraclaviculare fossa view. In combination with a lung ultrasound scan, this approach could replace chest radiograph for confirmation of catheter tip position and exclusion of a pneumothorax.
It is critical for ultrasound trained operators to become familiar with the ultrasound anatomy provided by the supraclavicular fossa view and correctly identify th...

Central venous catheter (CVC) tip position has to be confirmed since misplaced catheters can lead to trauma and erosion of endothelium and vessel walls with subsequent potentially fatal pericardial tamponade1. Furthermore, CVC in the upper superior vena cava (SVC) can provoke thrombotic events, especially in cancer patients. The same is true for misplaced CVC in opposite brachiocephalic vein or internal jugular vein (IJV)2.
Several methods have been established to confirm CVC tip position in the lower SVC. Chest radiograph has been performed traditionally as a bedside method to visualize the CVC tip and exclude pneumothorax. However, additionally to exposure to radiation and costs, the accuracy of chest radiograph for tip position and sensitivity for pneumothorax have been questioned, specifically for the patient in a supine position3. Computer tomography is highly accurate and sensitive for both CVC tip position and pneumothorax, respectively. However, the costs and exposure to radiation do not justify this method for the sole indication of CVC tip confirmation. Transesophageal echocardiography (TEE) is highly accurate for tip position, but indication for TEE is limited to patients with cardiac pathology4. Intra-cardiac electrocardiography (ECG) is an accurate method but depends on a p-wave cardiac rhythm5.
Parasternal and subcostal ultrasound view were suggested to verify the CVC tip position, but success depends on deep insertion of the guidewire into the right atrium. A negative result does not exclude misplaced catheters6,7. The right supraclavicular fossa ultrasound view has been solely described for diagnostic purposes in cardiac failure. In a pilot study, we have demonstrated that this view can also be safely used for venipuncture of the right IJV and accurate positioning of the CVC guidewire with subsequent CVC placement in real-time8. The right supraclavicular fossa ultrasound view can be established with a microconvex probe which has the advantage of a small footprint, deep pentetration and, yet a sufficient resolution for venipuncture when compared to a linear probe8-10.
The proposed procedure has the advantage of visualizing venipuncture and guidewire advancement with a single ultrasound probe within the sterile field in real-time. CVCs insertion length does not have to be corrected afterwards and extra manipulations and potential sources of contamination are prevented. In conjunction with lung ultrasound for exclusion of a pneumothorax, the proposed procedure has the potential to replace chest radiograph for CVC tip position confirmation and exclusion of pneumothorax, reducing costs and exposure to radiation and increasing patient comfort in any hospital setting where an ultrasound machine equipped with a microconvex ultrasound probe is available.

<table><tbody><tr><td>Skin disinfectant</td><td>Ecolab</td><td>2686556</td><td>Skinsept G</td></tr><tr><td>8C-RS microconvex probe</td><td>GE Healthcare</td><td>8C-RS</td><td>Any ultrasound machine equipped with a microconvex ultrasound probe should be suitable for this method.</td></tr><tr><td>Logiq e ultrasound machine</td><td>GE Healthcare</td><td>Logiq e</td><td></td></tr><tr><td>CVC kit</td><td>Teleflex Medical</td><td>OW-15802-E</td><td>8 Fr. 2 Lumen Blue-Flex tip catheter</td></tr><tr><td>Sterile gloves</td><td>Protexix</td><td>2D72NT70X</td><td>LatexMicro</td></tr><tr><td>Sterile gown</td><td>Medline</td><td>OP9512CE</td><td>OPS Advanced</td></tr><tr><td>Sterile ultrasound probe cover</td><td>CIVCO</td><td>610-637</td><td>CIV-Fle Transducer Cover; sterile 8.9 x 91.5 cm</td></tr><tr><td>Suture</td><td>Ethicon</td><td>EH7723</td><td>Ethibond</td></tr><tr><td>12L-RS linear ultrasound probe</td><td>GE Healthcare</td><td></td><td>any linear ultrasound probe is suitable for lung ultrasound</td></tr></tbody></table>

the supraclavicular fossa ultrasound view for central venous catheter placement and catheter change over guidewire

