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- Thanks for joining us everybody.

Welcome to the behind the scan webinar titled Look,

before You Leap POCUS for central venous catheterization

with our guest speaker, Dr. Cameron Baston.

My name is Chris Pennell

and I'll be hosting today's webinar.

Before we begin, just let me go over some important

information about this webinar.

The information in this webinar is

provided for general educational purposes

and 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's the professional responsibility of the practitioner

to exercise independent clinical judgment in

each particular situation.

Dufu Sonos assumes no responsibility

or liability for any misuse of this webinar.

During this webinar, all attendees are muted

and we'll be conducting a q

and 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 them at the end of the,

at the q and a session.

If you're on the zoom stream,

you can type your questions into the q

and a box on the toolbar located at the bottom

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And for our viewers on YouTube

and LinkedIn, you can enter your questions into the chat box

and we'll get to those now.

This webinar will be recorded

and archived for future reference on our webinars page

and on the Sono Site Institute.

To get started, let me introduce our guest speaker.

Dr. Cameron Bain is a clinician advisor for

for Penn Health Tech

and an associate professor

of clinical medicine in the Department

of Medicine at the University

of Pennsylvania's Perelman School of Medicine.

He serves as an associate program director for the pulmonary

and critical care medicine fellowship,

and as a director of clinician performed ultrasound

for the Department of Medicine.

I'm mechanical engineer epidemiologist critical care

physician and medical educator.

He spends about two thirds of his time caring

for critically ill patients

and the remainder working on education innovation

and health technology.

And with that, I'll get our presentation started.

- Hi everybody. Very excited to be here.

My name's Cameron Bastin.

I'm a pulmonary and critical care doc out of Philadelphia,

and I'm here to talk about how to use an ultrasound to look

and perform a central venous catheterization.

The title of this talk is Look Before You Leap

POCUS for CDC.

So there's five key objectives I'm

hoping to get through in this talk.

I want to make sure everybody understands the evidence-based

and regulatory guidelines supporting the use of POCUS

for CBCs.

I want to make sure you know how to identify the key

ultrasound and anatomic landmarks for catheterization

of the internal jugular subclavian e femoral veins.

I want to talk about different techniques

for needle insertion, how

to guide your needle into the vein, along with how

to confirm the wire once the wire is placed

for a modified selden injury technique insertion.

I want to talk about what you can do after the procedure.

So that's checking for pneumothorax,

having bubble studies done,

and I want to explore some of the emerging practices

and future directions of ultrasound

guided central line placement.

If I wanted to simplify this a little bit,

I changed those five objectives to why are we using focus,

what are we looking for?

How do we access the VE vessel, what comes after access

and what's coming next?

So here we go. Why? Why do we use pocus?

And, and the question might be, why

don't we just use landmarks?

And I'm sure that there are people

who are going to be watching this, who are going to say

that they've done so many subclavian

or femoral lines using anatomic landmarks

and palpation of a pulse that

that they feel safe and comfortable doing it.

And I'm not trying to talk them into changing all the time,

but I will offer that when we've tried teaching people

who use anatomic landmarks to start using ultrasound,

that complications decreased a lot.

We're talking about more than 50% decrease in complications,

a more than 80% decrease in arterial puncture alone

and more than a 40% reduction in failed first attempt.

And that's amongst experienced providers.

And part of the reason for that is that if you look at

where the artery and the vein are,

and this case you're looking at the right carotid artery

and left carotid artery and the where the jugular sits,

it doesn't always sit in the place that it's supposed

to according to netter's drawings.

All right? And that variability means

that sometimes you're perfectly aligned with your needle,

where it should be based on surface landmarks,

but you're not where the vein actually is.

And that might even be more true in the subclavian vein,

which is the place where I think I still see the most

landmark and palpation guided procedures where you can see

that where the artery and vein are vary a lot

and sometimes that vein just isn't superficial to the artery

and that can get you into a lot of trouble.

So this is why the guidance has changed and,

and man, the changes are not new anymore.

More than 25 years ago, the A HRQ was the first group

that said, Hey, real time ultrasound

for central lines is an important

evidence-based patient safety practice.

It was in their top 11 practices,

and this was shortly thereafter followed in the UK

by the nice TA 49,

which they basically said 2D ultrasound guidance is the

preferred method for elective IJ access.

And also had a little bit in there for the first time about

how important it is to train people

to competence in ultrasound guidance.

Skipping forward a decade, the American Society

of Echocardiography, the European Society

of Intensive Care Medicine did consensus documents talking

about how important using ultrasound for cannulation is

and talking about how to train and accredit people in it.

And this has continued with the Society

of Hospitalist Medicine explicitly calling out a minimum

number of simulated passes

before saying somebody's ready to start doing this on humans

and the American Society of Anesthesiology,

talking about real-time ultrasound access.

And then again in 2025,

this update from the A SE from the American Society

of Echo Echocardiography, talking about the three core roles

for ultrasound in central vein access.

So my conclusions from this, my takeaways are the area

of landmark guided central lines is basically over.

And at this point, if you're learning how

to do a central line from scratch, you need to be learning

how to do it with real time ultrasound guidance.

So let's move on to the next part, which is

what are we looking for when we say we're doing

real-time ultrasound guidance?

And the first thing you need to do is think about

how am I going to set myself up for success?

And that means choosing the right transducer.

And this can be done with other transducers,

but I'll tell you that I think in great sim greatly

simplistic terms that a linear transducer is the best

for anything that's less than six centimeters deep.

And even in the era of the American habitus,

that a, that a six centimeter deep

IJ is surprising to me.

Now, when it comes to the femoral vein,

sometimes we are talking about a greater depth

and that a micro convex

or a carboline transducer is necessary in

order to be able to see your needle.

But for most patients, especially for thoracic

and cervical lines, the linear

transducer is the way forward.

And then most modern machines have a venous access preset

or a venous preset that allows you to visualize the vein

and more importantly, has a high enough frame rate

that you're not going to miss your needle,

that there's not going to be lag in what you're seeing.

Sometimes you'll see people do this with a nerve preset

because it gives you the best image of the anatomy around,

and that's fine, but recognize that

that will have a slightly lower frame rate

and you'll see a slight delay.

And when it comes to thinking about positioning,

it's really important.

And the reason for that is we want to think about how

to optimize the vessels that we're targeting.

What you're seeing in this video, an internal jugular vein,

a carotid, the overlying SCM, and the skin above that.

