Abstract
Vascular access used in the treatment of patients involves central and peripheral vein accesses and arterial accesses. Catheterization of central veins is widely used in clinical practice; it is a necessary part of the treatment of patients in various settings. The most commonly involved vessels are the internal jugular, subclavian, and femoral veins. The mechanical, infectious, and thrombotic complications of central venous catheterization are markedly reduced when the procedure is performed with real-time ultrasound guidance or (to a slightly lesser extent) ultrasound assistance. Ultrasound guidance is also used to create peripheral venous accesses, for catheterization of peripheral veins and for peripheral insertion of central venous catheters. In this setting, it increases the catheterization success rate, especially during difficult procedures (e.g., obese patients, children) and reduces complications such as catheter-related infections and venous thrombosis. Arterial cannulation is used for invasive monitoring of arterial pressure and for access during diagnostic or therapeutic procedures. Ultrasound guidance reduces the risk of catheterization failure and complications. It is especially useful for arterial catheterization procedures performed in the absence of a palpable pulse (e.g., patient in shock, ECMO). Imaging support is being used increasingly to facilitate the creation of vascular accesses under difficult conditions, in part because of the growing use of ultrasonography as a bedside procedure. In clinical settings where patients are becoming increasingly vulnerable as a result of advanced age and/or complex disease, the possibility to reduce the risks associated with these invasive procedures should motivate clinicians to acquire the technical skills needed for routine use of sonographic support during vascular access procedures.
Riassunto
Gli accessi vascolari utilizzati nella cura dei pazienti comprendono gli accessi venosi centrali e periferici e gli accessi arteriosi. L’incannulamento di accessi venosi centrali è manovra largamente diffusa nella pratica clinica e si rende necessaria per la cura dei pazienti in molteplici contesti. I vasi centrali che usualmente vengono incannulati sono la vena giugulare interna, la vena succlavia e la vena femorale. Nell’incannulamento venoso centrale sia l’eco-assistenza che l’eco-guida real time, pur con una leggera superiorità di quest’ultima, riducono drasticamente le complicanze meccaniche, infettive e trombotiche. La guida ecografica viene utilizzata anche per l’accesso venoso periferico, per l’incannulamento di vasi periferici e di vasi centrali a inserzione periferica (PICC). In questo contesto la guida ecografica aumenta il successo della manovra di incannulamento soprattutto in condizioni di difficoltà, come avviene nei pazienti obesi o nei bambini, e diminuisce le complicanze quali le infezioni catetere correlate e le trombosi venose. L’incannulamento arterioso viene utilizzato per il monitoraggio cruento della pressione arteriosa e per garantire un accesso in caso di manovre diagnostiche e terapeutiche. La guida ecografica riduce il rischio di insuccesso, le complicanze e può essere utile per l’incannulamento arterioso soprattutto nei casi in cui non e’ reperibile un polso (shock, pazienti in ECMO). Il supporto dell’imaging per gli accessi vascolari difficili si sta quindi diffondendo rapidamente anche perchè è sempre più frequente l’impiego degli ultrasuoni nella pratica clinica al letto del malato. Nei contesti clinici attuali dove i pazienti sono sempre più fragili perchè anziani e con patologie più complesse, avere la possibilità di ridurre i rischi connessi alle metodiche invasive deve spingere i clinici ad acquisire le abilità tecniche per l’utilizzo routinario del supporto ultrasonografico per gli accessi vascolari difficili.
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A. Vezzani, T. Manca, A. Vercelli, A. Braghieri, A. Magnacavallo declare that they have no conflict of interest.
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Vezzani, A., Manca, T., Vercelli, A. et al. Ultrasonography as a guide during vascular access procedures and in the diagnosis of complications. J Ultrasound 16, 161–170 (2013). https://doi.org/10.1007/s40477-013-0046-5
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DOI: https://doi.org/10.1007/s40477-013-0046-5