The supraclavicular fossa ultrasound view can be useful for central venous catheter (CVC) placement. Venipuncture of the internal jugular veins (IJV) or subclavian veins is performed with a micro-convex ultrasound probe, using a neonatal abdominal preset with a probe frequency of 10 Mhz at a depth of 10-12 cm. Following insertion of the guidewire into the vein, the probe is shifted to the right supraclavicular fossa to obtain a view of the superior vena cava (SVC), right pulmonary artery and ascending aorta. Under real-time ultrasound view, the guidewire and its J-tip is visualized and pushed forward to the lower SVC. Insertion depth is read from guidewire marks using central venous catheter. CVC is then inserted following skin and venous dilation. The supraclavicular fossa view is most suitable for right IJV CVC insertion. If other insertion sites are chosen the right supraclavicular fossa should be within the sterile field. Scanning of the IJVs, brachiocephalic veins and SVC can reveal significant thrombosis before venipuncture. Misplaced CVCs can be corrected with a change over guidewire technique under real-time ultrasound guidance. In conjunction with a diagnostic lung ultrasound scan, this technique has a potential to replace chest radiograph for confirmation of CVC tip position and exclusion of pneumothorax. Moreover, this view is of advantage in patients with a non-p-wave cardiac rhythm were an intra-cardiac electrocardiography (ECG) is not feasible for CVC tip position confirmation. Limitations of the method are lack of availability of a micro-convex probe and the need for training.

In a previously published study, chest radiographs were obtained in all patients following ultrasound guided CVC placement8. The CVC tip position in relation to the carina on chest radiographs was analysed by a radiologist who confirmed a correct position of the CVC in the lower SVC in all investigated patients. In 90% of all cases CVC tip was within 35 mm distance of the carina. In 17% the CVC tip was above, in 19% at the level of and in 64% below the carina. In 4% the CVC tip was more than 55 mm below the ca...

Watch this Scientific Journal Video about The Supraclavicular Fossa Ultrasound View for Central Venous Catheter Placement and Catheter Change Over Guidewire at JoVE.com

The Supraclavicular Fossa Ultrasound View for Central Venous Catheter Placement and Catheter Change Over Guidewire

The overall goal is to enable clinicians to insert a central venous catheter under real-time ultrasound guidance via the right supraclavicular fossa view of the lower part of the superior vena cava. This view is useful for different catheter insertion sites, thrombosis detection before insertion and ultrasound guided correction of misplaced catheters.

The supraclavicular fossa ultrasound view can be useful for central venous catheter (CVC) placement. Venipuncture of the internal jugular veins (IJV) or ...

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Research

JoVE Journal

Medicine

18.8K Views.  University Hospital Bonn. The overall goal is to enable clinicians to insert a central venous catheter under real-time ultrasound guidance via the right supraclavicular fossa view of the lower part of the superior vena cava. This view is useful for different catheter insertion sites, thrombosis detection before insertion and ultrasound guided correction of misplaced catheters.

Video: The Supraclavicular Fossa Ultrasound View for Central Venous Catheter Placement and Catheter Change Over Guidewire

Non-fluoroscopic Catheter Tracking for Fluoroscopy Reduction in Interventional Electrophysiology

A technological platform (MediGuide) has been recently introduced for non-fluoroscopic catheter tracking. In several studies, we have demonstrated that the application of this non-fluoroscopic catheter visualization system (NFCV) reduces fluoroscopy time and dose by 90-95% in a variety of electrophysiology (EP) procedures. This can be of relevance not only to the patients, but also to the nurses and physicians working in the EP lab. Furthermore, in a subset of indications such as supraventricular tachycardias, NFCV enables a fully non-fluoroscopic procedure and allows the lab staff to work without wearing lead aprons. With this protocol, we demonstrate that even complex procedures such as ablations of atrial fibrillation, that are typically associated with fluoroscopy times of &#62;30 min in conventional settings, can safely be performed with a reduction of &#62;90% in fluoroscopy exposure by the additional use of NFCV.

Radiation exposure is an underestimated risk in complex ablation procedures. Here, we describe a protocol to significantly decrease fluoroscopy time and dosage for both the patient and the lab staff by using a novel non-fluoroscopic catheter visualization system.

A technological platform (MediGuide) has been recently introduced for non-fluoroscopic catheter tracking. In several studies, we have demonstrated that ...

