Transcript
Welcome everybody to the Sonosite Behind the Scan webinar,
Enhancing Vascular Access: Ultrasound Guided PIV Insertion
Fundamentals with our guest speaker,
Kenny Baptista Da Silva.
My name is Chris Pennell and I'll be
hosting today's webinar.
Before we begin, let me just go over some important
information about the webinar.
The information in this webinar is
provided for general education purposes as a supplement
to professional experience, education, and training,
and should not be considered the exclusive source
for this type of information.
At all times, it is the professional responsibility
of the practitioner to exercise independent clinical
judgment in each particular situation.
A Fujifilm Sonosite assumes no responsibility
or liability for any misuse of this webinar.
During this webinar, all attendees will be muted
and we will be conducting a Q&A session at
the end of the presentation.
So feel free to send those questions in while the
presentation is going,
and we'll be sure to get to them at the Q&A session.
If you're on the Zoom stream,
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located at the bottom or the side of your screen.
And for our viewers on YouTube
and LinkedIn, you can enter your questions in the chat box
and we'll make sure to get to those.
This webinar will be recorded
and archived for future reference on our webinars page
and the Sonosite Institute.
To get started, let me introduce our guest speaker.
Kenny is a nurse practitioner in a medical
and surgical ICU at McGill University Health Center in
Montreal, Quebec, specializing in ultrasound-guided vascular
access for peripheral IVs, PICs, and central lines.
Formerly an emergency nurse at a level one trauma center,
he developed a strong passion
for ultrasound-guided vascular access
and completed advanced training
through multiple programs in the Canadian Vascular
Access Association.
In 2018, Kenny led hands-on ultrasound training across two
emergency departments and continues to teach nurses
and nurse practitioners the importance
of real-time ultrasound guidance in everyday practice.
And with that, I'll get our presentation started.
All right. Well, thank you everybody for having me.
My name is Kenny Betis de Silva, as mentioned,
a nurse practitioner in critical care,
prior emergency care nurse.
And today we're going to be talking about enhancing vascular
access by using ultrasound guidance
to insert our IVs in our population.
Our schedule for today is we're going to start
with a brief introduction,
understanding why we're even talking about this topic.
I imagine you have an idea because you're here today.
Then we're going to talk about upper extremity anatomy.
The main focus is the differentiating veins
between the arteries, but also understanding
and recognizing whether other other findings such as nerves,
thrombi, bones or other things that we will talk about soon.
We'll go over a quick glance of the evidence.
Just so you know, for the presentation today,
all the references are going to be on the slides.
You'll be able to go back and reread or refreeze the image
whenever you want and take up those references
to read further into them if you want.
We're going to go over the basics of ultrasound.
How do we actually use an ultrasound machine?
Talk about the technique, different approaches that exist
in terms of accessing the vessels.
And then we'll finish with some tips
and takeaways that come from experience
and from evidence, what we know about ultrasound guidance.
And of course, at the very end,
you'll have some time to ask some questions.
So let's start. Let's get started.
First of all, just so you know my mindset when it comes
to ultrasound guidance, ultrasound guided IV access
for me is not about using ultrasound
nor even about placing more IVs.
It's about getting the right IV on the first try
for the right patient and at the right time.
Not half an hour later than we wanted, not delaying care,
and not poking the patient too much for nothing.
PIVs, well, you guys are quite
knowledgeable in them, I'm sure.
We use them mostly for administration of fluid,
lap products, medication, contrast,
and they're basically the most common clinical
procedure any nurse does.
There's over a billion IVs
who are inserted throughout the world each year.
Of those we know that patients in emerge, well, about 55%
of our patients actually require PIV.
Now, there might be some places
where more patients have PIVs.
That might be a local practice that might be preferenced
for IV versus PO access for drugs, for example.
But we know at the very least, 55%
of patients have no other alternative than
a vascular access.
And in North America, a vast majority of IVs are inserted
by nurses, not by technicians, not
by anesthesiologists or doctors.
Really, nurses are the first line of IV insertion.
And we know that of all IVs inserted in a year, 26%
of them are inserted in the emergency department.
So the emergency department IV is that much more important.
It might be the only IV your patient gets
during their hospitalization.
Now, the, the break of the problem
are difficult IV access patients, which are also referred to
as DIVA patients in the literature.
And what's the definition of that?
It's a patient that requires three
or more attempts for actual insertion,
or sometimes patients who go directly
to an alternative insertion method, whether
that's ultrasound guidance or a central line insertion.
In the adult emergency departments,
that's about a patient out of nine.
So much more common than some people might think.
And we know that if we look at anybody in a hospital,
there's about a quarter of all attempts
of IV insertions that fail.
So it's not, it's not always about you,
it's about using the right tools at the right time.
And we know that 50% of IVs will fail not just
because they expire,
but will fail with complications such as lobitis,
infiltration, occlusion, or dislodgement.
About 9% of adults, so one in 11,
requires more than four attempts before a PIV is inserted.
So what does that matter? It matters
because every fail attempt leads to vessel trauma.
It increases the risk of subsequent
risk of catheter failure.
It also decreases the amount of remaining options for access
and reduces the patient's willingness
to continue while increasing their pain and anxiety.
It also leads to downstream complications as well as a lot
of professional frustration.
Nobody likes failing to insert an IV two, three, four times.
So what's our objective here?
Our objective is to succeed the first time.
And our tool to do that is using ultrasound guidance.
What makes a patient more likely
to have difficult IV access?
There are things we pretty much know about already.
And those are diabetes, IV drug abuse, sickle cell anemia,
and BMI that's either very high or very low.
A history that's current
or prior of intravenous chemotherapy, non-visible veins,
or non-palpable veins.
For those two specifically, we know that 60%
of those patients are going to be diva again.
Now, there are things that people believe to be
risk factors, but actually evidence suggests otherwise.
Age or the use of dialysis does not increase the risk
of a patient being a difficult poke.
There's this doctor that said, Dr. Maya Angelou.
She said, "When people show you who they are,
believe them the first time, I've taken the liberty
of making a liberal adaptation in the context of
diva access.
And it is when people tell you they are a difficult poke,
believe them before the first poke.
Do not take the risk of poking a patient twice
before taking it seriously
or asking for help." Another way
of saying this is when a patient tells you I'm a hardstick,
that should be listened
and heard as a risk factor, not as a challenge,
and not as a personal personality trait.
