U/S in Internal

[entangledphoton]

It seems to me that bedside ultrasound is playing an increasingly important role in IM and will likely replace aspects of the physical exam in the future. Do you guys think IM is heading in this direction? And, do you know which IM programs teach ultrasound rigorously? I have heard Calgary does but I imagine there are others.

[A-Stark]

My program doesn't do any ultrasound directly; instead the emerg people run a point-of-care US course with designated scanning days for all enrolled residents. There is a separate course for ultrasound-guided central and peripheral line placement. We also recently acquired a portable (though hardly handheld) ultrasound which is presently sitting in our lounge.

[Real Beef]

Point of Care U/S (POCUS) is really spearheaded by the emerg docs in centers though there is lot of interest from other non-radiology specilaties - anesthiology, intensive care, etc. Not sure whether it is incorporated in the residencies however because a lot of staff are not familiar with it.

[NLengr]

My program doesn't do any ultrasound directly; instead the emerg people run a point-of-care US course with designated scanning days for all enrolled residents. There is a separate course for ultrasound-guided central and peripheral line placement. We also recently acquired a portable (though hardly handheld) ultrasound which is presently sitting in our lounge.

 

Are you guys still putting central lines in without u/s? At my enter they harp on and on about how it's std. of care now, especially for IJ's.

 

That being said, it's pretty useless for subclavian, and femoral's (venous and arterial) are so easy the U/S is overkill.

 

As a surgeon, I hate point of care U/S. Non surgeons often try to use it to replace formal imaging when they consult us. In reality, from a surgical perspective, it's role is to guide what formal imaging you pick prior to calling a surgical specialty.

[A-Stark]

We're definitely supposed to use it for IJs, hazy about anything else. The femoral dialysis line I put in was without U/S. I don't really use POCUS that much; I'm more interested in bedside echo and assessing the sizes of pleural effusions and ascites. But I don't do taps with it so much as to help landmark.

 

The emerg guys love it, but the requirements for certification are overly onerous.

[bloh]

I've only seen it used for IJs and occasionally for femorals just to look at the anatomy (not used during the actual procedure). The bedside U/S i've seen been used routinely for doing pleural taps; I've used it myself as a student and it isn't too hard. Any technology that reduces my reliance on rads and their **** hours is a bonus in my mind!

 

I've seen some cardio fellows use the bedside echos to assess for gross wall motion abnormalities during STEMIs and such but the entire process to me seems like lifting the XRays into the light to see things, i.e. prone to ****storms if people start relying on it too much.

[leviathan]

It is considered standard of care to use it for IJs and not just to look at the anatomy before you start but for the duration of the procedure. Far too many complications when it's not used, and it can happen even in experienced hands. If you have a complication and decided not to use a machine that was available, it might be hard to defend that in court.

 

Even with ultrasound guided insertion and allegedly verifying needletip in the IJ, there are still reported complications of dilating carotids and causing strokes. Some people are arguing that you need to transduce the pressure to confirm before dilating. That might be less important if you're using a double or triple lumen and more so with the vascaths, but the studies I've read don't specify what lines were used when complications had occurred.

[bloh]

I should have separated the IJ and the femoral examples into 2 sentences. Of course you use the ultrasound during IJ insertion.

[NLengr]

It is considered standard of care to use it for IJs and not just to look at the anatomy before you start but for the duration of the procedure. Far too many complications when it's not used, and it can happen even in experienced hands. If you have a complication and decided not to use a machine that was available, it might be hard to defend that in court.

 

Even with ultrasound guided insertion and allegedly verifying needletip in the IJ, there are still reported complications of dilating carotids and causing strokes. Some people are arguing that you need to transduce the pressure to confirm before dilating. That might be less important if you're using a double or triple lumen and more so with the vascaths, but the studies I've read don't specify what lines were used when complications had occurred.

 

You would think the high pressure plusatile spurting blood would tip people off that they are in the carotid prior to dilating. I know it did for me when I did it.

 

On a side note, I used to love banging in femoral art. Lines on ICU and watching people who weren't used to that access freak when the blood would be spurting the length of the bed when I would take the syringe off and still have the needle in place.

[leviathan]

You would think the high pressure plusatile spurting blood would tip people off that they are in the carotid prior to dilating. I know it did for me when I did it.

They must have had a solid blood pressure then? Unfortunately the type of people who get central lines are often very hypotensive and hypoxemic with narrow pulse pressures, so it can potentially fool you.

[NLengr]

They must have had a solid blood pressure then? Unfortunately the type of people who get central lines are often very hypotensive and hypoxemic with narrow pulse pressures, so it can potentially fool you.

 

Really? I've never been aware of the type of patient who gets lines.

 

I've usually got peripheral pressors running temporarily to get the MAP up. If your pressure is in your boots, as long as I have a decently reliable cuff pressure, the line can wait until the patient is stabilized. I'm a surgeon so I have never done CCU. Might be a different story there.

 

That being said, for IJ's I've always used real time U/S guidance. It makes the whole thing less of a hassle.

 

Either way, if I'm rushed and you are unstable, you are getting a subclavian wide bore access or a femoral.

[leviathan]

Really? I've never been aware of the type of patient who gets lines.