And you can see that this IJ is starting to collapse.

Is this a reasonable target? Yes.

Could we get into this with a needle safely? Yes.

But if we put our patient into trendelenberg, then

that same vein can become a much easier target to visualize.

It's not just whether

or not the patient's head down enough,

applying enough gravitational pressure to bring

that blood into the vessel

and fill the vessel that you're trying to target though, one

of the things that I see taught a lot is this idea

that you want the patient to rotate their chin.

And this is helpful for an internal jugular catheterization

because it exposes the anatomy

that you're trying to get access to it.

But if you over rotate, if you rotate too much, then

that anterior surface is now looking through the IGA

and carotid and they will lie just on top of each other.

As you can see here with this jugular vein

lying just on top of the car.

Carotid again, is this something that you can do safely?

Yes, but you have a choice.

You don't need to have this risk.

And we'll talk about why this in particular is a risk if

you're using an out of plane

or transverse approach when you're trying

to access this vessel with a needle

in the same patient's neck, if you just rotate the neck back

and instead look from some somewhere

that's more anterior on the neck closer to the thyroid,

you can see that the IJ moves lateral to the carotid.

And as you move back and forth, you can see

that IJ going on top of the carotid

and then back lateral to it giving you a safer target.

It's also really important to know how

to differentiate veins from arteries.

When we think about this, the first thing I think about is,

do I know my anatomy?

I know that the carotid should be deeper

and more medial than the ij.

And so I can think, Hey, am I looking in the right spot?

But as you might remember from an earlier slide,

that relationship,

that anatomic relationship while on the majority

of patients is not universal.

And so then I like to think about compressibility,

and it's not that arteries aren't compressible,

especially when we think about some

of our patients in severe shock.

But this idea of compressing and slowly releasing

and seeing that vein totally collapse,

lets us know which is the vein, which is the artery.

Perhaps even more sophisticated, is the use

of spectral doppler and making sure

what you're seeing is a venous waveform,

as you can see here, as opposed to an arterial waveform.

Or if you want, you can use colored doppler.

And it's important to remember when using colored doppler

that you have to understand some of those basic principles.

This idea that the color of the blood

and colored doppler does not tell you whether the blood is

ated or not, just tells you whether

that blood is moving towards or away from the transducer.

And you can see the color key over here on the left

and the convention, which I remember using the Simpsons Bart

blue means moving away from the transducer,

red means moving away, moving towards the transducer.

The other thing you want to make sure you're doing

before putting a needle or a wire into these

vessels is checking for thrombi.

And what you can see here is a non occlusive thrombi

thrombus, sorry, near the valve.

And that non occlusive thrombus is floating around in a

utter emergency lifesaving situation.

It's not that you can't pass a needle on a catheter here,

but if you can choose an alternative

vessel, that's really important.

This example in contrast shows a complete occlusive

thrombin, and this should not be accessed

because it won't be successful.

The risk with a non occlusive thrombus is

that the thrombus could be dislodged

and cause life-threatening emergencies later.

With a occlusive thrombus like this, there is no way

to pass the wire into the vessel.

All right, so let's move into choosing a location to do this

and we'll talk about the the main places we go,

the internal jugular vein, which is

probably the most commonly accessed site in the modern era.

The advantage to this is that it's compressible,

it's easily accessible.

There doesn't tend to be a ton

of adipose chi tissue blocking your path.

Philly's really into really impressive beards

and sometimes that can be a problem.

And there's more than one patient who I've had

to bring clippers to before doing this procedure.

But the idea is that if there were a complication involving

a vessel here, you can easily apply

pressure and control bleeding.

The disadvantages to the IJ is that

it's got a slightly higher infectious risk than the

subclavian, which we'll learn about.

And the reason that I see

that a lot in my patients in the intensive care unit is

because when a patient's in the supine position at 30

degrees, as we try to make sure they are

to minimize their risk of ventilator associated pneumonia,

saliva, and other secretions can sometimes

pool and drip down the neck.

The other problem is that this is valuable real estate.

This is something that that is going to limit a patient's

mobility of turning their head back and forth.

This is a place where you're going to want to be looking

for other applications.

What you're seeing in the video right now is an out

of plane approach showing a needle,

my needle accessing this vessel, breaking

through the anterior wall

and then stopping right in the center

of the vessel right there before going

through the posterior wall towards the crowded.

This is what that vessel looks like

in the longitudinal view.

In this case, you can actually see that smoke

or sec, spontaneous echo contrast.

Again, that spontaneous echo contrast does not mean

that this vessel has a thrombus in it just means

that there's a low flow state, still a reasonable target

for a for a procedure.

So this is the IJ I had mentioned,

that the subclavian vein has a lower risk of infection.

It's also almost always the most comfortable place

to have an indwelling catheter.

It doesn't interfere with moving the neck around.

It doesn't interfere with moving the arms around.

And this is what you're seeing.

You're often seeing, and this is in the transverse view,

you can see that vein as it dives under the clavicle,

which is on the left hand side of the screen,

this bright white line with a dark shadow behind it.

You can see the vein here as it goes,

you can see a valve in it and then it dives under.

I tend to do this procedure with a combination

of the transverse and longitudinal view.

This is the longitudinal view showing

that axillary vein joining together

and becoming that subclavian vein.

The advantages of the longitudinal view is

that you can see your needle the whole time,

and more importantly, you can start to look for how deep

below the vessel that lung sliding is.

If you look back up at this transverse view,

you can see the bright white line and dark shadow of a rib.

And then right next to it you can see the shimmering

and glistening of the plural line right here.

Knowing that depth allows me

to understand a little bit about how high the risk

of pneumo phx is going to be for this specific patient

for this specific procedure.

The other disadvantage to the subclavian vein

and subclavian artery is that because of the clavicle,

you can't apply direct compression to it.

So if there is a bleeding event, you're in trouble.

And that's why there is a contraindication

of doing this in a severely coagulopathic patient.

The next site that's often talked about is the femoral vein,

and here you're seeing the femoral vein

and artery with compression showing

that vein completely compressing.

And then, and the advantage of this is

that there's lots of real estate.

And what I mean by that is while you want to go

high up into the common femoral vein, usually have a couple

of centimeters to do it, and it keeps the torso free.

That means that this is the access point that I look

for when someone is actively getting CPR

or in a crash scenario where I need

to get central venous access.

