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Scale Lines to Facilitate Out-Plane Ultrasound Guidance for Vascular Access
LETTERS TO THE EDITOR
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Fig 1. Lung isolation techniques in patients with tracheostomies. BB, bronchial blocker; DLT, double-lumen tube; Fluoro, fluoroscopic guidance; FOB, fiberoptic bronchoscopy guidance; SLT, single-lumen tube
because of their size.1,2 Although lung isolation with bronchial blockers is recommended for these patients, the size of the blocker, when combined with an outer diameter of 3.5- to 3.7-cm pediatric bronchoscope, limits its use to a 7.0- to 7.5-mm or greater ETT.3 There are a plethora of techniques that can be used and individualized to obtain OLV in patients with tracheostomies (Fig 1). In our patient, to take advantage of the bronchoscope as a guide to placement, the wire loop of the blocker was placed over the distal tip of the ETT before placing it through the tracheostomy so that when the bronchoscope passed through the ETT, it also passed through the wire loop. The success of this technique depends on the wire loop not being dislodged because readjustment can be difficult after the bronchoscope has been removed. The advantages to having an extraluminal bronchial blocker are having the ETT lumen unobstructed, allowing passage of the scope for imaging and of suction catheters for clearing secretions; also, the compression of the bronchial blocker between the ETT balloon and trachea decreases the ability of the bronchial blocker to migrate.4 We have found that the described method of placement of the extraluminal Arndt bronchial blocker allowed for successful lung isolation despite the small inner ETT lumen in this patient with a narrowed tracheostomy stoma. Andrew P. Sekhon, BA* Brian K. Nishiguchi, MD*† Yasdet Maldonado, MD*† Ronald L. Harter, MD‡ *Temple University School of Medicine, Philadelphia, PA †Department of Anesthesiology, Allegheny Health Network Pittsburgh, PA ‡Department of Anesthesiology, The Ohio State University Wexner Medical Center Columbus, OH
REFERENCES 1. Campos JH: Lung isolation techniques for patients with difficult airway. Curr Opin Anaesthesiol 23:12-17, 2010
2. Marciniak B, Fayoux P, Hèbrard A, et al: Fluoroscopic guidance of Arndt endobronchial blocker placement for singlelung ventilation in small children. Acta Anaesthesiol Scand 52: 1003-1005, 2008 3. Tobias TD: Variations on one-lung ventilation. J Clin Anesth 13: 35-39, 2001 4. Skolnick E: Alternative methods of inserting a new endobronchial blocker. J Cardiothorac Vasc Anesth 14:234-235, 2000 http://dx.doi.org/10.1053/j.jvca.2015.09.020
Scale Lines to Facilitate Out-Plane Ultrasound Guidance for Vascular Access To the Editor: Vessel catheterizations are now common clinical procedures. Ultrasound technology for guidance is emerging to assist anesthesiologists not only in regional anesthesia but also in performing vascular access techniques. It can be used to ensure safe, successful catheterization and decrease the risk of complications. There are 2 basic approaches in the techniques: short-axis out-plane and long-axis in-plane techniques. The former apparently is easy to learn and grasp. In the out-plane approach, locating an appropriate site nearly above the vessel is very important, especially for superficial vascular access. Sliding the probe so that the vessel is centered on the screen and inserting the needle at the middle of the probe after the vessel has been identified is suggested.1 In fact, the marks of the middle position are not always available on the screen or the probe. It needs to be imagined by the operators. Quan et al2 tied a suture on the midpoint of the ultrasound probe as a guide. It may create a visible mark on the ultrasound view and improve accuracy in needle placement, but it is complicated. We often use scale lines to facilitate the procedure. According to the length of the screen and the probe, we designed 2 scale lines that were divided into tenths and marked
e16
LETTER TO THE EDITOR
Fig 1. A schematic of the scale lines for ultrasound guidance. (A) The scale lines pasted on the screen and the probe, respectively; (B) located at the site that was below the same line segment of the scale line on the probe.
by the numbers 1, 3, 6, or 9 at the corresponding cells. They easily were made on papers by using the table function of Microsoft Word. Slips of paper imprinted with the lines were cut out and pasted on the screen and the probe, respectively (Fig 1A). After covering the ultrasound probe with the sterile membrane and cleaning the skin with an antiseptic wipe, the vessel first was identified on the ultrasound screen. Then, we observed which line segment of the scale the vessel was below and located the site to puncture, ascertaining the same line segment on the probe (Fig 1B). Without sliding the probe so that the vessel is centered on the screen, the procedure is simple and more accurate, especially for inexperienced operators. The ultrasound device that would have this function will be welcomed.
