Training nurses to place tunnelled central venous catheters

In recent years experienced nurses working in radiology and haematology have expanded their roles to encompass placing tunnelled central venous catheters using real-time sonography and fluoroscopy. With training and supervised practice, such nurses can increase their knowledge and skills and improve services for patients requiring CVCs.     

The place of ultrasound diagnosis in gynaecology]

The indications for the implementation of ultrasonic diagnosis in gynaecology is discussed. Whereas the differential diagnosis between cystic and solid tumours is relatively simple in those tumours which have extended beyond the true pelvis, a profound knowledge of the examination technique is necessary to diagnose smaller lesions confined to the true pelvis. Knowledge of the ultrasonic anatomy of the female pelvis is not only the basis for the diagnosis of tumour recurrence following operation and irradiation of genital tumours, but, moreover, for the exact planning of radiotherapeutic management and follow up evaluation of therapeutic success. It is also shown that echotomography enables the demonstration of physiological changes within the ovary during the menstrual cycle.     

The place of ultrasound diagnosis in paediatrics]

Ultrasound as a diagnostic technique is of rapidly increasing value in paediatrics. The great advantages of this procedure are that it is without risk of the patient and, hence, may be repeatedly carried out. Furthermore, ultrasound yields information which cannot be obtained by other methods.     

The place of ultrasound diagnosis in urology]

Ultrasonic diagnosis is used in urology, as in other fields, for the differentiation between cystic and solid tumours and in the planning of radiotherapeutic management. A particularly valuable application of ultrasound is in the determination of prostatic size, which provides essential information of which the preoperative decision as to surgical procedure is based. Ultrasonic tomography also has a limited application in the examination of the scrotum.     

The place of ultrasound diagnosis in obstetrics]

A review is presented of the diagnostic applications of the ultrasonic scan technique in obsterics. In the 1st trimester of pregnancy the demonstration of the gestational sac and of an embryo is most important. During the further course of pregnancy the growth of the gestational sac and motions of the fetus can be observed. A disturbance in the development of the pregnancy can be deduced from these parameters. The various types of abortion can be differentiated by means of the scan. In the 2nd trimester the biometry of the fetus is most important. The motion behaviour of the fetus seems to be a good indicator of its well-being. The location of the placenta and the evidence of twins are easily demonstrable. In the 3rd trimester the biometry of the fetus is a good parameter of its maturity. The diagnosis of the fetal position is important for the management of delivery. Apart from these applications of ultrasound in obstetrics, the procedure is of great value in the diagnosis of tumours and the measurement of the true pelvis in pregnancy.     

Use of sterile saline as a conduction agent for ultrasound visualization of central venous structures

Objective: To determine whether sterile saline as a conduction agent provides adequate visualization of anatomic structures to attempt ultrasound‐guided vascular access. Methods: This prospective study involved a convenience sample of adult patients (18 years and older) who presented to an urban academic ED during a 3‐month study period. Each patient had three six‐second ultrasound video clips obtained of the right internal jugular vein and surrounding structures utilizing three different conduction agents, water‐based gel (the control), sterile saline or no conduction agent. Video clips were randomized and assigned a numeric code to blind reviewers to the conduction agent. They were then independently reviewed by two experts who determined whether anatomic structures were visualized with enough detail to perform ultrasound‐guided vascular access. The reviewers also rated the overall image quality of each video clip using a 100 mm visual analogue scale (VAS). Results: Forty‐seven patients were included in the final analysis. The raw agreement was 100% (95% confidence intervals [CI]: 93–100%) with a kappa of 1.0 between the two reviewers in assessing whether they would be able to perform vascular access using the images obtained using saline as a conduction agent. The median VAS for gel across both reviewers was 92 (95% CI: 90–93) and the median VAS differences for saline and no medium were –3 (95% CI: –1 to –3) and –46 (95% CI: –22 to –61), respectively. Conclusions: The use of sterile saline as a conduction agent allows adequate visualization of anatomic structures to attempt ultrasound‐guided vascular access.     

What you need to know about central venous lines

A central venous line is a device that is inserted into the superior vena cava or right atrium. There are a number of reasons why such a device may be used. Two of the main reasons are to monitor central venous pressure and for the rapid infusion of fluids. This article discusses the types of central venous devices, the insertion of the catheter, the manual and electronic measurement of central venous pressure, and the complications that can occur when the device is in place. The nurse's role in caring for a patient with a central venous line is discussed, as is the removal of the catheter.     

