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Vascular Access

Internal Jugular Cannulation with Ultrasound

  1. Select probe and settings -
    • Small footprint curvilinear (Sonosite C11) for long axis imaging
    • Linear array (Sonosite - L38) for short axis
    Use the highest resolution setting (7-14Mhz). Adjust the depth - usually start at 3cm.
  2. Position US by ipsilateral chest and stand on contralateral side of patient (to ensure needle follows a path from medial to lateral).
  3. Prepare sterile field and place US probe in sterile sheath. Use sterile US gel.
  4. Place probe at the cricoid level. Scan laterally to identify thyroid, carotid artery and jugular vein.
  5. Scan cranially then caudally to assess course of jugular vein. Find a position where the vein is most lateral to the vein.
  6. At root of neck angulate probe towards the thorax to confirm position of subclavian artery and subclavian vein.
  7. Select site of puncture to minimize risk of arterial puncture (carotid and subclavian).
  8. Perform puncture of vein. (Try to image needle tip at all times - For SAX imaging use an angle of 60°, for LAX a needle angle of 30-45° is best).
  9. Confirm puncture by aspiration and presence of needle/wire in vein.
  10. Long axis imaging wire and vein

Notes - Ensure you pass the needle in the direction of the ipsilateral nipple. Inexperienced users often position themselves is such a way as to pass the needle in a direction through the vein and towards the artery. This is especially likely when using SAX imaging. In SAX you see tissue movement. A bright spot DOES NOT mean needle tip, it merely signifies some part of the needle is cutting the US beam. Try to image needle tip by probe angulation. Make small jabs with needle, and confirm position with each. This is best learned in a tissue phantom.

Infraclavicular Axillary Vein Cannulation with Ultrasound

  1. Select probe and settings -
    • Small footprint curvilinear (Sonosite C11) for long axis imaging
    • Linear array (Sonosite - L38) for short axis
    Use the highest resolution setting (7-14Mhz). Adjust the depth - usually start at 5cm.
  2. Position US machine in line with puncture site.
  3. Prepare sterile field and place US probe in sterile sheath. Use sterile US gel.
  4. Infraclavicular axillary vessels
  5. Identify the delto-pectoral groove below the coracoid process. ABDUCT the arm. The vein will appear collapsed otherwise.
  6. Place the probe in the delto-pectoral groove and obtain a long axis (LAX) image of the axillary vein. Compared to the artery it is thin walled and compressible, varies with respiration and has a double pulsation. Pulse wave doppler interrogation shows a venous velocity signal rather than an arterial wave. Colour doppler can be misleading and should be used cautiously - the vein will often show a pulsatile colour doppler signal. The vein lies beneath pectoralis major and minor muscles.
  7. Introduce the needle at a 45° angle, entering the skin in line with the probe at its lateral aspect. Visualise the needle as it enters the vein which is often 3-5cm deep to the skin.
  8. Confirm puncture by aspiration of blood. Pass Seldinger wire. Confirm the wire is in the vein by scanning the length of the vein prior to dilatation.
  9. Ultrasound of axillary vein (LAX) with wire
  10. Complete cannulation as usual.
  11. CVP line in left infraclavicular axillary vein

Femoral Vein Cannulation with Ultrasound

  1. Select probe and settings -
    • Small footprint curvilinear (Sonosite C11) for long axis imaging
    • Linear array (Sonosite - L38) for short axis
    Use the highest resolution setting (7-14Mhz). Adjust the depth - usually start at 5cm.
  2. Setup US by contralateral hip.
  3. Prepare sterile field and place US probe in sterile sheath. Use sterile US gel.
  4. Confirm probe orientation by tapping one side of scanner head.
  5. Scan across the vessel just below the inguinal ligament and identify femoral artery and vein in SAX. As the scanner moves distally, the femoral artery divides and the superficial femoral artery overlies the vein. The long saphenous vein enters the femoral vein. The best site for cannulation is at the inguinal ligament superior to long saphenous. Rotate the probe 90° to obtain a LAX image of the vessels.
  6. Confirm the vessel to be punctured is the vein which is non-pulsatile, compressible and thin walled.
  7. Perform puncture of vein. Try to image needle tip at all times - For SAX imaging use an angle of 60-80°, for LAX a needle angle of 45-60° is best. Often needs a short stabbing motion to puncture vein wall.
  8. Confirm puncture by aspiration and presence of needle in vein. Pass Seldinger wire and confirm presence in vessel.
  9. Pass dilator and complete cannulation as usual.

Brachial Vein Cannulation with Ultrasound

  1. Select probe and settings -
    • Linear array (Sonosite - L38)
    Use the highest resolution setting (7-14Mhz) at shallow depth settings for superficial vessels.
  2. Basilic vein SAX - scan across antecubital fossa medially. Identify brachial artery, median cubital vein and superficially and more medially the basilic vein. This vein has no adjoining arterial and nervous structures and is usually of reasonable size (5-7mm). Follow vein up and down arm to confirm direction. Insert 20g cannula into vessel aspirating with 5ml syringe to confirm placement. Use shallow angle appropriate to the depth of vein and distance of skin penetration from probe. Pass seldinger wire into vein then continue with dilatation and cannulation.
  3. Brachial artery (red) with adjacent vein (left) and median nerve (right)
  4. Brachial vein SAX - the brachial vein is found in the groove between biceps and triceps on the medial side of the arm. The brachial artery is adjacent to it, and also the median and ulnar nerves. Use 20g cannula at 45° angle attached to 5ml syringe aspirating during needle advancement until blood is aspirated. Confirm vein by lack of pulsatility, response to pressure and change in size with valsalva or tourniquet release. Insert needle and cannula in line with probe and into vein.