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Super ultrasound helps doctors win the vein game

September 18, 2015
Anyone who’s ever endured a multi-attempt poking session in order to donate blood or have a blood test may well recall the faint-inducing frustration as the phlebotomist’s needle rummaged about for a suitable vein. That’s nothing compared to tiny babies who are about to undergo cardiac surgery, or who need an IV line for medication, or chronic patients of all ages who will require insertion of PICC lines and mid-lines over a lifetime of medical care. For those patients, unsuccessful attempts by the doctor to find the right vein are not only harrowing and painful, they can even be life-threatening. Not so long ago, doctors had no choice but to persist, with freaked-out children being held down by their equally distressed parents a frequent scenario.
That misery is history when doctors make use of the latest ultrasound technology to scan for the best veins and help them guide their needles.

“We’ve moved from guesswork to science,” says Dr Elizabeth Prentice, specialist paediatric anaesthetist at Royal Children’s Hospital, Melbourne (RCH). “We have used ultrasound for several years for central venous access, but now even with peripheral venous access and arterial lines, once you’ve failed a few times at using surface anatomical landmarks and hoping the vein’s where it should be, you move to a scientific approach where you scan the patient with the ultrasound, choose the best vein, the best position, and you don’t have any attempts if there are no suitable veins there.”
You move to a scientific approach where you scan the patient with the ultrasound, choose the best vein, the best position..

Prentice is part of a team of vascular-access specialists among the more than 20 consultant anaesthetists at RCH. “All of the anaesthetists are using the ultrasound machines now,” she says. “The technology got much better about two years ago, but it’s even better with the new machines—we’re just amazed by how easy it is to see these tiny little veins and arteries. It’s made a huge difference to our practice.”

The new ultrasound machines at RCH—two of them—are GE’s LOGIQ e. “Specialists told us they need to see clearly, see quickly and guide precisely, and those needs drove the creation of the new LOGIQ e,” says Matt Tucker, general manager, ultrasound, GE Healthcare Australia and New Zealand. “In paediatric anaesthesia, the new high-resolution L10-22-RS transducer operates at frequencies of 22 MHz, which provides unprecedented image quality for resolving tiny vessels, aiding in precise guidance for cannulation.”

/><br /> <br /> <em>Dr Elizabeth Prentice uses ultrasound to guide a needle into the vein of a young CF patient. </em><br /> <br /> Prentice explains how this new ultrasound equipment—which is the size of a computer and is simply wheeled on its trolley around the hospital—has transformed practice for her and her colleagues. “We watch the screen and we can see that needle—the IV cannula—go directly into the vein,” she says. “We track it from the entry point in the skin, going down directly into the vein, watch it going through the vein wall and then follow the needle tip up the vein. It’s so precise, it’s like steering directly into the vein or the artery, whereas with the old probes, even two years ago, we would just vaguely see movement in the artery or vein.”<br /> <br /> Ultrasound scans are being used throughout RCH, from the wards to the operating theatre. “For a regular drip, we get a call from the ward saying, ‘We failed to get a drip in a child. The child is crying, the parents are distressed. Can you come and help?’ We take the ultrasound down and we scan the whole body of the patient and decide on the best vein,” says Prentice.<br /> <br /> Horror stories from the pre-ultrasound days are still in recent memory for doctors, she says: “With a chubby one-year-old, it was often difficult to get a drip in—people might have had five, six, seven attempts to get IV access. Now, we get the ultrasound, scan the baby and find the best vein. In the old days, it might have taken 30 minutes of delayed surgery and six or seven or eight attempts at IV access, Now after a few minutes and two or three attempts we get someone with the ultrasound.”<br /> <br /> The ability to scan even the smallest baby has all but ended the venous cutdown, an invasive procedure performed to access a child’s artery or vein. “With the old ultrasounds, we couldn’t get a good image and see the needle shallower than 1.5-2cm,” explains Prentice of the depth field of the probes, which didn’t really cater for tiny bodies. “The newer probes have made a huge difference because from 0 to 8mm of depth we can clearly see all the details, and clearly see the needle going right into the vessel. You set 0.5-0.8cm as your maximum depth, and you can see that tiny little vein or artery in the middle of your field, and instead of just seeing vague needle movement, you can see the tip of the needle go all the way into that 1 or 2 millimetre-diameter vein or artery.”<br /> <blockquote>Ten years ago, cystic fibrosis kids might have had big PICC lines in tiny veins, because doctors weren’t able to assess them with ultrasound.</blockquote><br /> For children who need a central venous catheter or PICC line inserted, as may occur with oncology or cystic fibrosis (CF) patients, ultrasound pre-scanning is standard says Prentice. “CF kids, who need lots of PICC lines, need their <a href=veins preserved for life. The more attempts you have, or if you put the line in a vein that’s too little because you haven’t scanned, you risk those children not being able to have future PICCs—they have to get implanted vascular access ports. Ten years ago, cystic fibrosis kids might have had big PICC lines in tiny veins, because doctors weren’t able to assess them with ultrasound. Sometimes these kids’ arm veins were lost—the veins occlude and you can’t use them anymore. Today we would never do a PICC line or central line without an ultrasound.”

The stress reduction for patients, parents and doctors has been enormous. Prentice cites before and after quotes from parents of CF patients. One mother, of CF sufferer Harry, recalled a traumatic pre-ultrasound PICC line insertion: “A trainee doctor tried to put a line in and became very distressed. My son was hysterical and my husband and the nurses had to hold him down.” She contrasted this with Harry’s post-ultrasound world: “A pre-visit by an anaesthetist and an ultrasound machine got my son interested and involved—he loved seeing his muscles and his veins on the screen. The procedure itself went so smoothly and Harry said he didn’t feel a thing. It was over in about 15 minutes. I can’t adequately express how comparatively better this procedure was. It really is a game-changer for us.”