Pediatric emergency medicine trisk 4511 4511
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POCUS has the potential to make procedures safer and more efficient by reducing
the duration, the number of attempts, and complication rates. Ultrasound can be
used as an adjunct either before the procedure to identify landmarks and
important anatomic structures (static technique) or during the procedure (dynamic
technique), allowing for real-time guidance.
CENTRAL AND PERIPHERAL VENOUS CANNULATION
POCUS is an important aid in obtaining intravenous (IV) access for difficult
peripheral IV cannulation and for all cases of central venous (CV) access.
Ultrasound allows clinicians to identify the intended vein for cannulation and to
differentiate veins from nearby anatomic structures such as arteries and nerves.
Of note, most superficial peripheral veins are not paired with arteries.
However, deeper veins like the brachial veins and veins used for central access,
such as the femoral and internal jugular, do have arteries alongside them.
Central Venous Cannulation
Central vascular access is among the most commonly performed ultrasoundguided procedures. The Agency for Healthcare Research and Quality has stated
that ultrasound for CV access is a clear opportunity for safety improvement and
listed it as one of the “Top 11 Highly Proven” patient safety practices. It is
considered standard of care according to multiple subspecialty policy statements
and published international evidence-based consensus recommendations.
In adults, POCUS for central line placement increases success rates and
decreases procedural complications. Similar reports exist in the pediatric
population. In a recent meta-analysis, US-guided CV placement decreased the
number of attempts and improved success rates. The evidence in both the adult
and pediatric population, along with the generalizability of the procedure,
suggests that ultrasound is a necessary skill for the practitioner who places CV
lines in children.
Technique
The sonographic technique for identifying vessels is similar whether placing a
peripheral IV or a CV catheter. A high-frequency linear transducer is the probe of
choice. Relevant anatomy for the particular site chosen (femoral, internal jugular)
should be reviewed. Preprocedure steps are important to maximize success,
including adjusting the height of the bed, positioning the patient, positioning the
ultrasound machine, and having equipment and extra personnel ready for
assistance. For CV access, aseptic technique should be used with sterile probe
covers and sterile gel (if probe covers are unavailable, a sterile glove will suffice).
