Vascular Access,

Paracentesis,

and Thoracentesis

Rita Bakhru, MD, MS

Wake Forest University School of Medicine

Disclosures

• Serve as Faculty at American College of

Physicians: Central Venous Line Placement

Workshop

Vascular Access, Paracentesis,

Thoracentesis

• Indications

• Complications

• Anatomy Review

• Ultrasound:

• Equipment

• Use of Equipment

• Typical Images

Most Common Sites for Vascular Access

• Internal Jugular Vein

• Femoral Vein

• Subclavian/Axillary Vein

• Peripheral Veins

Assessing Vein

• Local anatomy

• Identification of artery vs. vein

• Is the vein patent?

High Freq. Linear Array Probe

• Crystals in a flat head

• 6-13 MHz

• Default scan depth: 2.6cm

• Minimum: 1.9cm

• Maximum: 6cm

Applications:

• Vascular Access

• Diagnostic Vascular

• Superficial biopsy guidance

• Nerve blockade

• Musculoskeletal evaluation

High Freq. Linear Array Probe

Other Options• 5-10 MHz general linear

array

• 9 cm Scan Depth

• Applications:

• breast, vascular, venous

access, nerve, IMT,

musculoskeletal

Internal Jugular Anatomy

• Anatomical

Triangle:– 2 heads of

sternocleidomastoid

– clavicle

N Engl J Med 2003; 348:1123-1133

Neck Anatomy: Internal

Jugular Sternocleidomastoid

Internal Jugular

Internal Carotid

Thyroid

Femoral Triangle Anatomy

Femoral Triangle Anatomy

Femoral Triangle Anatomy

Vein Patency

• Patent veins will compress completely to a thin line

IJ Compression

Femoral Compression

Venous Clot: Not compressible

Proper Hand Position

Probe Orientation

Directing the Probe• Pitch = mvmt up, down

• Transducer = transverse

• Fanning or tilting towards head or feet

• Yaw = side to side turn

• Angling probe left or right toward patient’s flanks

• Roll = spinning on central long axis

• Transverse orientation becomes sagittalNoble et al. Emergency and Critical Care Ultrasound

Roll: Cross-Sectional to Longitudinal

Direct Needle Guidance

Paracentesis

• Indications:

• Diagnostic evaluation of new onset ascites

• Diagnostic evaluation of known ascites for possible

secondary bacterial peritonitis

• Therapeutic paracentesis for comfort

Paracentesis Complications• Circulatory Dysfunction (large-volume para):

• hypotension,

• hyponatremia

• AKI

• Persistent Leak

• Localized infection

• Abdominal wall hematoma

• Intra-abdominal Hemorrhage

• Injury to Intra-abdominal Organs

Local Anatomy

Chest 2013;

143(4):1136–1139

Body Ultrasound

• Anchor your hand

• Gel on hand

• Scanning: probe marker toward head

• > 2 scanning planes for imaging structures

• Transverse and longitudinal

Probe Markers

Body Imaging Planes• Longitudinal Probe Position

• Transducer along long axis of the body• Probe marker toward the patient’s head• Cephalad structures by the marker

• Transverse or Axial Probe Position• Transducer 90 degrees from long axis of body • Cross-sectional display• For most, marker oriented to patient’s right

• Coronal Probe Position• Positioning the transducer laterally• Keeping marker towards head

Anatomical Orientation

www.saem.org/saemdnn/Education/Education

Resources/NarratedUltrasoundLectures

Phased Array Probe

• Crystals: curved, convex array

• Reduces lateral resolution in deeper tissue

• 5-1 MHz

• Phased array

• Default Scan Depth: 16cm

• Minimum Depth: 4.7cm

• Maximum Depth: 35cm

Phased Array Probe

• Applications:

• Cardiac

• Abdominal

• Obstetrics

• Biopsy

Abdominal Ultrasound

Paracentesis

Real-Time Paracentesis

Thoracentesis• Indications

• Diagnostic: Evaluation of New Pleural Effusion

• Therapeutic: Relief of Dyspnea

• Complications• Pneumothorax

• Reexpansion Pulmonary Edema

• Pneumothorax Ex Vacuo

• Puncture of Intra-Adbominal Organs

• Hemothorax

• Empyema/ Soft Tissue Infection

Phased Array Probe• Crystals: curved, convex array

• Reduces lateral resolution in deeper tissue

• 5-1 MHz

• Phased array

• Default Scan Depth: 16cm

• Minimum Depth: 4.7cm

• Maximum Depth: 35cm

Phased Array Probe

• Applications:

• Cardiac

• Abdominal

• Obstetrics

• Biopsy

Body Ultrasound

• Anchor your hand

• Gel on hand

• Scanning: probe marker toward head

• > 2 scanning planes for imaging structures

• Transverse and longitudinal

Probe Markers

Anatomical Orientation

www.saem.org/saemdnn/Education/Education

Resources/NarratedUltrasoundLectures

Thoracentesis Anatomy

Thoracentesis Anatomy

Patient Positioning:

Thoracentesis

Ultrasound of Pleural Effusion

Ultrasound of Pleural Effusion

Loculated Pleural Effusion

Hepatic Hydrothorax

Questions?