3D Angiography for Venous Compliance Assessment in Sheep

Quantifying Inferior Vena Cava Compliance and Distensibility in an In Vivo Ovine Model Using 3D Angiography

Synthetic vascular grafts overcome some challenges of allografts, autografts, and xenografts but are often more rigid and less compliant than the native vessel into which they are implanted. Compliance matching with the native vessel is emerging as a key property for graft success. The current gold standard for assessing vessel compliance involves the vessel's excision and ex vivo biaxial mechanical testing. We developed an in vivo method to assess venous compliance and distensibility that better reflects natural physiology and takes into consideration the impact of a pressure change caused by flowing blood and by any morphologic changes present. 
This method is designed as a survival procedure, facilitating longitudinal studies while potentially reducing the need for animal use. Our method involves injecting a 20 mL/kg saline bolus into the venous vasculature, followed by the acquisition of pre and post bolus 3D angiograms to observe alterations induced by the bolus, concurrently with intravascular pressure measurements in target regions. We are then able to measure the circumference and the cross-sectional area of the vessel pre and post bolus. 
With these data and the intravascular pressure, we are able to calculate the compliance and distensibility with specific equations. This method was used to compare the inferior vena cava's compliance and distensibility in native unoperated sheep to the conduit of sheep implanted with a long-term expanded polytetrafluorethylene (PTFE) graft. The native vessel was found to be more compliant and distensible than the PTFE graft at all measured locations. We conclude that this method safely provides in vivo measurements of vein compliance and distensibility.

Author Spotlight: Improved Imaging for Neovascular Development in Congenital Heart Disease Research

This protocol allows for the in vivo quantification of venous compliance and distensibility using catheterization and 3D angiography as a survival procedure allowing for a variety of potential applications.

Synthetic vascular grafts overcome some challenges of allografts, autografts, and xenografts but are often more rigid and less compliant than the native ...

Bioengineering

Standardized Model of Ventricular Fibrillation and Advanced Cardiac Life Support in Swine

Cardiopulmonary resuscitation after cardiac arrest, independent of its origin, is a regularly encountered medical emergency in hospitals as well as preclinical settings. Prospective randomized trials in human subjects are difficult to design and ethically ambiguous, which results in a lack of evidence-based therapies. The model presented in this report represents one of the most common causes of cardiac arrests, ventricular fibrillation, in a standardized setting in a large animal model. This allows for reproducible observations and various therapeutic interventions under clinically accurate conditions, hence facilitating the generation of better evidence and eventually the potential for improved medical treatment.

Cardiopulmonary resuscitation and defibrillation are the only effective therapeutic options during cardiac arrest caused by ventricular fibrillation. This model presents a standardized regimen to induce, assess, and treat this physiological state in a porcine model, thus providing a clinical approach with various opportunities for data collection and analysis.

Cardiopulmonary resuscitation after cardiac arrest, independent of its origin, is a regularly encountered medical emergency in hospitals as well as ...

Image Acquisition Method for the Sonographic Assessment of the Inferior Vena Cava

Over the past several decades, clinicians have incorporated several applications of diagnostic point-of-care ultrasound (POCUS) into medical decision-making. Among the applications of POCUS, imaging the inferior vena cava (IVC) is practiced by a wide variety of specialties, such as nephrology, emergency medicine, internal medicine, critical care, anesthesiology, pulmonology, and cardiology. Although each specialty uses IVC data in slightly different ways, most medical specialties, at minimum, attempt to use IVC data to make predictions about intravascular volume status. While the relationship between IVC sonographic data and intravascular volume status is complex and highly context-dependent, all clinicians should collect the sonographic data in standardized ways to ensure repeatability. This paper describes standardized IVC image acquisition including patient positioning, transducer selection, probe placement, image optimization, and the pitfalls and limitations of IVC sonographic imaging.&#160;This paper also describes the commonly performed anterior IVC long-axis view and three other views of the IVC that can each provide helpful diagnostic information when the anterior long-axis view is difficult to obtain or interpret.

Point-of-care ultrasound evaluation of the inferior vena cava (IVC) is commonly utilized to identify, among other things, the volume status. Imaging should be performed systematically to ensure repeatability. This manuscript reviews the methods and pitfalls of sonographic IVC examination.

Over the past several decades, clinicians have incorporated several applications of diagnostic point-of-care ultrasound (POCUS) into medical ...

