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The Speed of Sound

The Speed of Sound: Avoiding Central Line Complications with Ultrasound Needle

Butts, Christine MD

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doi: 10.1097/01.EEM.0000436452.07493.55
    The sterile shield and needle attach to a specialized transducer, which is used to locate the target vessel (in this case, the subclavian vein) or other object in the usual fashion and to locate the target before introducing the needle along the track. Once a flash of blood is obtained, the procedure can continue with the usual Seldinger technique.

    How confident do you feel when placing a central line in the ED under ultrasound guidance? Using ultrasound to place central lines, particularly in accessing the internal jugular, has become standard of care because of its ability to minimize complications and to decrease the time and number of attempts needed to secure the line.

    Many emergency physicians utilize ultrasound to guide them through this procedure, but growing evidence suggests that many are overconfident about their use of this technique. Some evidence also reveals that the feared complications of the traditional landmark technique (arterial puncture, pneumothorax) still occur more often than might be expected. A recent case report described two disastrous outcomes of ultrasound-guided internal jugular access gone awry. (European Surgery 2013;45[3]:179.) The catheter punctured the posterior wall of the internal jugular in both cases despite the operator's use of ultrasound, causing carotid dissection in one case and severe hematoma leading to airway compromise in the other. Other recent publications seem to emphasize that these are not isolated occurrences.

    Stephen Ridley, MD, an academic and community emergency physician at Palmetto Health Richland in Columbia, SC, noted that many of his residents and colleagues were having difficulty placing ultrasound-guided central lines. He vowed to create a product that would simplify the process and minimize complications created by inaccurate needle placement. Nine years of planning and development led to the creation of the AxoTrack, which is poised to revolutionize this common emergency medicine procedure.

    Dr. Ridley created a unique needle that can be tracked with a specialized SonoSite transducer utilizing the miniaturized magnetic technology seen in airplanes. This technology ensures that the needle and, more importantly, the needle tip remain visible within the scan plane and avoids sensitive structures, such as the carotid artery or lung pleura. The target vessel is located and positioned using the transducer. (Image 1.) The needle is then advanced along the track toward the target. Once the needle is placed in the vein and a flash of blood is obtained, the needle can be locked into place to facilitate passage of the guidewire and completion of the procedure. (Image 2.)

    AxoTrack is a relatively new product, but it is proving to be easy to use and successful in minimizing complications. Dr. Ridley said he has trained more than 40 physicians in its use and placed more than 100 lines. He has found physicians of all training levels are facile with the device after a short training session, and so far he has encountered no complications. More structured trials are underway currently and expected to be published in the coming months. Dr. Riley also noted that the AxoTrack shows potential for use in other procedures, such as regional nerve blocks.

    The “track” on screen shows the needle beginning to follow the path to the vessel. This ensures that the length of the needle directly follows the path, and does not deviate to affect other structures, such as adjacent arteries.

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