Qiusheng Ren, MD* Yanfang Wang, MD†
Hui Ye, MD* *Department of Anesthesia †Intensive Care Unit Yinzhou People's Hospital Ningbo University Medical College Zhejiang, China REFERENCES 1. Ailon J, Mourad O, Chien V, et al: Videos in clinical medicine. Ultrasound-guided insertion of a radial arterial catheter [J]. N Engl J Med 371:e21, 2014 2. Quan Z, Tian M, Chi P, et al: Modified short-axis out-of-plane ultrasound versus conventional long-axis in-plane ultrasound to guide radial artery cannulation: A randomized controlled trial[J]. Anesth Analg 119:163-169, 2014
http://dx.doi.org/10.1053/j.jvca.2015.09.023
e15
Fig 1. Lung isolation techniques in patients with tracheostomies. BB, bronchial blocker; DLT, double-lumen tube; Fluoro, fluoroscopic guidance; FOB, fiberoptic bronchoscopy guidance; SLT, single-lumen tube
because of their size.1,2 Although lung isolation with bronchial blockers is recommended for these patients, the size of the blocker, when combined with an outer diameter of 3.5- to 3.7-cm pediatric bronchoscope, limits its use to a 7.0- to 7.5-mm or greater ETT.3 There are a plethora of techniques that can be used and individualized to obtain OLV in patients with tracheostomies (Fig 1). In our patient, to take advantage of the bronchoscope as a guide to placement, the wire loop of the blocker was placed over the distal tip of the ETT before placing it through the tracheostomy so that when the bronchoscope passed through the ETT, it also passed through the wire loop. The success of this technique depends on the wire loop not being dislodged because readjustment can be difficult after the bronchoscope has been removed. The advantages to having an extraluminal bronchial blocker are having the ETT lumen unobstructed, allowing passage of the scope for imaging and of suction catheters for clearing secretions; also, the compression of the bronchial blocker between the ETT balloon and trachea decreases the ability of the bronchial blocker to migrate.4 We have found that the described method of placement of the extraluminal Arndt bronchial blocker allowed for successful lung isolation despite the small inner ETT lumen in this patient with a narrowed tracheostomy stoma. Andrew P. Sekhon, BA* Brian K. Nishiguchi, MD*† Yasdet Maldonado, MD*† Ronald L. Harter, MD‡ *Temple University School of Medicine, Philadelphia, PA †Department of Anesthesiology, Allegheny Health Network Pittsburgh, PA ‡Department of Anesthesiology, The Ohio State University Wexner Medical Center Columbus, OH
REFERENCES 1. Campos JH: Lung isolation techniques for patients with difficult airway. Curr Opin Anaesthesiol 23:12-17, 2010
2. Marciniak B, Fayoux P, Hèbrard A, et al: Fluoroscopic guidance of Arndt endobronchial blocker placement for singlelung ventilation in small children. Acta Anaesthesiol Scand 52: 1003-1005, 2008 3. Tobias TD: Variations on one-lung ventilation. J Clin Anesth 13: 35-39, 2001 4. Skolnick E: Alternative methods of inserting a new endobronchial blocker. J Cardiothorac Vasc Anesth 14:234-235, 2000 http://dx.doi.org/10.1053/j.jvca.2015.09.020
Scale Lines to Facilitate Out-Plane Ultrasound Guidance for Vascular Access To the Editor: Vessel catheterizations are now common clinical procedures. Ultrasound technology for guidance is emerging to assist anesthesiologists not only in regional anesthesia but also in performing vascular access techniques. It can be used to ensure safe, successful catheterization and decrease the risk of complications. There are 2 basic approaches in the techniques: short-axis out-plane and long-axis in-plane techniques. The former apparently is easy to learn and grasp. In the out-plane approach, locating an appropriate site nearly above the vessel is very important, especially for superficial vascular access. Sliding the probe so that the vessel is centered on the screen and inserting the needle at the middle of the probe after the vessel has been identified is suggested.1 In fact, the marks of the middle position are not always available on the screen or the probe. It needs to be imagined by the operators. Quan et al2 tied a suture on the midpoint of the ultrasound probe as a guide. It may create a visible mark on the ultrasound view and improve accuracy in needle placement, but it is complicated. We often use scale lines to facilitate the procedure. According to the length of the screen and the probe, we designed 2 scale lines that were divided into tenths and marked
e16
LETTER TO THE EDITOR
Fig 1. A schematic of the scale lines for ultrasound guidance. (A) The scale lines pasted on the screen and the probe, respectively; (B) located at the site that was below the same line segment of the scale line on the probe.
by the numbers 1, 3, 6, or 9 at the corresponding cells. They easily were made on papers by using the table function of Microsoft Word. Slips of paper imprinted with the lines were cut out and pasted on the screen and the probe, respectively (Fig 1A). After covering the ultrasound probe with the sterile membrane and cleaning the skin with an antiseptic wipe, the vessel first was identified on the ultrasound screen. Then, we observed which line segment of the scale the vessel was below and located the site to puncture, ascertaining the same line segment on the probe (Fig 1B). Without sliding the probe so that the vessel is centered on the screen, the procedure is simple and more accurate, especially for inexperienced operators. The ultrasound device that would have this function will be welcomed.
Qiusheng Ren, MD* Yanfang Wang, MD†
Hui Ye, MD* *Department of Anesthesia †Intensive Care Unit Yinzhou People's Hospital Ningbo University Medical College Zhejiang, China REFERENCES 1. Ailon J, Mourad O, Chien V, et al: Videos in clinical medicine. Ultrasound-guided insertion of a radial arterial catheter [J]. N Engl J Med 371:e21, 2014 2. Quan Z, Tian M, Chi P, et al: Modified short-axis out-of-plane ultrasound versus conventional long-axis in-plane ultrasound to guide radial artery cannulation: A randomized controlled trial[J]. Anesth Analg 119:163-169, 2014
http://dx.doi.org/10.1053/j.jvca.2015.09.023