Also, unless you're using your needle in some sort

of wildly inappropriate way,

it it should be almost impossible

to cause a pneumothorax with a femoral vein.

The disadvantage to this is that it's been shown

to have a higher rate of infection.

It also has a slightly higher rate

of DVT if this is left in place for a long time.

I tend to think of this anecdotally

as this is my short term emergency access,

and if I can I move the catheter to a thoracic

or cervical location afterwards?

All right, so I've offered some of the kind

of qualitative reasons why you might

want choose one site over another.

But the good news is that in the New England Journal

of Medicine, the three site study group actually

did this study.

They looked at a very large number of patients,

almost 3000 patients who got catheters placed in each

of these sites.

And they looked at what the rates were of mechanical,

infectious and clots

and mechanical implications, infections and clots.

And what you're seeing is that really

all three are reasonable.

The difference is between them are small.

That said the infectious complications was objectively

smaller and the subclavian vein compared to the other two

and and that mechanical complications were a little bit

higher in the subclavian as compared to the other two,

they did secondary pairwise analyses of these.

So you can just say, Hey, if I have to choose between an IJ

or e femoral, things look about the same in all honesty.

But if I'm choosing between the subclavian

or the femoral versus subclavian versus the ij,

you can see why you might decide that one

of these is better than another.

So how do I put this together into a conclusion?

I summarize this by saying, Hey, I'm going to look at the ij.

I'm going to say, Hey, this is where a place

where I've got great opportunity to control bleeding.

So my coagulopathic thrombocytopenic

patient, I'm going to think about this.

And in the era of ultrasound guidance pneumothorax is

relatively uncommon.

It's got a lower infection rate versus the femoral.

And if I need to think about things like a PA catheter,

it's a lot easier to float that through the right ij.

The disadvantages that I'm looking about is if I'm doing

this with a novice user,

carotid arterial injury is real and a problem.

It's uncomfortable for patients when they're trying

to move their neck and maintenance

of dressing is is a problem.

Also, if the patient has a tracheostomy,

I can get into real trouble with my landscape.

Also, the the, the truly the patient who's hypovolemic,

who's hemo hemorrhagic shock

or distributor shock, that IJ can be very prone to collapse

and that can make it tricky to get in safely.

With the subclavian vein, I'm thinking a lot about

how easy this is to maintain my dressing,

how comfortable it's for the patient,

how clear my external landmarks are,

and the fact that the subclavian vein being lower is a

little bit less collapsible than the ij.

It's also got that lowest infection rate.

And if I'm going from the left,

then I can totally float a PA catheter.

The disadvantages are the risk of pneumothorax is higher,

although again, not reaching statistically significant

levels in the studies that actually looked at this

and that the subclavian artery is very difficult to compress

because of the clavicle, the axillary vein is compressed.

And the reason this is important is

because when I do an ultrasound guided subclavian vein axis,

my needle is actually hitting

before the axillary vein goes under the clavicle.

So it's technically an axillary vein cannulation,

and that place is somewhere that I can compress the femoral.

Again, no interference with CPR, no risk of pneumothorax,

but the highest and infection rate difficult PA cath float,

and the risk of the femoral artery being

damaged or of A DVT.

This, this IDSA guideline.

This joint guideline in 2022 says

that the subclavian vein should be our first

and most desirable target

for central venous catheterization.

So my conclusions for this, when you're talking about how

choosing your vein and how to get there is make sure you

know the road D plan and falling.

Know the anatomy that's nearby, know

what it looks like on ultrasound.

Know how you're going to get from the skin

to the vein that you're targeting.

All right, moving on. Let's talk a little bit about

how we are to access the vessel.

And this is the part that I think is most interesting.

And the reason I say that is

because there was an initial period

where we were using ultrasound to make a mental map of

what was below us and then putting the probe down

and doing our same pass.

And we've moved beyond that

and now we're doing real time guidance.

And the first, and probably the most common way

to do real-time guidance is the out of plane approach.

And that's where the transducer is held

perpendicular to the needle.

And you can see this schematic that I that I made

where you start

by entering the skin on the proximal side towards you from

where the probe is.

And then once you can visualize

that needle tip just under the skin,

then you move the transducer away, you move it away

until you can't see the needle anymore,

then you stop moving the transducer,

then you advance the needle just until the tip appears.

Then you move the probe away until you can't see it

and you repeat this process until the needle is starting

to enter the vessel.

We'll see that right now. So you can see the probe every

time the needle tip appears, the probe is moved away

until the needle enters into the vessel

because you're seeing the needle tip and

because the tip has a bevel to it, I like

to then advance a little bit more until I'm sure

that my needle tip is in the center of the vessel.

Otherwise you can get into trouble with the wire trying

to be advanced through a needle where half

of the bevel is in the vessel

and half of it's in the VE vessel wall.

And then when that thick wire tries to get through,

it gets caught up in the vessel wall,

can cause damage to the vessel.

So continue to follow that tip.

Continue the steps three

and four until you're well inside the vessel so

that you can be sure that your wire's going to

go where you want it to go.

When you're doing this, there's a couple things you can do

to make your the process as easy as possible.

One of them is recognizing

that physics can help or hurt you here.

If your linear transducer is pointing perpendicular

to the needle, you get the brightest, most visible image.

If on the other hand you're at a 45 degree angle, some

of those sound waves bounce off

and you see less, it becomes a less bright issue image.

And if you're really far off,

you can lose the image altogether.

This can be mitigated a little bit

by having etched needles which have little grooves cut into

them to make them easier

to see from different angles of ultrasound.

The brighter on the ultrasound screen regardless

of the angle of insulation.

But in the end, you just want to make sure that you know

where your tip is.

And this is so important. You can see that on the screen.

All you're going to see is a single bright dot,

that's the echo from the needle.

But you don't know

without moving your probe whether that is the tip

of the needle or the body of the needle.

And so this is why that process,

that iterative step-by-step process of moving the probe away

until the needle disappears is so important

because it lets you know that you are at the tip

of the needle as opposed to looking in the middle.

And this is why the out of clean approach

has some dangers to it.

Those dangers really are, hey, am I looking at the tip

or am I looking at the body of the needle?

If I'm looking at the body of the needle thinking I'm

looking at the tip, then the tip of my needle is much deeper

and can potentially damage deeper structures.

The next option is the in plain approach.

And you're seeing that right here where the, the

linear transducer is now aligned with the needle.

