Training and competence in ultrasound-guided vascular access

Published on 22/03/2015 by admin

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Last modified 22/03/2015

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Training and competence in ultrasound-guided vascular access

Overview

Despite well-established evidence on the use of ultrasound for placement of any vascular access,1 a formal training program on how to perform ultrasound-guided vascular access (UGVA) and how to certify adequate competence has not been clearly defined.2,3 According to recommendations by the National Institute for Clinical Excellence, those involved in UGVA should undertake appropriate training to achieve competence.4 Defining a competent practitioner in objective terms is a difficult task. Recently, the American Society of Echocardiography declared that training in UGVA should include a minimum of 10 proctored procedures, but the learning curve needed to perform these procedures was not defined, nor was it specified who should be considered expert and supervise new users.5

Evidence-based guidelines for defining a common educational process and establishing credentialing for any type of UGVA that can be considered as a model for any kind of training course in UGVA were recently published by the World Conference on Vascular Access.6 The guidelines emphasized that the use of ultrasound reduces insertion-related complications, increases the success rate at first attempt, assists in selection of the correct vascular device according to safety, and enables preservation of veins.

Didactic education

Educational programs facilitate a reduction in delayed complications such as infection and thrombosis.7,8 The didactic contents of UGVA courses should be specifically directed at how to perform UGVA. Clinicians’ knowledge of certain subject areas and competence in device insertion affect the rate of UGVA-related complications. The following topics should be discussed in formal educational training programs:

• Ultrasound physics: characteristics of sound waves, effects of interactions with ultrasound waves, and creation of image from ultrasound beams

• Sonographic anatomy of relevant structures such as vessels, nerves, bony structures, soft tissues, muscles, lung, pleura, and basic cardiac anatomy

• Knobology and interpretation of vascular images (transverse and longitudinal views) and needle visualization (out of plane and in plane)

• Techniques for insertion and assessment (“4 P’s” technique: preprocedure scanning of relevant ultrasound anatomic structures, preparation of a sterile field and sterile ultrasound probe for vascular access, puncture of the vein or artery, placement of catheters)

• Sonographic detection of the tip of the catheter (contrast-enhanced echocardiography9)

• Evaluation and management of complications: accidental carotid or posterior venous wall puncture, hematoma, pneumothorax, and abnormal position of the tip of the catheter

• UGVA in neonates and pediatric patients and ultrasound-guided cannulation of peripheral veins and arteries

All didactic content should be included in a training manual so that trainees can read it before beginning the didactic portion of the training. A minimum of 6 to 8 hours of didactics has been suggested. Theoretic competence should then be evaluated with a multiple-choice test that has at least 100 questions. The trainee must pass the test with at least 70% correct answers before proceeding to hands-on training.6

Simulation training

Training laboratories should offer a variety of ultrasound machines to facilitate understanding of their basic functions such as depth, gain, and freeze (knobology). Training should start with examination of normal vascular anatomy in healthy volunteers and with hands-on simulation (models). Several inanimate models of vascular access are available. The best simulation model should not only include vessels but also mimic the normal body anatomy in terms of muscles, soft tissues, and bones. Inanimate animal models such as turkey breasts may be useful to demonstrate these anatomic findings. In the future, virtual simulators could be useful for measuring the correct hand-eye coordination of the trainee. Although it is not possible to include visualization of abnormal vascular anatomy in inanimate models, a collection of videos should be incorporated into the didactic material to show all significant abnormal findings during preliminary evaluation of the vessels before cannulation (e.g., intraluminal thrombosis, significant collapse of the internal jugular vein during inspiration). Trainees should complete 6 hours of hands-on training on normal human volunteers for detection of normal ultrasound anatomy and 4 hours of hands-on training on inanimate models.2,6

Learning curves and training time

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