And this we know is backed both by personal experience,
birth experience of different people around you.
I'm sure if you ask them, patients who tell you they're hard
to boke tend to be hard to boke,
but it's also backed by evidence.
They are here linked to different studies
that looked at patients who specifically say they're hard
to poke, and reality is they were.
Now, you know patients can sometimes be harder to poke,
and most of them are fine, but some can be a challenge.
Why would you want to use ultrasound in
those cases that are challenging?
Well, ultrasound allows us
to visualize the structures under the skin with accuracy,
not just make an educated guess.
It allows us to avoid undesired targets.
That could be nerves, that could also be arteries.
It ensures we are targeting an appropriate vessel.
Nothing is worse than taking the time to try
and get an IV for that IV to fail
because you can't cannulate it.
We get the blood return, you're in the right place,
but that vessel is too short.
It takes a weird curve. It's not an appropriate length.
It also allows to visualize the vessel, decreasing the risk
of trauma by avoiding things like piercing through
and through the classic, I got the vein, but then it burst.
Well, let's work on that.
Ultrasound. How does it actually work?
The technology can be quite complex to explain,
but the principles are simple.
It starts with transducers that sand
and receive echoing sound waves through crystal to size -
sizoelectric crystals.
Higher frequencies achieve an image with better resolution.
And we know lower frequencies can
penetrate deeper into the tissue.
And this is a classic ultrasound trade-off.
We have to choose between high frequency
or low frequency, depending on whether
or not we want more depth or we want better quality image.
When we hit an object that's very dense,
there's a bigger proportion of the waves that come back,
and we cannot see the structures
that are further away from that object.
Classic example will go over soon is bones.
If you hit a bone with an ultrasound probe, well,
you will have a shadow or an acoustic shadow we call.
Basically the portion that's more distal,
that's a bit down on the screen will not come back
because every single ray that was actually sent in
that direction bounced back once it hit the bone.
We have another enemy, which is air.
Air does not reflect waves due to low density.
The complete opposite of a dense object.
And this does not allow an image to be regenerated.
Images are generated when we actually are able
to receive back the waves that were sent.
For today, we will focus strictly on gray scale and B mode,
and we'll talk about echogenicity first.
So echogenicity is the ability of ultrasound waves
to come back and create an echo,
which can then be understood, received,
perceived by a transducer.
So if we start with the most simple concept,
if you have a gray scale rectangle
and I have a structure within it
that I cannot functionally discern, it's the same gray tent.
This is something we called isoechoic.
If I have the same rectangle, same gray shape,
but now the structure inside is a bit darker.
This is something we call hypoechoic.
There are less waves coming back from this area.
The image is not generated with as much contrast.
Next, if I have same gray scale,
but this time the structure comes back
with a lot more intensity, a bit wider, clearer.
This is something we call hyperechoic.
And the last is in a structure
that appears completely black.
This is something we call anechoic.
There's a lack of differentiation
between things within that, that area.
So tissues have different factors
that affect their echogenicity.
That could be the density of the tissue itself,
the water content, the fat,
the mineral content, and presence of air.
Once you accumulate all those effects,
all those tissues together,
this is something we call acoustic impotence,
and that's the speed of sound
going through a certain medium.
Pure fluid, whether that's blood, water,
or urine, is rendered black or echoic
because the sound waves go straight through
without returning echoes back.
When you see a more distal structure from an unechoic
structure, that's
because, for example, the tissue,
the subcutaneous tissue distal to the vessel
is the one now sending the waves back.
Now going back to air, air is the image,
the enemy of image acquisition.
Air has a very low velocity
of sound waves when compared to any other tissue.
That creates a near total reflection of waves.
And basically we cannot generate an image.
As a fun fact, lung ultrasound relies on artifact
interpretation rather than true visualization
because a normal lung is filled with 98% of air.
So we cannot actually look at a normal
healthy lung parenchyma.
So what can we do to fight this enemy of our objective,
which is looking at the tissues?
Well, we use our ally, which is water.
We want to drown the interference.
Back in the 1950s, air's interference
with ultrasound waves was managed
by a submerging patient's hole
in large bathtubs filled with water.
That was not very practical.
So we developed
and use now ultrasound gel, which serves functionally
as a sticky water that adheres to the skin
and actually helps also lubricate it,
which facilitates probe sliding.
It's a much appreciated improvement from
what we used to do in the past.
However, the water bath technique is still used to this day
for very specific situations.
For example, if a patient has a painful pathology
of their hands and feet, we could ultra -
we could ultrasound their hand
or feet without having to put pro- probe pressure on
that pathology.
Probe comes as sterile and non-sterile forms.
This is very important.
The non-sterile forms are still considered clean.
However, know that there is an expiration date
to these bottles, and there is a after opening best before.
And that's typically about 30 days.
I don't know about you, but in my department, when we look
around, most of the time the bottles are not dated,
which suggests we should not be using these ultrasound gels
particularly if we're going to be doing anything invasive.
When you're in doubt in ultrasound
and you're not getting the image you want,
you can always add more water or gel.
Probes, this is going to be your first decision.
To understand, we need to know what are our choices.
We need to choose an appropriate probe
for the designated task.
For superficial vein detection
and cannulation, only the flat probe
or the straight linear array probe is required.
This is the one that we see in the image.
The end part of the probe is, as you guessed, flat.
This probe is designed for superficial imaging.
It has high resolution,
and it generates an image that's aligned
and non-stretch, creates a non-stretch image.
It's really a rectangle you will see on screen,
which facilitates lateral resolution both in
interpretation and use.
If you have something that's a bi-shape like you would use
in a cardiac or abdominal probe, it takes a bit more nuance
to know what moving a centimeter to the left actually means
for your hand when the one centimeter at the top
of the screen and the bottom of the screen come
with very different angles.
When you're looking at a rectangular image made from a
flat probe, it becomes much more easy
to understand where you're going.
You know the linear probes come with higher frequency,
and that allows for more resolution, easier
to see the milk tip and see the structures around.
Now, arterial versus venous anatomy.
Arteries, well, you know, they pump exchange blood.
They're multi-layered vessel walls
that appear more thick on ultrasound.
They exhibit a pulse flow that becomes more pronounced
with gentle transducer compression.
This is important because postile flow is not always as easy
to see as we should.
If your patient's very atherosclerotic,
or if they have a very low blood pressure
because they're in shock, it might not be as obvious
as it typically is
that the vessel you're looking at is actually an artery.