And so that means that you can visualize the entirety

of the needle and the vein at the same time.

This allows you to ensure that you're seeing your needle tip

as opposed to kind of having to guess and check and guess

and check like you do for the out of plane approach.

The advantage here is

that you're not going to have your tip be deeper

than you think that it is.

That disadvantage here is what you're seeing at the end

of this clip, which is that the hand skill

of keeping both the needle

and the vessel aligned is more difficult

than the out of plane approach.

If you're trying to optimize your image here, you can see

that this, while this needle is bright,

by angling your transducer slightly

and having the sound waves go perpendicular to the body

of the needle, even in this out of plane approach,

you can get even brighter images.

So when you're trying to optimize your image in the

longitudinal view, you need to make sure you

know your imaging plane.

And what I'm showing you here is a clip

where somebody was trying to follow that longitudinal view

of the IJ but gets a little bit lost

and you can see that they're off axis

and they no longer are in the center of the vessel.

So I like to encourage my, my learners to pre-scan

before they put the needle in, follow

that vessel know which angle it's going at,

know which way you're going to be moving your transducer,

and then to look back

and forth between their hands in the screen

because I want make sure they can see whether

or not their needle and their probe are aligned.

You'd be surprised at how tricky that can be.

This is what that'll look like in a, in the subclavian vein

where you can see a vein

with a valve in it at the beginning of this clip.

And you can see that artery coming into view, the main

danger of the longitudinal view since you can easily see

whether or not your needle tip

is going through the back wall.

The danger is whether

or not your unseen needle is hitting a lateral structure.

And this clip shows you just how close

that subclavian artery can be to that subclavian vein.

So how do we choose this orientation?

How do we decide whether this is something

where we're going to go in the short axis or the long axis?

And the answer is there's advantages

to each and the short axis.

You get to see the whole field,

but it can be tricky to find the tip

and you have the risk of going through the back wall,

the long axis, you see the whole needle.

It's tricky to see both the

needle and the target at the same time.

You have risk of lateral structures.

You would think that one of these would prove to be better.

But after multiple attempts

to randomize experienced operators

to using either this long axis

or the short axis view, the conclusion really is

that it's just the one that's most comfortable for you.

In all honesty, the way I do this is I go back

and forth between the longitudinal view

and the short axis view.

And the reason I do that is

because that allows me to know where I am, to know

where the structures are.

And then when I come close to truly accessing the vessel,

the longitudinal view lets me see that that needle tip

and make sure I'm not going through the back wall.

One of the options that I see interventional radiology

colleagues using is an oblique approach.

And that's where you actually see the vessel in the

short axis.

But you're seeing your needle and the long axis.

And you can see the first description of this was

that I was able to find was in ultrasound

and emergency medicine.

And the idea behind this is you're gaining the

advantages of both.

You're getting by looking at the vessel in the out of plane

or transverse approach, you get to see the anatomy

that's surrounding it by looking at the needle

and the longitudinal view.

You get to see both the tip and the body at the same time.

And the, the idea is this should allow you

to get the strengths of both while mini

minimizing the weaknesses.

The danger to this of course, is that instead

of targeting a tube,

you are now targeting a circle as you enter the vessel.

And that means that if you're talking about a small vessel,

you may think of your needle as entering pretty

and having a short distance to travel

before getting to the far wall.

But you can see how this looks in a, in a real patient

and the way that that needle approach is different

between the oblique and the transverse

or in plain approach

once you've accessed the vessel.

The next thing that I make sure that my learners know how

to do is to visualize the wire.

And the reason for doing that is, again,

in the transverse view, they may think they're in the vessel

but actually be looking at the body

of the needle while the tip is deeper

and into a deeper structure.

And especially in those examples we saw where they're

jugulars overlying the carotid, that can mean

that the needle tip is in the carotid.

So I like to watch the wire and you can watch the wire

and you can see the J hook on the wire

as it enters the vessel

or insert the wire, take the needle out

and then look with the ultrasound.

This is in the transverse or out a plane view.

And what you're watching is you're watching as

that in internal jugular vein,

the the user is fanning down

and following that wire

and watching as it stays inside the venous system

and does not go through the back wall,

which is the real danger here in the longitudinal view.

You can watch it and you can see the wire in this case,

navigating past a valve.

So my conclusions

for this area is no matter which angle you take,

the important thing is that you know where your needle is,

especially where your needle tip is

and where your veins are.

And so that means that whether you're accessing the internal

jugular vein, the subclavian or axillary vein

or the femoral vein, you just have to know

what you're seeing on the screen

and how to identify your needle when you're doing it.

Then we can talk about what do you do after your procedure?

And I'm not going into detail about

how you can use the modified sel deger technique

to transition from needle to wire,

from wire to catheter.

Instead, I really want to talk about what can we do in order

to confirm that that catheter's in the right right place.

The first thing I want to talk about is assessing

for pneumothorax.

And this is again, lung sliding

and lung ultrasound is my favorite thing

'cause I'm a pulmonologist.

But it's important to remember

that ruling out pneumothorax can be done either

with B lines,

you're seeing B lines here or with lung sliding.

You're also seeing lung sliding In this clip, I would like

to point out that this needs to be checked pre

and post procedure.

And the reason that is because if you don't check

before the procedure and the patient had a pleurodesis

or they had other reasons for them to have an absence

of lung sliding, then when you check afterwards,

you're not going to be able to rule out pneumothorax.

Now if they have B lines, you're in good shape

because that's going to be the case pre and post.

But if they had B lines before and then you check afterwards

and there's no lung sliding

and there's a lines that's concerning

if they don't have B lines

and they just have a lines, as you can see in this one

with lungs sliding, you just want to make sure

that you feel very confident that what you're seeing before

and after is that sliding

of the visceral pleura against the parietal pleura causing

that shimmering and glistening artifact.

In contrast, you can see here on that same patient

what it looks like when there is not lung sliding.

And very important in this is being able

to identify the anchoring anatomy of the ribs

with the dark shadow behind it, ensuring

that this white line that's not moving, that's not sliding,

that's not glistening, but has pixels

that are not going black, white, gray, black, white, gray.

You need to confirm that that is anatomically the pleura.

The other thing you can look

for is a hematoma.

This clip was caught in an emergency situation in a

profoundly coagulopathic patient

where you could actually see the hematoma forming in real

time above the IJ as they were navigating it.

