Any advantage over standard surface anatomy or

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Any advantage over standard surface anatomy or landmark-based tech- niques should be a welcome addition to the arsenal of all critical care phys- icians. As with the diagnostic applications of ultrasound, ultrasound for procedure guidance is meant as an adjunct to the physical examination. When the sternocleidomastoid muscle cannot be seen or felt, ultrasound can help visualize the internal jugular vein and obviate the need for such landmarks. When clinical acumen alone cannot distinguish a subcutaneous abscess from an area of induration, ultrasound can help make the distinction. The chapters that follow describe techniques whereby ultrasound can aid in the performance of common and often lifesaving procedures. As with all ultrasound use, the skills described here are operator-dependent. But then so is the interpretation of electrocardiograms or laceration repair. This should not be an excuse, but a call to practice and to build comfort with the tech- niques described. In addition, the same tenet of a simple, algorithmic approach toward procedural ultrasound should apply. In the case of proced- ure guidance, the questions may be “How deep is the effusion?”, “Is there an abscess at this site?”, or “Where exactly is my needle with respect to the vein?”. There is an ever-increasing body of literature to support the use of ultra- sound for procedures, and patient safety is becoming a leading priority for both federal and private healthcare agencies. As ultrasound use becomes more widespread, and as its impact on patient satisfaction, safety, and oper- ator preference becomes more pronounced, we may see the end of the era of procedures performed without the use of radiographic guidance. Procedural ultrasound 271 Procedural ultrasound
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15 Vascular access Introduction Vascular access is one of the most basic skills required of the critical care physician. Many factors, including body habitus, volume depletion, shock, history of intravenous drug abuse, prior cannulation, scarring, thromboses, congenital deformity, and cardiac arrest, can make vascular access difficult or even dangerous. Traditionally, surface anatomy and anatomic landmarks have served as the only guides for locating central veins. The incorporation of ultrasound into the procedure allows for more precise assessment of vein and artery location, vessel patency, and real-time visualization of needle placement. The paradigm for radiology is to perform invasive procedures such as vascular access under real-time direct visualization so as to reduce compli- cations. Although patients may have complicating medical problems, those scheduled for procedures in radiology are usually hemodynamically stable. Why, then, would critical care physicians perform invasive procedures on more unstable patients without the same tools and techniques to increase safety?
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