 

I've usually got peripheral pressors running temporarily to get the MAP up. If your pressure is in your boots, as long as I have a decently reliable cuff pressure, the line can wait until the patient is stabilized. I'm a surgeon so I have never done CCU. Might be a different story there.

 

That being said, for IJ's I've always used real time U/S guidance. It makes the whole thing less of a hassle.

 

Either way, if I'm rushed and you are unstable, you are getting a subclavian wide bore access or a femoral.

Didn't mean to come across as condescending, it's just not been my experience that the patients I'm putting lines in have pressures high enough to cause arterial blood spurting across the room. I have to imagine that the reported complications you read about did not have pulsatile bright red blood coming out beforehnad, but I guess you never know who's doing those lines!

[cheech10]

U/S guided central line insertion is definitely NOT standard of care, and if placing central lines is in your scope of practice you need to learn how to do it via landmarks as well. There are plenty of ICUs around the country that don't even have a portable ultrasound. Subclavian lines don't benefit much from U/S either. And there's always the chance of equipment failure. See here for the viewpoint of a very pro-ultrasound ICU staff that still advocates for learning and using anatomic landmarking. Ultrasound is a very valuable tool particularly for difficult to place lines, but please don't throw around words like standard of care that have specific medicolegal meaning.

[NLengr]

U/S guided central line insertion is definitely NOT standard of care, and if placing central lines is in your scope of practice you need to learn how to do it via landmarks as well. There are plenty of ICUs around the country that don't even have a portable ultrasound. Subclavian lines don't benefit much from U/S either. And there's always the chance of equipment failure. See here for the viewpoint of a very pro-ultrasound ICU staff that still advocates for learning and using anatomic landmarking. Ultrasound is a very valuable tool particularly for difficult to place lines, but please don't throw around words like standard of care that have specific medicolegal meaning.

 

I was quoting several of the ICU staff at my center.

 

The necessity of knowing landmark placement is kind of like how lap chole, appendectomy or nephrectomy is standard and better for most cases, but you sure as hell better know how to do it open in case something happens during the lap procedure.

[cheech10]

Then your staff should be more careful of what they say. I'm also an ICU attending, and I can say unequivocally that it is not standard of care, at least for now. Standard of care has a precise legal meaning, and we should be careful in using it. If U/S for line insertion were standard of care, then every time that we do a line based on landmarks we would be practising deficiently, and open to the legal risk of medical malpractice.

 

Anecdotally, my line insertions break down like this:

-50% subclavian, 5% done with U/S guidance

-30% jugular, 90% done with real time U/S guidance, the other 10% done by landmarking after U/S visualization

-20% femoral, 90% of which are during emergency situations and done without ultrasound, the other 10% are done with real time U/S guidance

 

My colleagues tend to do more jugular approaches than I do, but the U/S breakdowns are similar, at least at my centre.

[A-Stark]

I really appreciate your chiming in here. The first time I attempted an IJ, it was in the OR, and eventually my staff got rid of the ultrasound and did it by landmarking.

 

CVC insertion complications are certainly bad, but as ever the greatest danger is not recognizing them. That's why we get xrays to check placement and assess for pneumos. And you bring up a good point about equipment failure - when it comes to airways, for example, it's true enough that having a C-Mac or Glidescope close by is ideal, but that's not a substitute for learning direct laryngoscopy or the use of tools like the bougie. And if that tube does in the esophagus, the only danger comes in not recognizing it.

[leviathan]

Thanks for your input cheech. My understanding of 'standard of care' is that it applies to what a reasonable specialist would have done in the defendant's shoes. I've heard a few intensivists who have said that it is standard of care, meaning a reasonable person would use an US machine because of the evidence that proves it decreases the complication rates, even in experienced hands. There are also many who say it is still becoming standard of care.

 

That said, I think that only becomes 'known' for sure if someone has the misfortune to end up in court and a legal precedent is set.

[cheech10]

The key is, standard of care is set by our practice, not expert opinion. We haven't yet gotten to the point of 100% U/S guided insertions. Plenty of ICU attendings still put in lines by landmarks alone at present, therefore that is the standard of care. Sure, it could be challenged in court, but it would be pretty easy to find another ICU attending to support this position.

 

Having said all that, I'm a big proponent of U/S use in the ICU, and use it daily myself, including line placement, bedside ECHO, leg dopplers, looking for ascites and pleural effusions, and more. But I've noticed a disturbing trend of residents rotating through and not being able to place a line without U/S guidance.

[leviathan]

I bet most residents these days are not comfortable doing IJ without US. I've done a few IJs without ultrasound but am not comfortable with it, and that might never change because of the fact that we always are asked to use the machine.

[leviathan]

Here's a case report of an experienced anesthesiologist dissecting the common carotid artery after confirming what she thought was venous blood:

http://www.cardiovascular-anthology.com/case_report_PDF/AA.58.pdf

[rogerroger]

For us newbies IJ = U/S and always will IMHO. There is no way I'm going near the carotid with a sharp object unless there is a probe involved.

 

I agree, the ultrasound is also replacing major components of the physical exam... Eg. If I really want to assess venous hypertension/volume status I'm going to visualize the IVC, forget the shady JVP.

 

There have been a lot of other specialties (both residents and staff) who have been attending the various bedside U/S courses being offered at my location. I think these skills will be standard primary care stuff in the near future.