Being able to assess this can help you

with understanding whether you want to transfuse the patient

who is thrombocytopenic

or who's coagulopathic in order to control bleeding.

And I've, I have some friends in who are proceduralists

who really think that the best way to ensure

that your wire has navigated any turns on the way,

especially from that left internal jugular vein navigating

across midline.

And then down into the SVC, the best way to ensure that is

to advance your wire

until you can visualize it in the right atrium.

And there's several articles, but this is one

that I really like the images for that show you how to do

that, either seeing it in the IVC if it's a femoral

catheterization or seeing it in the right atrium,

it's a neck or subclavian catheterization.

The challenge with this of course, is that accessing

that part of the body requires you to go under the drape

to go into the non sterilized area in

order to do these scans.

Logistically, the way that we do this is either you have

somebody else in the room

or if you have the ability to pre-scan

to lay your cardiac transducer in exactly the spot you want to

be, and then to grab that transducer through the drape

and apply it to the subclavian space.

So the subcostal space, you can visualize

that wire while maintaining your sterility.

And then one of the ones I like to do is, since I,

once I have my catheter in place, is I like to check

and see whether

or not if I pass agitated saline, this is not

filling a syringe with air.

This is merely a fast flush of saline through that catheter.

Can I visualize that in the right atrium

within three heartbeats?

And that lets me know, hey,

I am definitely in the venous space

because I can see that agitated saline entering

the heart very quickly.

So my conclusions with this area,

but this portion of the talk is it is

really, really important to make sure that the complications

of central line placement pneumothorax, bleeding

malpositioning of the catheter have not

happened during your procedure.

And the big advantage you have is that you're at the bedside

with a diagnostic imaging modality with ultrasound.

And so by checking for lung sliding for beelines, checking

for the wire, you can rule out several

of the complications right then and there.

And if you see a hematoma,

you can monitor it appropriately to the clinical scenario.

This saves your patients' time.

I don't know how many times I've been waiting and waiting

and waiting for a chest x-ray to arrive

before I can write that nursing order, okay

to use IJ catheter.

Whereas with this, I can feel more confident,

especially in an emergency situation.

All right, so talking a little bit about what comes next,

where are the places that we can go with point

of care ultrasound and assessment of central line placement?

So one of the questions that might come out

of this post-procedural assessment is,

do we even need chest x-ray anymore?

Now, just as a reminder,

a post-procedural chest x-ray is standard of care

for all neck and shoulder central venous catheters.

You don't need to do one for e femoral catheterization,

but you do need to for an IJ or subclavian vein

because it confirms that the tip's in the right position

and it rules out pneumothorax and it's required

by many institutional protocols, including several

of the institutions that I work at.

But there's practical limitations

to this waiting for that test.

X-ray delays the catheter use

and supine ICU chest x-rays

for those critically ill patients have poor sensitivity

for pneumothorax, especially for small pneumothorax.

Lung ultrasound is just known to be more sensitive.

And the fact of the matter is with all the variability

of anatomy that occurs in our patients,

you can't truly confirm venous versus arterial patient

with just an x-ray.

Although if it does follow the right path,

you can say pretty clearly, all right, this,

this feels like it's in the SVC

or this feels like it's in this, the point

of care ultrasound kind of lets us do this.

The bubble test confirms that it's in the venous system.

If you can see beelines or lung sliding,

you effectively ruled out pneumothorax

and it's faster 'cause you're there.

So you can have, you have your sutra line ready

to use without the delay of waiting.

The limitations to this is that while I brushed

by these skills as if they were simple,

they take real training, there are false positives

for an absence of lung sliding that need to be known.

And if you're moving your hand when you're assessing

for lung sliding, you'll make it look like there's lung

sliding when there's not.

Also the bubble study wall lets me know

that's in the venous system, does not confirm

for sure whether I'm in the proximal distal SVC

or if I'm right at the junction.

So it's not universally endorsed in

guidelines from societies.

And that means that adoption for a pocus confirmation of

an ultrasound play, a central venous catheter is still

institution by institution, know where you are

and know what level of competence and competence you have.

Some other things I've been seeing is that things

that would be effectively impossible with anatomic based

placement can be done with an ultrasound.

And so I've done this several times,

but I I, I brought up a,

a case report from the COVID pandemic

of when the prone patient can't be supinated

or needs central access quickly rather than waiting

for the process for them to supinate be stabilized

and then placing the central catheter to actually pursue

using ultrasound, having the patient in a swimming position

with their neck up.

And instead of going through the SEM visualizing the ma, the

the mandible

and then looking posteriorly, seeing things backwards

and then recognizing what direction your needle's going to go.

And as long as you're doing this with knowledge

of the existing anatomy

and the ability to confidently track your needle,

track your needle, this can be safe.

I'll offer that the dilation step, especially

for a bigger stiffer catheter such as a dialysis catheter,

can be tricky.

Getting the stiffer dilator to navigate the curve of that

prone IJ requires some finesse,

but accessing the vessel can be done safely

and even those catheters can be placed

similarly in a prone patient.

The popliteal vein can be used,

and again, this is not something that you would think

of doing without ultrasound, but if you can see

that popliteal vein, you can measure it.

And as long as it's big enough for the catheter

that you're hoping to place, this is a way that you can

gain access in a patient who doesn't have other options,

whether it's an overlying cellulitis in their femoral area,

a lack of access in their neck or shoulders

or other thrombo vessels.

This is another place that can, that can be evaluated.

And then there's this idea that what I've seen is that

as people become more afraid of causing a pneumothorax, as

that becomes closer and closer to a never, never event,

I see my trainees starting to go higher and higher

and higher on the neck

and an attempt to avoid their needle getting

anywhere near the pleura.

And while there's some safety to that, the problem is that

that means they're going through the belly

of the sternal colleto mastering,

which is even more uncomfortable for, for patients.

This this article describes, Hey,

while this would not be a safe thing

to do in a purely anatomically guided procedure,

by visualizing with ultrasound, a lower IJ can allow you

to avoid beard, can allow you to avoid overlying ej,

allow you can avoid overlying carotid

and allow you to access the internal jugular vein just

above the clavicle.

I'll offer that this procedure does carry

to me this increased risk of pneumothorax.

'cause you're objectively closer.

And if I have a patient with bolus emphysema

where their lung is rising up

above their clavicle, this becomes scary.

But with an ultrasound, I can see that blood.