Gentle pressure with transducer
will end up increase the pulsatility.
And the other thing is arteries are typically in
predictable areas.
We know where most people have their arteries located at.
When it comes to veins, we know they bring the oxygen blood.
They have much smaller vessel walls.
They rely on gravity, muscle pumps, and a valve system,
and they have a very thin tunica media.
The valve system is important.
If you see a valve in a vessel, you know
that vessel is a vein because there are no
valves in the arteries.
Normal veins should always be compressible
with gentle pressure when that is applied by a transducer.
If you start having resistance and as you press harder
and harder, that vessel's not compressing.
Something is occupying the lumen of the vessel.
And more often than not, that something is clot.
So we will not want to target a
vessel that's not compressible.
Now, there is a lot of anatomical variance
in location and size.
The major vessels are typically always at the same place,
but there is, there is some variability
from patient to patient.
All right.
So veins or arteries, we have a couple
of different distinguishable features that we use
because sometimes it's not always clear when you're only
basing yourself on one alone.
Arteries tend to have hyperechoic walls.
They're easier to see. They're a bit thicker as well.
They are not compressible.
And I put a star there because it's important
to know everything that if you press hard
enough, anything's compressible.
So what I mean by that, there's, they're
not easily compressible.
And if you press a bit, we know that the pulsatility tends
to be more visible as well.
Veins on the other hand have walls
that are a bit harder to see.
They're hypochoic and/or thinner.
They're easily compressible and they are non-pulsatile.
If you see a structure inside the wall, such as a valve,
you also know that it's a vein.
Now, there are other structures we could see.
For example, bone, which we see here in this image.
There's a dense reflect.
Because it's dense, it reflects ultrasound waves.
And as such, only the proximal
contour of the bone is visible.
If you can see in the upper portion here,
there's this white line that's very, very thick, very,
very hyperechoic, very white.
And distal to it, all we see is an acoustic shadow.
We cannot know if this bone is very flat or very big
because we cannot generate an image distal to it.
So as such, we cannot see structures that will be posterior
to the bone.
Anatomical pred - they're in anatomical
predictable locations.
If you're scanning an area where there's a bone,
you obviously probably know there might be a bone at
approximately X or Y at that.
Nerves. Nerves have honeycomb-like appearance,
and that comes from the standard
anatomy of peripheral turns.
Nerves, sorry. They come with nerve fascicles.
They have a collagenous perineural sheath
and their utmost epineural connective tissue layer.
All of these different tissues
that surround the nerves make it look like a honeycomb.
Nerve bundles have predictable pathways,
and their location of recognition is the basis
for nerve blocks used by an aesthetics.
As such, for example, we know there tends to be
a nerve bundle close to the brachial artery.
We will try to avoid nerves when we see them
because, well, that could cause pain, but also nerve damage.
Other structures that we might see.
There are many mother findings
that can be seen on ultrasound,
and most of them are com - uncommon
and fall outside the scope of this short lecture.
But it's important to know at least a couple of these
could mimic a normal vein.
There's thrombus, lymph nodes, cyst or abscesses.
Major differences. A thrombus will be non-compressible.
A fresh thrombus might not appear hyperechoic.
It might look like a normal vessel.
If you press on the vein, it should collapse.
If it's not compressible, something's occupying that space.
Lymph nodes and cysts
or abscesses tend to have a bit of difference anatomy.
First of all, they're not elongated like a vein is.
So if you follow that lymph node
or that cyst over a certain period of time,
it will come to an end.
There are structures that have a starting point
and an endpoint as opposed to our veins, which I mean,
obviously you have a starting endpoint,
but much, much longer.
So the anatomical shape
and the compressibility of these vessels will not be the
same as what you expect to find in a vein.
Don't target a circular-shaped dark area
if you're not sure it is a vein.
We'll just do a quick video recap of what we went through.
Veins appear as annechoic, fluid-filled, round vessels,
and are easily compressible with light pressure.
Determine whether the vessel is a vein
or artery by compressing the structures partially
with the ultrasound transducer for several seconds.
With partial compression of an artery,
pulsations will be visualized.
The non-pulsatile vein should compress
and collapse entirely.
Arteries are also annechoic and fluid-filled
and appear rounder in shape
and have a thicker, brighter wall.
Arteries generally require more pressure
for compression than veins,
and pulsations will be noted with partial compression.
Nerves are non-compressible structures commonly described
as having a honeycomb appearance
because of their dark punctuated areas.
Venous thrombosis will appear as a non-compressible
or partially compressible area, having echogenic
or bright material within the vessel
and maybe partially or fully occlusive.
All right. Now,
there are some contraindications actually using ultrasound
guidance, and they are functionally the same as
any contraindications you would have
to insert an IV in a specific patient or target.
So do not poke in areas where there might be cellulitis
or a localized infection.
If there's a fracture with a slobitis,
if there's any anatomical issues, including a very close
by presence of an arterial venous fistula.
Don't poke if you don't see an appropriate cannula
vul - cannulable vein.
The next question is, what is an
appropriate vein to cannulate?
And the most important
or easy to remember rule is the rule of threes.
What is the rule of threes? Is you want to target a vessel
that's at least three millimeters wide,
at least three centimeters long,
and is less than three centimeters deep.
And why? Because this is going to help you actually be able
to succeed in your insertion, insert a catheter
that will last long enough and be usable.
There's other insights. If you're going to be looking
with ultrasound, target the nicest vein you find,
with the exception maybe of the basillic vein.
The basillic vein is deep
and it is usually one of the nicest veins an arm will have.
It is in the, the upper portion of the, the arm.
However, it's typical location for a PICC line insertions.
If your patient's hard to poke, you want to preserve
that vein for a more permanent axis if possible.
If you are relatively new, try
to avoid veins near surrounding structures like
arteries and/or nerves.
We saw in the video earlier, often you had an artery
with two veins next to each other.
That happens, for example, at the brachial vein
and brachial nerve location.
They're a bit more challenging
and you want to be sure to avoid hitting nearby structures.
So not for the first few insertions.
Now size, we talked about three millimeters.
Why does that matter? Well,
we know there's rules of physics.
Large bore and short tubes allow for faster flows.
And basically the smaller a vessel is,
the more resistance you'll have.
But that also means the smaller a vessel is,
the higher the pressure going through it for the same flow.