Intubation, Central Venous Catheter, and Arterial Line Placement in Swine for Translational Research in Abdominal Transplantation Surgery

Translational surgical research models in swine are crucial for developing safe preclinical protocols. However, the success of the experimental surgeries does not solely rely on the research team's surgical skills; perioperative care and management procedures, like intubation, central venous line, and arterial line placement, are necessary and of the utmost importance for favorable experiment results. As it is uncommon for research teams to have anesthesiologists or any other staff other than the surgical team, the surgical team involved in translational research must acquire and/or develop the skills to perform the perioperative care. The purpose of this paper is to show the techniques of intubation, central venous catheter, and arterial line placement used and perfected at the Toronto Organ Preservation Laboratory over the last 10 years, to be used as a reference for future researchers joining either this team or any other lab performing translational research protocols in swine and/or abdominal transplantation.

To obtain the best possible results, surgeons performing translational research experiments should be proficient at intubation and vascular line placement. This paper describes the techniques used by the Toronto Organ Preservation Laboratory to perform these procedures.

Translational surgical research models in swine are crucial for developing safe preclinical protocols. However, the success of the experimental surgeries ...

Training Novices in POCUS for Vascular Cannulation Using Simulation Models

Using Simulation Models to Train Clinicians in the Use of Point-of-Care Ultrasound

The use of point-of-care ultrasound (POCUS) has shown to be a beneficial non-invasive vascular access assessment method by clinicians, which can provide critical elements of visual and measurable information that proves to be useful in the context of vascular access cannulation, in combination with the practical skill of the clinician performing the cannulation. However, the use of POCUS in this context is to practically train and enable individuals who are novices in using this technique to become proficient in performing this task subsequently on patients in a careful and successful way. The simulation of these vascular conditions may be useful to help healthcare professionals learn, understand, apply, and establish such practical skills for vascular cannulation safely to achieve the desired outcomes. This project intended, through the attendance of a half-day workshop, to establish skills to use POCUS in connection with simulation models and perform specific tasks to enable clinicians to use this method in their clinical practice for vascular access cannulation in patients. A mixed-methods longitudinal study design was used to evaluate the effect of a point-of-care ultrasound workshop for peripheral intravenous cannula insertion, including specific tasks for the participants to be performed on simulation models. A total of 81 individuals participated in 11 half-day workshops through 2021 and 2022. Offering a workshop that uses simulation models in combination with various POCUS devices is useful in establishing this newly learned skill in clinicians, such as measurements of depth, caliper, and direction of a vein with POCUS prior to cannulation providing essential anatomical facts to the operator, which increases the likelihood of first-time success in cannulation.

Author Spotlight: Evaluating Clinicians' Adoption of Ultrasound-Guided Vascular Cannulation Through Simulation Training

The present protocol describes an ideal solution to train novices in the use of point-of-care ultrasound devices for the practical clinical skill of visually assessing distinct individual anatomical vascular conditions prior to and during an intended venous vascular cannulation using point-of-care ultrasound in a patient.

The use of point-of-care ultrasound (POCUS) has shown to be a beneficial non-invasive vascular access assessment method by clinicians, which can provide ...

COVID-19 / Coronavirus Outbreak: How To Establish A Central Venous Access By Placing A Central Venous Catheter

In pandemic times, medical staff is becoming a key resource in fighting the infection. To achieve the best medical care, relevant techniques and procedures have to be taught to medical staff while reducing the risk of infection. Intensive care medical&#160;treatment can necessitate central venous catheters due to different indications like vasopressor therapy or treatment of&#160;the patient with vein irrigating substances. This video shows the placement of central venous catheters for intensive care patients.&#160;

COVID-19 / Coronavirus Outbreak: How to Establish a Central Venous Access by Placing a Central Venous Catheter

In pandemic times, medical staff is becoming a key resource in fighting the infection. To achieve the best medical care, relevant techniques and ...

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Coronavirus / COVID-19 Procedures

Peripheral Venous Cannulation

Source: Sharon Bord, MD, Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Maryland, USA
Placement of an intravenous (IV) catheter is one of the key procedures in medicine. The IV catheter allows patients to receive critical medications, including pain medicine, insulin, antibiotics, blood products, and fluids for rehydration. Additionally, placing an IV catheter allows for blood samples to be obtained, which can be sent to the laboratory for testing and evaluation. A majority of peripheral IV lines are placed in the superficially located veins of the upper extremities. IV catheters can be placed in any superficial vein from the upper arm to the hand (though the veins in the antecubital fossa are larger than those in the hand). IV catheters can be placed in the lower extremities as well; however, this procedure should be performed with caution in patients with a history of diabetes or poor peripheral circulation.