I know whether or not that's true

and more to me, this is the one where

that oblique approach really starts to come in handy

because the needle is now no longer advancing towards the

lung, but it allows you to get

your catheter lower on the neck,

which makes it more comfortable for the patient no longer

through the body of the SEM end, easier

to keep the site clean, which is essential as we try

to get our CLABSI rates down in this post COVID era.

And then while it's not central access, one of the reasons

that I do so many fewer crash or dirty lines during cprs

because of how good we've gotten with interior with

intraosseous access, I will offer though

that I have had failure of io

and it's incredibly concerning when it happens

because you don't get the same feedback that you do when

that becomes a little dislodged

as you would if a catheter came out of a vein.

And the nice thing about this is while the bone blocks sound

waves, the modern ultrasound machines are strong enough

that they can actually visualize a flush pushed through

through the bony cortex.

And you're seeing this in this ICM paper from just a few

years ago, the ability to validate

that the iOS in place is incredibly helpful under those

circumstances where you, you're just not sure.

The last thing I want to talk about is competency.

And this is something that man, you could talk about

for an hour.

We could spend time talking about the decreasing number

of opportunities for repetitions

that the internal medicine residencies

and thus the, that internal medicine subspecialty fellows

are presenting to fellowship with.

We could talk about the fact that the combination of iOS

and ultrasound guided peripheral IPS means that there are

so many fewer central lines being placed,

which is a good thing for our patients,

but decreases the procedural exper

and experience that our trainees have.

In the end, the thing that I just want to highlight is that

multiple expert bodies, E-S-I-C-M, the American side

of echocardiography cited hospitalist medicine are

converging on the same skillset for how to do this.

And it's this ability to, to follow that needle tip,

to identify the anatomy to differentiate

vein from artery and that there's a minimum number.

You know, I, as an educator, I don't believe that numbers

are enough for competence,

but I do believe it's that it's hard to say

that if somebody hasn't done at least five simulated first

pass cancellations that that they are ready

to do this on a real person.

And so that's, and that's where SHM landed

and this group led by Neil

and Sony et all for their point

of care ultrasound task force.

And it's also where the A SE landed, just this idea that

before doing this procedure on a human,

you should do this procedure on plastic

and not just do I know how it feels to push a needle through

to draw back, to pass a wire,

but more do I know how to follow my needle and know whether

or not I'm seeing my needle tip

or if I'm seeing the bot bo the body of the needle,

do I know how to see that needle in a longitudinal view

and follow that into the vessel without losing it

or the vessel warm?

So my conclusions for this, what's happening now,

what's happening next is that we can think about new sites,

new places, the ultrasound opens up, areas of the body

that might not have been accessible

and that we can think about validating our IO placement

and more we can think about, hey, are the skill sets

that we need for this following a needle tip,

those are the same skill sets we need

for ultrasound guided peripheral ib

or ultrasound guided arterial access.

How do we make sure our training

and our competencies align such that we're teaching people

what they need for all the parts of their job?

So bringing us back to the initial objectives,

we very quickly went through those, the evidence base

and the regulatory guidelines

that tell us why we should be using ultrasound

for every central line

and why specifically there's a benefit to patients.

We talked about how in order to do this well though you need

to be able to identify your anatomy.

And so we talked about what the anatomy looks like in the

ij, the subclavian and the femoral vein.

And we talked about how to guide your needle, whether

that's in plane or longitudinal or if that's out of plane

or transverse with the, hopefully the conclusion that

there's no right or wrong there,

but that there are different risks.

And knowing which the, what the risks are as you go into it,

allow you to mitigate those risks as you do your procedure.

We also talked about how to confirm your wire in the

vessel and track your wire.

And then we talked about how to do a post-procedural

assessment and like checking for a pneumothorax, looking

for bubbles in the right atrium

and knowing that you're in the venous system.

And we a little bit about some of the new places

and future directions that ultrasound guided

central line placement can go.

So my conclusion is that, that I really want you

to walk away with our pocus is the standard

for central line placement at this point.

And the reason is it saves time and decreases complications.

There are multiple techniques to access multiple vessels

and there are advantages and disadvantages

to every technique and to every vessel.

But the idea is that in the future we're going to continue

to increase our target options

and increase our confidence immediately post procedure as

to whether or not the procedure was a success.

I got information incited data from a horrifyingly long list

of articles about this.

This is something that's well studied and well established,

but hopefully this was helpful.

I want to thank you so much for signing on

for paying attention and I want to make a space for anybody

who wants you to ask questions.

Thanks so much.

- Alright, Dr. Basson, thank you so much for

that excellent presentation.

We'll go ahead and take some times

for questions from the q and a box.

Now, just so everybody remembers,

we're currently broadcasting on multiple platforms,

so if you're on our main zoom broadcast, the q

and a box should be available at the bottom

or the side of your screen.

And for our YouTube

and LinkedIn streams, you can put your questions in the chat

box and we'll get to those.

It looks like we do have a question pop up.

Do you have any tricks for navigating short necks?

- Yeah, great question.

So this comes up a fair fairly frequently in the modern era.

And one of the things that, that I notice when I have a,

a bit of a short neck is that we have

to take a steeper approach

because we have less landscape in order to do kind

of a longer more shallow approach down to the vein.

And so what that says to me is I am more likely to go

through the posterior wall than I would be if I'm taking

a, a more shallow approach.

And that to me gives me even more reason

to be switching back and forth between that long

and short axis and

to be thinking more about am I angling my ultrasound such

that I am really seeing the tip of my needle?

So, so when I think I have a short neck, I try

to avoid the intuitive response

of just go higher on the neck.

And instead I think about, all right, I can map

with my ultrasound exactly how much real estate I have.

I can figure out what angle I need to go at in order

to achieve my necessary depth while also making sure

that I have visualization of the needle

tip the whole way through.

- Awesome. And we have somebody else asking,

do you prefer short or long axis for subclavian

and axillary CVC?

- This is, this is a great question. This is actually

something that, that I think there's some debate about.

You know, there, there's a great article that

that talks specifically about whether which one is better

for this line, specifically

for the axillary subclavian vein.

And, and the original textbooks encouraged a longitudinal

view, a long access view.

And the reason for that was you can actually visualize the

vessel and the clavicle itself

because once the axial vein dives under the clavicle,

it's almost impossible to see it.

But if you can visualize the clavicle,

you can see your needle and say,

I am accessing it exactly at the

point where I can no longer see it.