So vessels are more likely
to get injured if you have a small small vessel for a large
bore catheter.
For example, if you use a 14-gauge PIV,
it takes about three or five to five minutes to give a PRBC.
Now, if you try to give the same amount of fluid
through a 22-gauge PIV, even in a pressure bag,
it will take you about 10 to 15 minutes.
Catheters ideally should not occupy more than 45%
of the diameter of a vessel to decrease the risk
of phlebitis and thrombi.
Now, MAT is not always easy
or particularly when you're calculating it in your head.
So I like to simplify by using a rule of thirds,
being a bit more conserved on the size that I actually use.
If I have a three-millimeter vessel,
I know it can accommodate an 18-gauge PIV
or anything smaller than that.
And if I want to go big and use a 14-gauge, then I'll want
to target a vessel that's at least five millimeters wide.
Now, there are also systems that exist, including
with sonocyte, where you have assisted calculations
and assistance with AI tools that will allow you to
better gauge what size
of catheter can be used on a specific vessel.
The next part is very important.
Catheters should have over 65% of the length
of the catheter within the vessel to prevent dislodgement.
If that's part of why we say don't target vessels less
deeper than three centimeters,
because most of our IVs are not long enough to target them
and stay in place.
If you go too deep, your catheter will be too short.
And we know that 100%
of catheters will fail if they have less than 30%
of its length in the intraluminal position upon insertion.
So we go to 65%.
That's the recommendation
to make sure it lasts for very long.
But for sure, if you don't even have a third
of the catheter length, then you are 100% sure
that the IV will fail within the next little while.
And we remember the Pategorims triangle
hypotonisis, right?
So if you are targeting a vessel that's very deep,
you will want to target it at a much deeper angle
so you don't lose too much of that catheter length
as you're trying to reach the vessel.
We'll get back to that soon. The evidence.
Now, does ultrasound IVs actually help?
Well, we know that the first attempt success was much better
ultrasound than with landmark alone in
patients who are hard to book.
We know that ultrasound use
is particularly useful in patients
who are considered difficult to access,
and the first pass success
and the overall success rates are much, much better
with ultrasound guidance in that population.
And this is Maison Cochran reviews.
If you're looking at nurse-specific data, we know that
ulsound-guided use is actually associated
to a higher first attempt success rate.
You're actually almost three times as likely
to succeed than if you didn't use ultrasound guidance.
It also requires less time to access
and fewer skin punctures.
And less time to access is something
that's I find very important.
We have this idea often
that ulsound guidance takes a lot of time.
But what takes more time than one well-set up
ultrasound-guided insertion is three, four attempts asking
for a colleague for help,
multiple people being involved, right?
You're better off taking a bit more time maybe
in one attempt, but getting that attempt
to succeed rather than spending a smaller amount of times,
but more time, much more times to succeed.
Can nurses actually learn to do ultrasound guidance IV?
And we know we have systemic reviews of many, many studies
that show that to achieve competency,
nurses need only about five proctor procedures.
And competency was independent
of prior experience or seniority.
It's not because you've done a lot of IVs that you're going
to be good at this skill, and it's not
because you still have a bit of challenge occasionally
with ultrasound, but blind technique that you will fail
to do ultrasound guidance.
There's studies in PICU nurses as well that they show
that within within the span
of a simple training day nurses improve
Prove their success, doubled basically their success.
And sunguided IVs lasted longer in patients than
regular inserted IVs.
Partially because we target appropriate vessels,
we make sure there's enough length of
catheter inside the vessel.
Many different things that we do slightly better
with those sound guidance.
There's also the American Society of Echo that
recommends training that includes three different steps.
First, you should get a didactic or web-based knowledge.
You should then try and simulate. That could be in.
There's a lot of different gels out there that exist
to simulate vessels
where you can practice without poking a patient.
And then you finish by supervised clinical practice.
How many insertions are enough?
Well, we mentioned the fives earlier.
That's based on a lot of different studies
and a systemic review.
But there is variability among different organizations
and standards reflecting a limited evidence based
rather than a definitive outcome.
The American Society of Echo suggests 10 procedures minimum.
Acknowledging though that there's limited studies
regarding the actual threshold.
You know, there's 35 of them that looked at it,
but the threshold of, of,
of evidence is not always agreed upon.
The Urban Society of Insology recommends 30 successful
procedures within 12 months after a course.
And then there's societies, for example, the Society
of Hospital Medicine that does not actually
recommend any specific amount of proctor procedures.
Rather, they recommend a competency
and skill-based evaluation.
If you succeed very well within a few insertions,
then you're probably safe to do so,
but some people might need more assistance.
My personal experience training nurses,
I have developed a course a theory course
that's a four-hour course that I teach at
my hospital center.
And we've trained dozens of nurses since.
And really, I find I agree
with the evidence that was presented already in the sense
that it's hard to predict who will succeed or not, but,
but everybody can get there with enough practice.
I think the most challenging part is to recognize how
to look at a 2D image while doing a procedure
that's fundamentally 3D.
And that just comes with practicing, practicing, practicing.
And practicing on a gel is enough to get comfortable
with the pattern recognition of different movements
and how to target and follow your needle over time.
But nothing beats, then you have
to practice on an actual patient under supervision
because the image acquisition you will
generate is not going to be the same.
Gels tend to be very echogenic, very easy
to follow needle inside of them.
Patient's skin is very variable.
So again,
I think anybody can learn the skillset if you put in the
time and the work and you're surrounded by the right people.
Now the actual technique, how can we do it?
Now, this is the recommended technique,
and this is what we're going to be talking about today.
It's the one operator method.
You will hold the probe with your non-dominant hand,
and you will hold a catheter with your dominant hand.
It requires a bit more dexterity to do everything yourself,
and you need to be confident in both aspects
of the technique, both inserting a needle
and guiding yourself by ultrasound.
However, it's much easier for proprioception.
You know what it means when the screen moves.
You're the one who moved the probe.
You know what it means when you see the catheter show up
because you're the one who moved the catheter.
There's no need for communication between operators
because everything's happening at the same place.
Your brain is the only one in charge.
Now, you might see some people who try
and do a two-operator method.
This I've seen often what happens is you'll have,
for example, an emergency physician holding the probe
and a nurse poking the patient at the same time.
And the idea is every one
of those operators is a bit more confident in
that part of the skillset.
The problem is, if you have twice the people,
you have twice the opportunity for error.