The current place of diagnostic ultrasound in cardiology]

A non-invasive technique such as echocardiography has numerous advantages over invasive examinations of the cardiovascular system. Echocardiography involves no hazard or risk to the health of the patient, it can be repeated at any time and provides truly basal haemodynamic information by avoiding sedation, excitation of the patient and injection of dye. Problems arising from peculiarities in the behavior of ultrasonic energy and chest malformations in the patient have been largely overcome by technical improvements and a more sophisticated wasy of examination. The current diagnostic applications of echocardiography are reviewed on the basis of our own experience and the advantages and limitations of this method discussed.     

Use of ultrasound to enhance percutaneous absorption of benzydamine

The influence of ultrasound on the percutaneous absorption of benzydamine hydrochloride from a gel base was investigated in a double-blind, placebo-controlled clinical study of 10 healthy volunteers. Using two similar experimental protocols, the effect of both 1:1 (2 msec on, 2 msec off) pulsed-output ultrasound (3.0 MHz at 1.0 W/cm2 and 0.0 W/cm2 [control]) and continuous-output ultrasound at a range of frequencies (0.75, 1.5, and 3.0 MHz at 1.5 W/cm2) were investigated. A placebo control (benzydamine gel massaged with ultrasound applicator switched off) was incorporated into each protocol. Percutaneous absorption of benzydamine was assessed by measurement of the residual amount of drug in the formulation base after treatment. Drug assay was by reversed-phase high-performance liquid chromatography and ultraviolet detection. Statistical analysis of the results for both continuous and pulsed ultrasound treatment showed that no significant differences existed between data for ultrasound treatment versus no ultrasound. In conclusion, although phonophoresis has been alleged to enhance percutaneous absorption of numerous drugs, ultrasound did not enhance the percutaneous absorption of benzydamine under the experimental conditions of this study.     

Use of ultrasound guidance for central venous catheterization: a national survey of intensivists and hospitalists

PurposeThe purpose of the study is to evaluate the frequency and barriers to use of ultrasound guidance for central venous catheter (CVC) insertion by physicians specializing in critical care and hospital medicine.Materials and methodsA national cross-sectional electronic survey of intensivists and hospitalists was administered from November 2014 to January 2015.ResultsThe survey response rate was 5.9% (1013/17 233). Moderate to very frequent use of ultrasound guidance varied by site: internal jugular vein (80%), subclavian vein (31%), and femoral vein (45%). Nearly all physicians (99%) who insert internal jugular CVCs daily use ultrasound guidance, whereas only 46% of physicians who insert subclavian CVCs daily use ultrasound guidance. Use of real-time ultrasound guidance varied by insertion site: internal jugular vein (73%), subclavian vein (28%), and femoral vein (42%). Most physicians (59%) reported not being comfortable with real-time needle tracking at the subclavian site. The most frequently reported barriers to use of ultrasound guidance were (1) limited availability of ultrasound equipment (28%), (2) perception of increased total procedure time (22%), and (3) concern for loss of landmark skills (13%).ConclusionsMost intensivists routinely use ultrasound guidance to insert internal jugular CVCs but not subclavian CVCs. The most commonly reported barrier to ultrasound use was limited access to an ultrasound machine.     

超声引导联合塞丁格技术在PICC置管术中的应用

目的探讨超声引导联合塞丁格技术在经外周置入中心静脉导管(peripherally inserted central catheter,PICC)置管中的应用效果。方法将1008例需行PICC置管的恶性肿瘤患者,根据肘部血管条件,良好者(即直视或可触及有弹性的肘部静脉)作为对照组(540例),差者﹙即直视或触摸不到肘部静脉﹚为实验组(468例)。对照组患者按常规在肘部静脉置入PICC导管,实验组患者通过贵要静脉或肱静脉在超声引导联合塞丁格技术下置入PICC导管。比较两组患者一次穿刺成功率、一次置管成功率及术后机械性静脉炎、静脉血栓、导管相关性感染发生率。结果两组患者一次穿刺成功率比较,P0.05,差异无统计学意义,但实验组一次性置管成功率明显高于对照组,置管后机械性静脉炎、静脉血栓、导管相关性感染发生率明显低于对照组,两组比较,均P0.001,差异具有统计学意义。结论超声引导结合赛丁格技术行PICC置管成功率高,术后并发症少,安全性高。     

Topics in ultrasound education: Use of patient models to teach endovaginal ultrasound skills

Learning how to perform endovaginal pelvic ultrasound is often challenging for novices in a busy clinical practice. In this article, we describe a program in which we hired female patient models to help residents acquire basic endovaginal scanning skills.     