Thus it is really a subclavian vein cannula

instead of an axillary vein cannula.

I'm less obsessed with whether

or not I'm accessing it while it would be anatomically

axillary or subclavian.

So I go back

and forth though my technique, which is,

is also in at least one other article I've read,

is I start in the transverse view, map the vessel,

ensure I can see it in the longitudinal view, go back

to the transverse use so that I'm doing my needle insertion

exactly over the vein.

I can see that I'm not pointed at the artery,

that I'm not pointed at the pleura.

I can see the depth of the pleura

and then I switch to the longitudinal view as I get close

to the top of the vessel so I can see my needle going in so

that, because I know the depth,

I can use the transverse view for a period of time.

And then when I get to the point where going

where I'm even close to the vein

and going through the posterior wall would be possible,

I switch to that longitudinal view

and ensure I can see my needle and the bevel.

And I find that that back

and forth gives me the most confidence

and that's what I try to teach my trainees too.

- Awesome. Next question is

for thicker neck and chests.

Oops, sorry. Yeah, for thicker neck and sorry. Yeah,

- I, I got this so I can see what, see what is right.

- Okay, - So this is a question about, hey,

if you're dealing with somebody who is super obese

and the depth of their vessel is greater than the length

of your needle that comes in your kit,

which is usually a six centimeter

needle, then what do you do?

And there's a couple things here.

Number one, if you're talking about being at a depth

that you can't use the long needle in most

of these kits which are made for femoral access, then yes,

you can use a, a longer,

you can, you can ask for a longer needle.

One of in the question was the,

was the explicit question about an 18 gauge spinal needle.

And the challenge with that,

with using any other needle other than the one that comes

to the kit is you have

to make sure the wire can pass through it.

First. I have been in the situation where out

of desperation we've reached for

a new wire when a wire was kinked or a, a new needle

and found that the wire in the kit

or the new wire we reach for would not pass a needle

that was already in the vessel.

And the frustration of being like, all right, we have

to give up this access, get a new wire, new kit

and re-access this vessel,

vessel in a critical situation is incredibly stressful.

So you can use any needle, I will offer

that a spinal needle explicitly, especially if it's

for an lp, may not be a cutting needle, number one,

which means, gosh, are you going to be pushing through tissue

and, and, and having some challenges there.

And if it's a calcified vessel, you're going to have a lot

of trouble getting through the vessel wall.

Number two, if you're using a a spinal needle, that tells me

that this vessel is so deep that it's going to be challenging

for you to see it with a linear transducer.

And now we're talking about additional risk

of the decreased resolution you're going to get with

that curve of linear probe.

And number three, that needle's not etched.

So this needle, which is already harder to see

'cause of the depth you're using it at,

is not going to have the advantages

of the etched central access needle.

So my, my take on this is yes, there are situations very,

very large legs, incredibly thick necks where we get close

to the depth that the long needle in our kits

are, are not deep enough.

But, but I haven't had a patient where I couldn't find

between the, the six sites that we're talking about

where I couldn't find a site where I had a less than four

centimeter, four or five centimeter deep, deep vessel

that I could access with the needles in the kit.

And the deeper it gets, the more I value

that etched needle and the ability to see it.

'cause it's okay, I'm going to go into the next question

that's, that's typed up in the chat.

- Yeah, absolutely. - So the next question is,

is asking if I have a site preference

for temporary hemodialysis catheters

and I I do a lot of temporary HD lines

and the short answer is yes, but it's not necessarily

because of the ultrasound part of it.

The, my reason for really preferring

that right internal jugular vein is

because it's a straight shot

and the fewer turns you have for

that slightly thicker catheter,

the fewer opportunities you have for it to kink,

for it to have slower flow.

There's a question that we have, there's an open debate with

between our critical care group

and our renal group about whether our second choice should

be femoral or the left ij

because again, the femoral veins have a straight shot

and the left IJ has, has these turns.

And actually there's a study that looked at this

looking at the complication rates

and the success rates of femoral versus left neck.

And what they found was in the obese patient,

the left neck was superior

and in the non-obese patient,

the femoral was superior for your second choice.

If the right IJ is not an option,

I am doing very few subclavian hemodialysis catheters.

And the reason for this is because of an extrapolation

of some long-term dialysis access studies that suggest that

a larger catheter in the subclavian vein runs the risk

of stenosis and,

and that that stenosis then limits options for,

for surgical dialysis access in the future.

Full transparency, I'm not sure

for short-term temporary dialysis whether

that matters the way it does for long-term axis, but,

but it makes me make the subclavian veins my lowest

least prefer preferred target of the six.

Again, I've done it, I I still will do it,

but I I I'm only going to do a subclavian axis if both IGAs

and both fems are not reasonable

targets for some other reason.

Hopefully that answers the question,

but please let me know if there was a

another thing you were hoping I would get at

- All.

Right. It looks like we have a comment from LinkedIn.

It says the receive a protocol is a great assessment tool

for both pre and post-assessment as well

as intraprocedural monitoring of the needle,

G wire and catheter.

Do you have any comments or things to say about that?

- No, I love, I love that you're bringing this up.

There's, receive is is a great way to say, Hey,

have I evaluated before, during, and after this procedure?

It's, it's a situation where it's not, it's not everywhere.

And, and my concern

and the thing that I think that everybody should hold onto

is, this is a perfect example where the checklist style of

of medicine is really pays off.

And so whether that's receive a checklist

or if it's a different protocol that you've developed

inside your institution, I want to make sure that you're

using a checklist that people can check off.

And the reason for that is because everyone has had a time

where they forgot a step in something

that they've done a hundred times, whether that's forgetting

to remove the wire, whether that's forgetting

to do your standardized chlorhexidine scrubs

to the degree you want, whether that's forgetting

to put the patient in tr ellenberg, whatever it might be,

checklist, make this better.

And when we're talking about the ability of ultrasound

to prevent complications later on, to look

for the thrombus beforehand to make sure it's compressible

to look whether the wire's able to pass to know

what depth you're going to all these sort of things,

the more you can rely on a checklist

to make sure you're not forgetting something,

the better off you and your patients are going to be

so huge fan of any checklist thing,

not endorsing any one protocol over any another right now,

because I don't, to my knowledge, don't know

that any one checklist has been demonstrated

to be better than the other

ones. Yeah, go ahead.

- Yeah, it looks like we have another question here.