It's very complicated
to actually communicate well when both people are not maybe
as comfortable with the other part of the procedure.
So it is less likely to work than the one operator method.
And I'll just mention that it exists,
but please don't do that.
You can do better by doing it alone.
And finally, there's a static insertion, which, you know,
I put dri- driving with your eyes closed,
but with a GPS on, it's functionally
you use the ultrasound machine to mark
and locate a vein that's appropriate and adequate to target.
And you're assessing for surrounding an anatomy,
but then you do a blind insertion
and you use ultrasound only as a guide in the sense
of understanding the anatomy.
For example, you might know
that if a vessel is one centimeter deep,
then if I poke one centimeter away at a 45-degree angle,
I am likely to hit it at the right time.
However, I'm not actually falling my needle throughout the
whole procedure, and I'm more likely to make mistakes
or hit something that I don't want to hit
or show up at an appropriate depth once I get to my target.
If you're not tracking your needle lover, know that
what you're doing is you're doing the static
technique without realizing it.
So this is not so much something that a lot of people do,
but it is something
that people do without knowing they're doing.
If you don't know how to follow your needle tip,
you are going to be blind following targets
that you don't know if you're hitting or not.
All right, so let's get ready. We need to get our material.
I'm not going to go through all this
but just know you need to have some equipment
to do in a septic technique, including sterile gloves
during insertion and a sterile ultrasound gel.
They can come sometimes, and most
of the time they come in a small little packet that comes
with an ultrasound probe sterile sheet,
which will cover the ultrasound probe
and make sure that it does not contaminate your
field as you're doing the procedure.
Use a tourniquet. I just have this here quickly.
As a reminder, we're using a fancier technique.
We're using a machine to guide us,
but know that the basics still apply, right?
We want to use a tourniquet to just increase the size
of those veins and get them easier to target.
So step by step globally, just know that we have
to start again, like I said,
with just making sure things are clean and adequate.
There's very, very low rate of peripheral IVs
that get infected, which is 0.15% of all the catheters.
However, they have functionally the same mortality
and morbidity as central line inserted catheters.
So CLABSI and PLABSI have, despite vastly
various rates of incidents, have this,
have a similar rate of complication.
And the only reason I'm saying this is to emphasize
that we do have to do this technique cleanly.
So we started by preparing the scene, preparing ourselves.
We're going to perform antigen, start
by just using non-sterile gel
and looking at the vasculature, finding our best target.
As soon as we find our best target, then we're going to,
we're going to set up for that specific vein.
We're going
to make sure the settings are
appropriate on the ultrasound machine.
Because we don't want to have to manipulate too much
ultrasound machine as we are going to be focused.
Both of our hands are going to be busy.
We're going to put large amount of gel
and ulsound probe on the probe directly
and then cover that with an ultrasound probe cover.
Clean the area like we do every time we poke a patient.
Open an IV package without touching the catheter.
And then we're going to open a sterile sheet, a sterile gel
without touching either of them.
And we're going to transition
to a more sterile part of our technique.
We're going to use sterile gel on the
patient at an appropriate location.
We're going to remove our sterile gloves,
clean our hands, and put sterile gloves.
We're going to put a sheet on the ultrasound probe,
making sure that it remains clean.
And then we're going to put a large quantity
of gel on the ultrasound probe.
This is sterile gel. We're going to find a vein again.
Now this time, we're going to be ready.
We're going to center it horizontally on the screen.
We're going to talk about
how we follow the needle very shortly.
We're going to take a sterile catheter
and then proceed to insertion.
As soon as you see a blood return, you are not done.
You're going to decrease the angle of your needle,
and you're going to continue to advance one
or two millimeters further
before cannulating the vein, the vessel.
Don't be happy with just simple blood return.
You want to see your needle tip well within the
center of the, the vessel.
Once the catheter is cannulated, once you've pushed it in,
make sure it's secured with an appropriate dressing.
This is a IV that was difficult to get.
Let's make sure it lasts.
And then you're going to connect your sterile extension
with the needle a free connector
and flush it with 10 mls like we usually do.
How do we guide our needle?
There's a couple of different options.
The two main things is you can do a transverse
view or a longitudinal view.
The transverse view is the one that's probably the easiest
once you're starting to find
and locate the vein surrounding anatomy.
It allows you to see a lot more structures around.
It is, however, sometimes a bit more difficult
to assess the length and irritation of the vessel.
So the way we will do that is by
sliding the probe over three centimeters
that will confirm if the vessel continues
to exist over three centimeters, then
that vessel is long enough.
The catheter tip might be harder to see
because it's only going
to be a small little dot that shows up.
However, in the longitudinal view,
you see the vessel over a long period of time.
It's usual, I keep it more
for confirming the successful cannulation.
Once I have my blood return
and I can lay the vessel, I will rotate my probe in tune
by 90 degrees to get a longitudinal view that will allow
to make sure that the catheter is fully well-rested
inside the vessel lumen.
It is however much harder I find
as a technique when you're following the needle
during insertion because all you need is
to be a few millimeters off
and you're in a completely different plane
where you will not see a needle at all.
The top version, the transverse view,
is much more forgiving in the sense
that you are seeing a large plane of area
where the needle could appear.
We're going to want to start by piercing the skin.
And the initial insertion angle can vary a lot,
a lot more than regular IV insertion
because we're looking at vessels
who sometimes are much deeper.
Anywhere between 15 and 90 degrees could be appropriate
depending on what you're targeting.
But you want to choose an angle that fits the depth
of the vessel being targeted.
If you're targeting a superficial vein,
please use a shorter angle.
If you're targeting a vein that's at three centimeters
and your catheter is short, you might have
to really go in at a steep angle.
It's easier to visualize the needle at the steep angle
if you're really flat or if you're 90
degrees with the probe.
And basically you want to have an angle that's 90 degrees
between the probe and the needle to optimize the likelihood
that you actually see the needle.
Steeping angles make it more challenging to canilate
as you will be more likely to go through and through simply
because there's less distance if you're really going from
top to bottom than if you're going
inserting through a diagonal.
Now, how do we find the needle once we pierce the skin?
The first trick is to make sure you
are starting at the right place.
Center the vessel on screen, left to right,
and then guide your needle towards the center of the probe.
The center of the probe itself is typically marked by a line
that will tell you where to poke initially.
On the screen though, there can be a optional center line
that you can make appear that will also guide you into
what is actually the true center on screen.
