В клинике госпиталя Yale New Haven Hospital - широко муссируется вопрос о целесообразности применения т.н. ультразвукового контроля при катетеризации ВЯВ, что значительно снижает риск пункции и катетеризации сонной артерии, гематомы, не успешной катетеризации и т.д.
Всем известный профессор Бараш призывает делать ультразвук Всем.
Для этого используется аппарат site-rite с линейным УЗ датчиком, который на моих глазах пару раз отбрасывался в сторону при повторных попытках пунктировать вену под его контролем, после чего опытный мастер пунктировал ее вслепую обычным способом...
Кроме того, можно использовать эпиаортальный датчик....
На закуску я бы предложил, полезную на мой взгляд модификацию этого подхода, любезно вытащенную из недр интернета Игорем Булатовым:
CLINICAL ANESTHESIOLOGY
ISSUE: NOVEMBER 2006 | VOLUME: 32:11
TEE Uncovers Cardiac Pathology, Guides Central Line Placement
Researchers Suggest Expanded Intraoperative Use of Echo for Cardiac Surgery
Linda Pembrook
All patients undergoing cardiac surgery, whether on- or off-pump, should have a complete intraoperative examination with transesophageal echocardiography (TEE), Chicago investigators have advised. The use of TEE also maximizes the guidance of central venous catheters in the immediate perioperative period.
“Our data show how valuable echo is and how much surgeons depend on it for the proper management of patients,” said Mark Chaney, MD, Director of Cardiac Anesthesia at the University of Chicago Pritzker School of Medicine. “We decide whether to do surgery on- or off-pump based on intraoperative echo. That is very important information to have, considering the risks associated with cardiopulmonary bypass,” Dr. Chaney said.
TEE currently is used in only about 60% of patients undergoing cardiac surgery, the researchers noted. Previous studies of routine use of TEE have been small in number and poorly designed, and have not involved patients undergoing off-pump surgery.
The prospective, observational study included 181 consecutive patients (122 males) scheduled for cardiac surgery; the mean age of the patients was 62.7 years. Intraoperative TEE examination uncovered new cardiac pathology—that is, not detected preoperatively—in 55 patients (30.4%). In 41 cases (22.7%), the surgical plan was altered because of new findings. Surgical alteration involved the mitral valve in 24 cases. Four patients (2.2%) were converted from on-pump to off-pump surgery and one patient (0.55%) from off-pump to on-pump surgery.
One unexpected finding was that of the 55 patients, 14 had preoperatively undiagnosed tricuspid valve disease, the investigators said.
Study results were presented by Komal Patel, MD, a cardiac anesthesia fellow at the University of Chicago, in a poster session at the 2006 annual meeting of the Society of Cardiovascular Anesthesiologists.
“A number of observational studies have come out over the years on the incidence of new findings with TEE and their relative effect,” Stuart J. Weiss, MD, PhD, Director of Intraoperative Echocardiography at the University of Pennsylvania School of Medicine in Philadelphia, told Anesthesiology News. “Our experience is that we pick up findings that had not been noted previously in 30% of cases. Although the findings may not affect either the conduct of bypass or the surgical management, they often will affect our management of pharmacologic agents and volume administration,” Dr. Weiss said.
Dr. Weiss suggested that TEE, often a limited resource, is most efficiently used in selected cases. He referred to a study by Savage et al (Ann Thorac Surg 1997;64:368-373) of 82 high-risk patients in which intraoperative echo led to at least one major alteration in surgical management in 27 patients (33%) and at least one major anesthetic/hemodynamic change in 42 patients (51%).
In a second prospective observational study, also presented as a poster at the meeting, the Chicago team concluded that insertion of a TEE probe before insertion of a central venous catheter provided excellent bicaval views for confirmation of proper guidewire insertion. The use of TEE may help prevent complications resulting from improper guidewire positioning or dislodgment of an unanticipated superior vena cava thrombus. Furthermore, they said, visualization of the intra-atrial guidewire may represent a new confirmatory gold standard that has substantial advantages over pressure transducing, estimating arterial oxygen saturation by color, or percutaneous ultrasound guidance.
“In most cardiac surgery cases, the central line is inserted before the TEE probe or even before induction of anesthesia,” Dr. Chaney said. “It’s always been somewhat controversial how anesthesiologists verify proper placement of the line. We found that if you put the echo in before the central line and visualize the guide wire directly within the right atrium, you know with 100% assurance that you are in the proper place.”
The study included 20 patients (13 males) with a mean age of 61.1 years. A bicaval TEE view was obtained after induction of anesthesia. The Seldinger technique was used and the intra-atrial guidewire position confirmed by TEE before guidewire insertion. Central venous access was safely performed in all patients without complication. Internal jugular cannulation was performed in 17 patients and subclavian cannulation in one patient.
Femoral vein cannulation was performed in two patients; in one, TEE detected a large superior vena cava thrombus and the femoral vein was chosen as the desired approach. In the other patient, the advanced guide wire was not visible by TEE after a difficult right internal jugular cannulation, and left internal jugular and subclavian cannulation attempts similarly failed.
David Muzic, MD, a cardiac anesthesia fellow at the University of Chicago, presented the findings.
“Use of echo for cannulation would be a good technique for patients in whom you suspect a difficult cannulation,” said Dr. Weiss. “I don’t know how clinically practical it is for routine cases, especially in private practice. It may prolong placement of the catheter. And you need someone to manipulate the probes and someone else to do the cannulation.”
A major question, he said, involves reimbursement. “Anesthesiologists use TEE for routine CABG [coronary artery bypass graft] at the request of the surgeon, but we only receive reimbursement if we find something delineated by the present CPT [Current Procedural Terminology] codes for TEE. Should we be advocating the use of TEE, accepting any added expense, time commitment and risks for routine cases in the absence of adequate compensation?”
Мнения:
- насколько необходим УЗ во всех случаях катетеризации ВЯВ?
- какой вариант предпочтительнее в условиях проведения кардиоанестезии? Что дает 100% гарантию правильного введения катетера?
- может ли заменить УЗ контроль здравый смысл и необходимость практики пункции на основе анатомических ориентров?