Do you try and avoid subclavian

and coagulopathic cirrhotics?

These patients often have high CLABSI

risks in our institution.

- Yeah. And that's not just your institution.

These patients with cirrhosis are clearly immunocompromised.

And Yeah. So the, the avoiding

of the subclavian site is a strong

but relative contraindication in patients with coagulopathy.

The thing that makes me feel a little bit better about it is

that I'm really accessing the axillary vein

instead of that subclavian vein.

So this'll, if I have a patient who's a little bit

coagulopathic, I'll move slightly farther out.

And the reason for that is because then I'm accessing

a compressible vessel.

And so if something goes wrong

and I have to pull the needle out,

or God forbid there's a,

there's a arterial puncture at out there,

you can apply pressure and hold pressure.

Whereas once you're under the clavicle,

it's almost impossible.

So that's where ultrasound to me is

so much gives us this such a big advantage over the landmark

guided subclavian, the landmark guided subclavian,

you're appropriately accessing well under the clavicle.

That's where the, the vein

and the artery are most consistently placed,

and that's what you're passing and trying to get to.

But man, it's easy to inadvertently access the artery

to inadvertently scratch the vein

and then not get full access when you're doing this blind.

Whereas with the ultrasound, I can be like,

I am watching myself go in.

So, so ultrasound makes me slightly more comfortable.

That said, you know, there was a recent trial about

give empirically giving platelets

to thrombo cytokine thrombocytopenia

patients who are getting central lines.

And you can interpret that the outcomes of

that trial in a couple different ways.

But in the end it was, this isn't a bad idea.

And the ones who got transfusions

before the procedure were less likely to get transfusions

after the procedure for oozing for what that's worth.

But, but this is one of those situations where

I normally don't transfuse before temporary access, which

before central access, but if I have a coagulopathic patient

for whom I'd really like to get a subclavian vein accessed,

I am more likely to give them FFP

or platelets depending on what they need.

But I, I, I hope that my answer had enough hedging

and hand waving and to let you know, it's a tough situation.

Those patients are vulnerable both to infection

and to bleeding and figuring out the right thing

for 'em is not something that I feel like there's

a definitive answer to.

But in this era where I think your institution,

like every other institution is trying

to make CLABSIs a almost never event,

it's important to take into account the fact

that the IDSA really does believe

that this subclavian is our, should be our first choice.

Yeah. But, but man, do I I I am mu I'm pretty scared

of a true subclavian bleed in those patients.

- Right. I think we have time for one more question.

How do I rescue a wire that won't pass?

- Yeah, this is great.

So there's another one of the ones where

in landmark

or blind techniques, you can sometimes feel the wire

and feel what you're running up against.

But with ultrasound sometimes you can see it.

And so with the wire in place, wherever I'm at,

I can actually look

and so if, if I'm not able to pass at the level

of my needle tip, I'll take a longitudinal view

or if a train's doing it, I'm supervising,

I'll move the ultrasound

and look at the longitudinal view of their needle

and actually see if the wire isn't passing

because their needle's in the vessel wall anteriorly

or through the posterior wall,

and that's where they're getting their

resistance, I can actually see that.

And under ultrasound guidance,

I can have them pull their needle back

until they're in the center of the vessel

and then pass their wire and see that wire coming out.

Initially, if I'm having trouble passing farther along,

I can actually look in other sites.

And so just to give an example, anybody who's

had this happen has been incredibly frustrated when you do a

left sided IJ and it goes across

and then ends up in the patient's right arm

and you're like, I can't get to the depth.

I think my wire should be too,

but I'm at 12, 14 centimeters, I don't know where I am.

I can actually look for the wire in the subclavian vein on

their right and I can see whether the,

the wire has done something silly like in one

of my patients I once saw going down the left IJ

and up the right or down the left

IJ and into the right subclavian.

And by, by eliminating some of these common sites,

I can get more confidence about whether my wire's in the

right spot and if I'm set up in advance

or have an extra scanner in the room, I can do that thing

where I look for the wire in the right atrium or the IVC

and that really can help me gain the confidence

to say I'm in the right place.

Hopefully that answers the question that you're asking.

- Awesome. All right, well it looks like we've covered all

of our questions for today.

A big thank you to Dr.

Bain for taking the time to put together this incredible

in-depth excellent presentation

and for hanging around to answer questions for us.

We really appreciate you sharing your expertise.

Quick reminder that you can watch previous webinars

and sign up for upcoming webinars on sonos site.com/behind

the scan webinar.

And those webinars can also be found on the Sono Site

Institute as well.

Thank you so much for joining us today, everybody,

and thank you so much again to, for Dr.

Bain for joining us and we'll see you at the next one.

- Thank you everybody.

Enhance your clinical expertise with our focused webinar on ultrasound-guided central venous access. Discover the latest evidence and guidelines supporting ultrasound use for central line placement. Gain practical skills in identifying vascular landmarks and mastering needle guidance techniques with real-time imaging. Learn to confidently perform post-procedure assessments for patient safety. Plus, explore trends that are transforming the field, including advanced patient positioning strategies and reduction of chest x-rays.

 

What You'll Learn

  • Identify key anatomical ultrasound landmarks for internal jugular, subclavian, and femoral vein catheterization.
  • Demonstrate proficiency in various needle insertion techniques, along with wire confirmation and tracking.
  • Recognize essential post-procedure assessments such as checking for pneumothorax and bubbles.
  • Explore emerging practices and future directions of US-guided central line placement.
     
Cameron Baston
Presenter: Cameron Baston, MD, MSCE
Position: APD Pulmonary and Critical Care Medicine, DOM Director of Point of Care Ultrasound, Faculty Associate Director for PennHealthTech, Assistant Professor of Clinical Medicine, University of Pennsylvania

Cameron Baston, MD, MSCE, is a clinician advisor for Penn Health-Tech and an Assistant Professor of clinical medicine in the Department of Medicine at the University of Pennsylvania's Perelman School of Medicine. He serves as associate program director for the Pulmonary and Critical Care Medicine fellowship, and as director of clinician-performed ultrasound for the Department of Medicine. He has an interest in helping create low-cost medical devices in the resource-limited Critical Care setting and works with several organizations on POCUS and Critical Care education. A mechanical engineer, epidemiologist, Critical Care physician, and medical educator, he spends about 2/3 of his time caring for critically ill patients, and the remainder working on education innovation and health technology.

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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.