Before the skin gives away,
there's often a ring-down artifact, like this dark line
that comes down the screen from the displacement
of tissues as you're piercing the screen.
That's your first cue. If that la -
dark line appears on your screen left
or right, you're not poking where you think you are.
And be careful not to press too harsh to pierce the skin
because you'll end up deeper than intend.
Some skin is easier to pierce than others.
And if you're pushing very hard
before it gives, by the time that skin gives, you're going
to end up being at one, two centimeters depth instead of
where you want it to go, which is a controlled way.
There's a couple different things you can do if you're
not seeing it very obviously.
The needle, remember, is most needles are hypercholic.
So you can search it by moving the probe,
sliding or sweeping.
Sweeping being an angulation of the probe to try
and hit it at nine degrees.
Slide back and forth to find the actual end
and starting point of your needle, which is the needle tip.
That's the preferred method. You're going to have
to get comfortable with the idea
of sliding your probe away and towards you.
And you can do this as repeated small movements.
There's the stop and go we call for cannulation.
Once you see the needle tip, you advance your probe,
then advance the needle, then advance your
probe, then advance your needle.
It's a tangle of both hands, one at a time.
You can tilt like a set sweeping to change the angle
of view, and you can change
between views if ever you're having a hard time.
Go from longitudinal to transverse
or vice versa to see if you see the needle a bit better.
If you cannot see your needle,
despite all your best efforts,
you can do something called indentation.
And what you do is you actually take your
needle and you catter it a bit.
When you're doing that, it's going to create an echo
on adjacent tissue, and it helps you estimate
where approximately it should be on screen.
Tissues will move in a specific angle.
Now let's see following the needle tip just
Once.
Center the vessel image in the center
of the ultrasound screen.
Aim the catheter at the center
of the ultrasound transducer and puncture the skin.
Be sure not to puncture so close to the transducer
that the transducer cover may also become punctured.
It is important to maintain a slow, sequential,
and methodical approach to ensure continuous visualization.
Advance slowly until the hyperechogenic needle tip is
visualized, appearing as a hyperechoic white dot,
and then stop moving the catheter.
With the needle stationary,
the inserter will move the transducer away from the needle
until the echogenicity of the needle tip just disappears
and then stops advancing the transducer.
The inserter then advances the needle just
until the needle tip is seen,
and then immediately stops advancing the needle.
This sequence
of actions is repeated using slow methodical one
to two millimeter increments.
It -
So the slow methodical part is very important.
Go, you want to always be in control
and being able to see a needle tip
because this image I will represent
again in just a second here.
It's hard to know that
what you're looking at is a needle tip.
The only way to know for sure is that you go more distal
with the probe until it disappears,
and then you come back until the first step you could see.
If I put, let's say this line is a vessel
and the beige is subcutaneous tissue.
If I put my probe in the first position,
it will look like my needle's not deep enough.
And I will see this hyperechoic white dot
and want to push further down.
If I happen to look a bit further down
and the position number two, I will think
that I'm right on spot and I'll question why am I not
getting blood return, right?
And if I look further away even more, I will see
that I actually went through and through,
ended up on the deep sent,
and will have to retract my needle.
So make sure that what you're looking at,
the white dot you're seeing on screen
is actually the needle tip.
So the only way to find out
and make sure the needle, what you're looking at is needle
tip is you move past it with the probe and you come back.
The first thing you see, the first portion
of the needle you'll see is going to be the needle tip.
All right, nobology. How do we use an ultrasound machine?
Well, there's a couple of buttons everybody needs to know.
One of them is on and off.
Just make sure your, your machine is plugged
and has an adequate battery life.
Nothing's more annoying than running out of battery midway.
Freeze is more useful than you would think.
The main use of the freeze button is to unfreeze.
Often, most machines have a automatic freeze in order
to save battery life and probe life.
So you'll have to know where the freeze button is
to unfreeze once things become static.
But there's also secondary usefulness.
You can use it to make any measurements,
screenshots you might need.
Probe selection. There's a button on every machine
that will allow you to indicate to choose which
probe you want to use.
Some probe selectors use a design showing you
a rectangle triangle.
For example, the angle of the image
that will appear depending on the probe used.
Some of them use the probe name and number.
You just have to know your machine. Preset selection.
Basically every probe monitor could send waves
that are interpreted differently depending on how you want.
For vascular access, you want to select a preset
that's called vein, PIV, vasculature, superficial veins,
or anything that sounds about the same.
In terms of depth, you want
to make sure we have an appropriate depth.
So at first, as you are learning
to do ultrasound guide diabetes,
I recommend you always use the same depth just to get a feel
of what it means to actually push down
or not at different, at, when you're looking at the screen.
If at once you're looking at an ultrasound screen
that's at one centimeter, next time you're pushing on a
screen that's at five centimeters, it's going
to be very hard for you to guide yourself.
Gain affects contrast or how bright the image appears.
If it's too much, it looks like a snowy winter storm.
If it's too little, it's going to be dark.
You will choose the gain that fits your comfort.
In terms of B mode gray scale, well,
that's the basic setting of most ultrasound
for vascular access use.
That's the most basic ultrasound setting.
You just need to know where the button is in case it's not
already in that mode.
Somebody was doing some color Doppler before
or some tissue wave Doppler
and you want to be able to switch back into the B mode.
Color Doppler.
The important part where I'm not going too much in depth in
this today, but just know
that blue does not always equal vein.
There's an acronym called BART,
and basically blue, it means liquid is,
or whatever you're seeing moving is going away.
Red means two words. So if I take a probe
and I flip it, whatever was blue will become red.
Whatever was red will become blue.
It's all about how you're angulated where you're looking at.
And then the center line is an on
and off vertical line that appears on screen center,
allows you to guide yourself when you're
looking for the screen center.
So it's important to know your machine.
Every machine will have different knobologies.
Some of them have touchscreens like the one we see here
from pseudocyte where you can press and go down.
This here is probe selection.
You see the probe design,
you could press on it and choose your probe.
This is the next screen on the right.
And you can also just choose your preset, which is venous,
PIV, nerve, MSK.
And here we'll choose PIV.
Again, a lot of machines have a knob like this
where you can basically circle around and press,
but some of them also have just like the depth
that you see here, plus or minus.
And the freeze button is universally, from my knowledge,
from what I've seen, is always a snow flake button.