Use of ultrasound to detect intestinal wall ischemia in piglets

To evaluate the use of ultrasound (US) to detect intestinal wall ischemia, we isolated segments of jejunum on single vascular pedicles in five piglets. We sequentially clamped these segments in intervals of 0 to 6 h, reperfused them for 24 h, and then examined them in vitro histologically and with an 8.5 MHz US scan. All segments were grossly viable except those with 6 h of ischemia. Histologically, mild submucosal edema developed after 1 to 2 h of ischemia; after 3 to 4 h, mucosal necrosis, loss of folds, worsening submucosal edema, and prominent neutrophilic infiltration occurred; after 5 to 6 h, severe mucosal necrosis with hemorrhage and submucosal edema was present. Ultrasonically, we saw five wall layers in the control group corresponding to mucosa, submucosa, muscularis propria, and subserosal fat. After mild (1 to 2 h) ischemia, all layers were present except for a discontinuity in layer 3. After moderate (3 to 4 h) ischemia, the five layers persisted but with a markedly thickened submucosal layer, reduced echogenicity, and flattened mucosal folds. With severe (5 to 6 h) ischemia, we observed a loss of all normal layers with no discernible architecture. Using these US criteria, blinded observers were able to differentiate normal/mild from moderate/severe ischemia with a sensitivity and specificity of 100%. These data suggest that US can differentiate, in vitro, normal from moderate and severe degrees of intestinal wall ischemia that correlates well with the histological appearance. Endoscopic US or surgically implantable US probes can potentially help diagnose clinical intestinal wall ischemia.     

Use of ultrasound to determine ventricular capture in transcutaneous pacing

Determining ventricular capture when using transcutaneous pacing (TCP) can be difficult. Our objective was to evaluate the use of ultrasound (US) to determine capture in patients undergoing TCP. We studied 15 patients in a convenience sample. Videotaped US views were obtained during TCP with concurrent electrocardiographic monitoring on the US screen. The treating physician made capture determinations first by using clinical indicators, followed by US images. Two reviewing physicians blinded to the treating physician's findings and to each other determined capture on videotape. Kappa levels of agreement were calculated. A value of kappa = 0.84 was found for agreement of the treating physician's findings through clinical measures and US. Agreement between the first reviewer and the treating physician had kappa =.47 and between the second reviewer and the treating physician was had kappa =.67. All P values were <.05. US and clinical impression of ventricular capture have good to excellent agreement. US may be useful for determining ventricular capture in patients undergoing TCP.     

Estimation of central venous pressure by ultrasound

INTRODUCTION: Increasing blood volume and cardiac output is one of the most commonly needed intervention in the primary care of traumatized and severely ill patients. Although cardiac filling pressures have severe limitations in assessing the preload, central venous pressure (CVP) is the invasive measure most frequently used in clinical practice for the assessment of volume status and cardiac preload. We combined ultrasound and tissue pressure measurement for non-invasive jugular and brachial venous pressure estimation. MATERIALS AND METHODS: CVP was measured invasively and non-invasively using the new technique in 32 critically ill patients. In six volunteers, increasing PEEP was used for the assessment of changes in non-invasive CVP. RESULTS: Non-invasive CVP increased linearly with increasing PEEP, independent of the investigator. Median (range) coefficient of variation (CV) for five consecutive measurements performed by three investigators in volunteers was 15% (6-31%), 14% (4-31%), and 21% (8-42%). Absolute differences between the average non-invasive CVP between investigators was 1.7 cm H2O (0.4-6.6 cm H2O), and the inter-examiner CVP was high (182%, 40-415%). In patients, invasive CVP was 10 mmHg (5-18 mmHg), and the corresponding non-invasive venous pressures were 8 mmHg (3-14 mmHg, basilic vein, p<0.01) and 6 mmHg (3-13 mmHg, jugular vein, p<0.01). The coefficients of variation were 4% (<1%-64%, invasive CVP), 22% (5%-51%, non-invasive basilic vein pressure), and 17% (7%-34%, non-invasive jugular vein pressure). CONCLUSION: Ultrasound-based, non-invasive measurement of venous pressure provides a relatively easy method rapid estimation of changes in CVP, although absolute values may differ substantially from invasive CVP and between different investigators.     

Use of ultrasound in breast disease

Ultrasound in the most frequently used adjunct imaging modality to mammography for the evaluation of the breast. This review discusses the history of breast ultrasound and its current use, including equipment, appropriate method of scanning, and normal breast anatomy. Sonographic characteristics for lesion assessment as well as appropriate uses for breast ultrasound are reviewed. The use of ultrasound to guide minimally invasive breast biopsy as well as emerging technologies and applications for ultrasound are also discussed.