Peripheral Venous Cannulation and Catheter Insertion

Source: Sharon Bord, MD, Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Maryland, USA
Placement of an intravenous (IV) ...

Emergency Medicine and Critical Care

Central Venous Catheter Insertion: Internal Jugular

Source: James W Bonz, MD, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
Central venous access is necessary in a multitude of clinical situations, including vascular access, vasopressor and caustic medication delivery, central venous pressure monitoring, intravascular device delivery (pacing wires, Swann-Ganz catheters), volume resuscitation, total parental nutrition, hemodialysis, and frequent phlebotomy.
Safe reliable placement of a central venous catheter (CVC) in the internal jugular (IJ) vein using ultrasound guidance has become the standard of care. It is therefore imperative to understand the anatomy, the relationship between the IJ and the carotid artery, and their appearance on ultrasound. It is also necessary to have the psychomotor skills of vessel cannulation under ultrasound guidance.
Seldinger technique is an introduction of a device into the body over a guide wire, which is inserted through a thin-walled needle. In the case of CVC insertion, the device is an intravascular catheter and the target vessel is a central vein. First, the target vessel is cannulated with an 18 gauge thin-walled needle. A guide wire is then passed thought the needle until it is appropriately positioned within the vessel. The needle is removed, and a dilator is passed over the wire to dilate the skin and soft tissue to the level of the vessel. The dilator is then removed, and the catheter is passed over the wire until it is appropriately positioned within the vessel. Lastly, the guide wire is removed.
Successful placement of a CVC using ultrasound consists of a working understanding of the target anatomy, facility with procedural ultrasound, and fluidity in Seldinger technique. An IJ CVC can be placed in either the right or the left IJ vein. In general, however, the right IJ vein is preferred because of its straight route to the superior vena cava (SVC), which makes malposition of the catheter less likely.
There are several types of CVC kits commonly available marketed by different manufacturers. CVCs may a single lumen, a double lumen, or a triple lumen. For purposes of this discussion, we will place a triple-lumen CVC, as this is commonly needed when multiple different medications need to be delivered simultaneously. The procedure for placing any type of CVC is the same.

Catheter Insertion in Internal Jugular: the Seldinger Technique

Source: James W Bonz, MD, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
Central venous access is necessary in a multitude of ...

Central Venous Catheter Insertion: Femoral Vein

Source: James W Bonz, MD, Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
Central venous access is necessary in a multitude of clinical situations, including vascular access, vasopressor and caustic medication delivery, central venous pressure monitoring, volume resuscitation, total parental nutrition, hemodialysis, and frequent phlebotomy. There are three veins in the body that are accessed for central venous cannulation: the internal jugular, the subclavian, and the femoral. Each of these vessels has distinct advantages and disadvantages with unique anatomical considerations. 
Femoral vein cannulation can be easily performed both under ultrasound guidance and using the surface landmarks; therefore, femoral access is often used when emergent placement of a central venous catheter (CVC) is needed (such as in the case of medical codes and trauma resuscitations). In addition, cannulation of the femoral artery allows one to simultaneously perform other procedures needed for stabilization, such as cardiopulmonary resuscitation (CPR) and intubation.
Successful placement of a femoral CVC requires working understanding of the target anatomy, access to with procedural ultrasound, and fluidity in the Seldinger technique.
Seldinger technique is the introduction of a device into the body over a guide wire, which is placed through a thin-walled needle. In the case of CVC insertion, the device is an intravascular catheter and the target vessel is a central vein. First, the target vessel is cannulated with an 18-gauge thin-walled needle. A guide wire is then passed through the needle until it is appropriately positioned within the vessel. The needle is removed and a dilator is passed over the wire to dilate the skin and soft tissue to the level of the vessel. The dilator is then removed and the catheter is passed over the wire until it is appropriately positioned within the vessel. Lastly, the guide wire is removed.
The main disadvantage of a femoral CVC is the high incidence of infection due to proximity to the groin (and often as a result of the quasi-sterile nature under which emergent CVCs are placed). Femoral lines should be replaced early on in the patient's hospital course if sustained central access is needed. A line placed with minimal sterility should be replaced as soon as the patient is stable.