Dips and tricks. Okay?
This is just so you end up with a bit of,
of the knowledge that can impart.
So first of all, believe your patients and your instincts.
We know the risk factor for diva,
but we also know that non-palpable veins
and non-visible veins is a bad sign.
If a patient had difficult access
before, believe them, they're likely to have it again.
Take the first attempt seriously.
Don't wait until the fifth test attempt
before pulling out the ultrasound machine.
Part of it is also that you're going
to traumatize some veins that might
have been your targets otherwise.
Practice makes perfect.
So I mentioned it before, you need
to continue practicing, practicing.
We know that if you have dedicated teams
and they do at least five cases a day,
they have a first pass success rate of almost 90%.
So that's, that's the goal standard that we want to get to.
In the meantime, we know that at least five is the minimum
to be able to be competent when you're doing it yourself.
And it comes easier, faster to some,
but it comes to all loop persist.
So you just have to keep going at it. Believe in yourself.
There's a nod ratio of almost three favoring ultrasound on
the first insertion success.
This also decreases time to access
because you don't have to poke as many times.
So know that your skillset is useful.
Don't be shy to go old-schooled.
What I'm saying is landmark approach remains
something that's quite useful when the veins are visible
or palpable.
But don't shy away from ultrasound
guidance in the diva cases.
Those are the cases where you want to be messing around.
Be proud of the graphical work.
And what I mean by that is that a PIV is hard
to get occasionally.
And in those cases, we want that PIV to last.
If you have a patient that's di- diva access,
markets in some way,
however way makes sense for your institution,
because you want to make sure that we keep
that access for as long as we can.
Now, two tricks, avoid the static technique.
So the first thing is you're saying you're doing ultrasound
guidance, please do so.
So aim for real-time needle tracking,
not any funny business.
Always make sure you're looking at the tip.
So most common mistake I would say by early learners is
following a dot on screen
that is not the ultrasound guided needle tip.
And you're pushing way too deep,
you're hitting secondary targets, you're causing trauma.
Make sure what you're looking at is the needle tip.
As long as you do that, you will be safe.
Don't hesitate to verify.
It only takes a couple of seconds to do so,
and it can avoid complications and delays.
If you're not sure where you are,
take the couple seconds it takes to slide the probe away,
slide it back until you find the needle tip.
Avoid putting too much pressure on the probe.
So a couple of reasons.
First of all, it's easy to compress
supervisional veins into oblivion.
You might think the patient has no veins.
Well, actually, they have only superficial ones
that you're just pressing too hard to see.
The other thing that happens often is people press too hard
when they're looking or targeting at deeper vessels.
The procedure lasts long.
And as you're doing the procedure,
you end up pressing harder and harder on that probe,
and you are compressing the soft tissue.
But that soft tissue will then retract once you let
go of the pressure on the probe.
And then the catheter will also retract
and you will have caused infiltration.
Ultrasound guidance is better for TVAL patients.
There's an increased odds ratio of success.
There's fewer attempts, less pain, anxiety,
and less wasted time.
But more importantly,
and this is a very important takeaway,
ultrasound-guided IVs help reduce the amount
of central lines insertions.
There's a study I look at over 400,000 patients in ERs,
and they showed that there was a decrease of 80%
for the central IV line insertions
once they trained their personnel into
using ultrasound-guided IVs.
We can do better and we can do safer
by using ultrasound guidance.
So that's it. These are the references.
I'm just going to go slowly over them so you can stop
and look if ever you want afterwards.
All right. And now we are on to questions and answers.
If anybody has any, that now will be the time to ask.
And I'd be happy to answer to my advice of my lodge.
Kenny, thank you so much for that excellent presentation.
When, what would you say people struggle
with the most when they, they get started doing this?
I think the, the hardest part
of this when you're starting initially is actually being
able to look at the needle tip, knowing where you're look,
that you're looking at which part
of the needle you're looking at, and being able
to guide yourself
to the target you're trying to get to on screen.
Part of the counterintuitive aspect is that if, for example,
I want my needle to go towards screen right, well, I have
to move my hand towards screen left in the sense that
everything has like there's a, a point of junction where
at the skin pierce, where we pierce the screen.
So if I want to go towards the right, I need
to move my hand towards the left.
Vice versa. If I want to go up on the screen, I need
to either retract the needle or, or press down.
And, and, and this movements that we do in order
to guide ourselves on the screen
take a bit of getting used to.
Making sure we have appropriate length
of catheters when we are starting.
Really, you're better off having a longer
IV that you don't need to be.
Let's say you only need about two centimeters to get
to your target and leave a decent amount inside.
Well, you might as well take a longer catheter in the case
that it takes you longer to actually counter the vein.
One of the things that can happen sometimes is the needle
tip looks like it's inside a vessel,
but you haven't actually pierced the vessel wall.
Particularly with smaller vessels the vessel wall can kind
of bend and the needle tip just kind of tents it
inside the lumen instead of actually piercing it.
Sometimes you need to have a little prick movement at the
end once you target the vessel.
When you think you're in the right place
and you've confirmed what you're looking at is needle tip
and you're still not getting the blood return,
sometimes it'll prick to make sure
that you're actually piercing the vessel wall rather than
just sliding along it
as you're tenting it ins - along the way.
All right. Let's Like
A few more Questions
Coming in.
Some questions. I don't know how in
which order we want to address them.
Yeah, we can kind of start from the top here.
So we have what is the optimal angle in general?
This person was taught a ride the slide mantra
to go at a softer angle,
but being mindful to ensure a majority
of the catheter is in the vessel.
Yeah. So that's why in the presentation I said any angle
between 15 degrees and 90 degrees is okay
because really you have to adapt yourself
to your target and to your materials.
If I have a short catheter, I will need to go steeper.
If I have a deeper vessel, I will need to go steeper.
Functionally speaking, if you want to be able
to see the needle, ideally you're hitting it at a 90
degree angle with your probe.
So if I'm, for example, hitting at 45 degrees here, well,
I might have to tilt my probe catheter
to actually meet it at 90 degrees as well
and increase the odds of me actually seeing the needle tip.
Always make sure you're sweeping
or you're sliding away to make sure that when you come back,
what you're looking at is the needle dip.
But the ideal length of the needle,
I would say the longest you can find would be my answer.
I mean, we do have a lot of literature on midline catheters
as well, so there's context.
But even for a PIVs, there are some out there
where about seven, eight centimeters long.
