9/5/2012RaCeVA: a guide for a rational choice of the most appropriate vein for central venous catheterization Mauro Pittiruti Catholic University, Rome,Italy Introduction Ultrasound guidance is an evidence‐based methodology that significantly reduces the complications related to insertion of central venous catheters (CVC). Though, the benefit of using ultrasound (US) is not limited to real‐time US guided venipuncture. Introduction GAVeCeLT (The Italian Group for Venous Access Devices) recommends to use US during CVC insertion for five different purposes: (1) US evaluation of all veins available, (2) choice of the vein on the basis of rational criteria, (3) real time US guided venipuncture, (4) US‐based control of guidewire/catheter direction, (5) US‐based control of pleura‐ pulmonary integrity 1 which has been standardized by our group and is currently taught in our GAVeCeLT courses about US guided central venous access. This can be easily performed following the RaCeVA protocol. but also to evaluate the possible options and choose the best approach. not only to exclude veins morphologically abnormal (thrombosis. external compression.9/5/2012 Introduction Of particular relevance is the use of US for a rapid assessment of the central veins. 2 . RaCeVA Rapid Central Vein Assessment It was designed as a tool… … to teach the different US guided approaches to the central veins … to help the operator to scan systematically all possible venous options … to guide the operator in choosing the vein to be accessed. etc.). anatomical variation of size and shape. on a rational basis Rapid Central Vein Assessment a) Probe at mid-neck: visualization of the internal jugular vein (IJV) and the carotid artery (both in short axis). visualization of the valve in distal IJV. ideal position for ‘in plane’ puncture of the internal jugular vein IJV = in short axis Rapid Central Vein Assessment b) Probe sliding down the neck towards the sternum: visualization of the lower tract of the IJV (in short axis) and of the subclavian artery (in long axis).9/5/2012 Ideal position for ‘out of plane’ puncture of the internal jugular vein IJV = in short axis Also. 3 . behind the clavicle: visualization of the subclavian vein (SV) and external jugular vein (in long axis).9/5/2012 Rapid Central Vein Assessment c) Tilting the probe so to get an almost frontal plane: visualization of the brachio-cephalic vein (BCV) (in long axis) Ideal position for ‘in plane’ puncture of the brachiocephalic vein BCV = in long axis Rapid Central Vein Assessment d) Sliding the probe lateraly. more laterally. visualization of the subclavian artery (in short axis) 4 . 9/5/2012 Ideal position for ‘in plane’ puncture of the subclavian vein SV = in long axis Rapid Central Vein Assessment e) Probe below the lateral 1/3 of the clavicle: visualization of the axillary vein (AV) and of the axillary artery (in short axis) and of the cephalic vein (in long axis) Ideal position for ‘out of plane’ puncture of the axillary vein AV = in short axis 5 . taking into considerations six criteria. 6 . it is possible to choose the most appropriate vein and the most appropriate ultrasound guided approach.9/5/2012 Rapid Central Vein Assessment f) Rotating the probe anti-clockwise: visualization of the axillary vein in long axis. performed bilaterally. Ideal position for ‘in plane’ puncture of the axillary vein AV = in long axis Rapid Central Vein Assessment After this rapid assessment. collapse during breathing 4 .convenience of the exit site in terms of management 1 – Caliber of the vein Avoid veins too small: they are difficult to puncture. 7 .depth 3 . it may difficult to puncture and to cannulate.9/5/2012 Six criteria 1 . difficult to cannulate and might be associated with higher risk of thrombosis Variable size of IJV 2 – Depth of the vein If the vein is too deep (for example.caliber of the vein 2 . AV).closeness to ‘dangerous’ structures (pleura) 6 .compression by arterial pulsation 5 . even with US. The risk of accidental arterial puncture is high. 5 – Close proximity to pleura Puncture of the subclavian vein is rarely the first choice.9/5/2012 3 – Collapse during breathing Some veins (typically AV and IJV) may collapse during breathing (inspiration = negative thoracic pressure): this makes them difficult to puncture and cannulate 4 – Compression by artery Some veins (typically IJV) may be compressed by the artery which runs close to them. considering the close proximity to pleura. in such cases. 8 . evanetwork.It is a useful guide for a rationale choice of the central vein to be [email protected]. ‘in plane’ IJV.Cost-effectiveness .Patient’s safety . approaches associated with an exit site in the infraclavicular area (AV) or in the supraclavicular area (BCV.it Please visit the website of the European Vascular Access Network www. in terms of: .It takes only 20-30 sec for each side . easy to learn . please send an email to Mauro Pittiruti: mauro. SV) are preferable to approaches associated with an exit site at mid-neck (‘out of plane’ IJV) RaCeVA Rapid Central Vein Assessment: .info 9 .9/5/2012 6 – Convenience of exit site For non-tunneled catheters.Improved performance of the VAD For a copy of this presentation.It is easy to teach.