And I would probably recommend those over a smaller if
you're going to be targeting deeper vessels.
Okay. It looks like we have a question about how
to prevent poking an artery.
Well, that's a great question Bob.
It's one of the objectives of using ultrasound guidance.
I would say the first
and easiest answer is to target vessels
that are away from arteries.
If you are going, for example, to, for the brachial veins,
which usually come in a Mickey Mouse pattern
where you have the artery in the center
and two veins, one in each side, well, you don't want
to be targeting those vessels initially
as you are learning to follow your needle.
Make sure you're targeting a vessel
that is isolated from arteries.
And then if you are, if you have no other choice,
if you are the only person who has the expertise
and the only vessel you can target is one
that's near an artery.
Well, one thing you can do is trying to make sure
that if ever you do lose your needle tip, that the angle
of insertion does not lead you into the artery.
For example, I, I am, hopefully this can show on screen.
If you have a, a vein here in a artery here, I will want
to hit that vessel at an angle like this so
that if I go deep in and actually go through
and through, I'm not going towards the artery,
but I'm going away from it.
So I will aim instead
of hitting at an artificial clock at 12 o'clock,
I will probably aim at something like 10 o'clock
or 1:00 PM, 1:00 PM to 2:00
and with my needle on the vessel in order for my distal tip
to go away from the artery.
Hopefully that's clear with just verbal explanations.
Right. Next question is I panic when I lose my needle tip.
I try to wiggle the needle or bounce it,
but sometimes I can't find it.
Any suggestions?
Yes. That's a very common happening.
This is when you're starting to learn
to do ultrasound guidance Happens all the time.
It's the first thing people will do is to wiggle,
which is a great tip in itself.
As you're jiggling the needle, you're moving left
and right quite a lot drastically.
It's going to move slightly at the tip,
and that makes it easy to guesstimate
where the needle tip is likely situated.
But really, I would say if you are not sure, the best way
to know is first make sure you have the best image.
Make sure your gain's appropriate, death's appropriate,
you have a crisp image that you have in front of you,
and then try to angulate your probe in a way
where it's meeting the needle at the angle at 90 degrees,
where you have a higher likelihood of seeing it,
and then slide away and then slowly come back down.
The first thing you can find is going to be the needle dip.
If ever you still cannot manage to see the needle tip,
the next trick, which might be a bit more advanced,
but works just fine, is to actually rotate your probe nine
degrees and change views.
You will change from longitudinal to transverse
or from transverse to longitudinal.
Hopefully, in that way, you get to see it a bit better.
Right. Looks like next question is
what would you advise on patients with very loose skin
and runaway veins?
Yeah, that's our next challenge, right?
For runaway veins
and loose skin I tend
to stretch.
Well, whenever I hold the probe, you always want to have two
or three fingers max on the probe,
and you want to have at least one
or two fingers touching the patient in order
to anchor yourself with the probe hand.
Those fingers that I'm using to anchor myself with,
I will also use to stretch the skin a bit.
And I would. Same thing with my
end that's holding the needle.
I will use two fingers, usually these two, the,
the last two, the smaller ones,
and I will kind of stretch away.
So I'm stretching and I'm squeezing the skin from one side
and the other, from the probe away from my,
both hands away from each other in order to stretch the skin
and kind of settle things duplex.
All right. Next question is what would you do
for central lines for acute care nurse practitioners?
So in terms of needle guidance,
it is functionally very similar.
The getting the needle to the right target
is about the same, except
that the targets you are using in central lines tend
to be larger vessels.
It's actually functionally easier
to get the needle to the right area.
Now, you do have the mental barrier of poking a neck
or poking a groin where you know
complications could be a bit higher.
So there's a bit of a stress there that you have to handle.
But other than that, following the needle is about the same.
The only thing that changes is the following steps
once you hit that vessel.
If you're doing PIV, well,
we know we can laid the vessel over.
We have usually a PIVs around a needle
and then you can just slide it in.
If you're doing central line, most kids come
with a technique called a cell digger technique.
So you'll push a guide wire in, get the needle out,
verify the guidewire is within the vessel
before proceeding to dilating the vessel
and preparing your, your central line for insertion.
So there's just a few more steps once you get into the
vessel, and you have to always be sure that you are allowed
to do whatever it is you do, whether that's PIV insertion
or central line insertion.
There's different bodies of regulation depending
where you live or where you, where you practice,
but it is definitely a skillset
that could be developed safely.
All right. Well, it looks like that's all of our questions
for today, and we're a little bit over time here, so we want
to make sure that we respect everybody's time.
But thank you so much, Kenny, for joining us today
putting together that excellent presentation
and hanging around to answer questions for us.
So we really appreciate you sharing your expertise
with our audience here.
It's been a pleasure. Thank you, everybody.
And a quick reminder that you can watch previous webinars
and sign up for upcoming webinars on
sonosite.com/behindthescan webinar.
Thank you so much for joining us today,
and we'll see you all at the next one.
This educational webinar will equip you with a comprehensive understanding of ultrasound-guided peripheral IV insertion, including when and why to use this technique across diverse patient populations. You'll learn how to select the most appropriate transducer and how to optimize the image for the best visualization. The session will also cover key upper extremity vascular anatomy, enabling you to distinguish veins from arteries, nerves, and surrounding structures. Step-by-step guidance on real-time ultrasound-guided IV placement will be provided, along with strategies to identify and manage common complications. This educational webinar aims to enhance your skills to improve first attempt success rates and extend catheter dwell time for better patient outcomes.
What You'll Learn
- Benefits, indications, and limitations of PIV access across patient populations
- Master ultrasound basics for vein visualization
- Identify key anatomy, distinguishing veins, arteries, nerves, and more
- Discover step-by-step technique for real-time PIV placement
- Spot common challenges to boost first attempt success and catheter longevity
Kenny is a Nurse Practitioner in a Medical and Surgical ICU at McGill University Health Centre in Montreal, Quebec, specializing in US-guided vascular access for peripheral IVs, PICCs, and central lines. Formerly an emergency nurse at a Level 1 Trauma Center, he developed a strong passion for ultrasound-guided vascular access and completed advanced training through multiple programs and the Canadian Vascular Access Association. In 2018, Kenny led hands-on ultrasound training across two emergency departments and continues to teach nurses and nurse practitioners the importance real-time ultrasound guidance in everyday practice.
This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.