Transcript NWTS sonosite guide

NWTS Vascular Access and
Ultrasound Training
 Guide to NWTS Ultrasound equipment
 Guide to vascular access techniques in Paeds
 Sonosite’s Ultrasound physics presentation
NWTS Ultrasound Training
Disclaimer: This is a basic guide to familiarise you
with NWTS ultrasound equipment. There is also
advice on techniques for vascular access in children.
Techniques should be learned under direct
supervision and you should be assessed as
competent before using this equipment on patients.
An introductory guide
for NWTS trainees
NanoMaxx
EDGE
Contents
 Equipment overview
 Transducers
 A guide to the screen and main controls
 Edge
 NanoMaxx
 Setting up for line insertion
 Tips for use
Uses of portable ultrasound
 Most common use is to guide central venous and arterial access
 Other NWTS uses include:
 Thoracic imaging for effusions and exclusion of pneumothorax
 Focused echocardiography
 Peripheral venous access
 Abdominal imaging e.g. bladder volume, intra-peritoneal free fluid
 Cranial Ultrasound
Equipment location
NWTS uses two
Sonosite portable
ultrasound systems.
These are the Edge and
the NanoMaxx.
They are located in the
trolley/equipment
room, on the lower wire
shelf, in two grey bags.
The Edge - bag contents
Power pack and cable
Sonosite
Edge
The ‘echo’
transducer
The ‘hockey stick’ transducer
The NanoMaxx - bag contents
Power pack and cable
Sonosite
NanoMaxx
Linear array transducer
Introduction
 The Edge is the newer of the two systems. It has a
larger display and two transducers.
 It is similar to a laptop, and is controlled using a
keyboard and a touchpad.
 The NanoMaxx is the smaller system, is highly
portable and has a single transducer.
 It is controlled using a touchscreen and a control knob.
It has a kickstand to aid viewing.
Changing transducers
(always switch machine off first)
(click play on the videos below)
Removing a transducer
Connecting a transducer
Compact Linear Array (Hockey stick) and Linear
Array 25mm Transducers (13-6MHz)
 These are high frequency
transducers with a small footprint.
 They are ideal for vascular access,
as they produces high resolution
images of superficial structures.
 They can also be used for
superficial pleural/lung imaging,
and imaging of nerves.
 The maximum imaging depth is
6cm.
Compact linear
array transducer
(Hockey stick)
Linear array
transducer
Rectangular image produced by linear
array transducers
Probe
Beam
Phased Array 10mm Transducer (8-4MHz)
 This is a lower frequency
transducer with a smaller
footprint.
 It is ideal for echocardiography, as
its small footprint allows imaging
between ribs.
 It can also be used for paediatric
thoracic and abdominal imaging,
and also neonatal cranial imaging.
 The maximum imaging depth is
14cm.
Sector image produced by the phased array
transducer
Probe
Beam
A guide to the main controls
Control keys
with on-screen
functions
Power
On/off
Exam menu
Depth
Adjustment
Imaging
mode
Gain controls
Zoom
Touchpad and
Select key
Screen layout
Orientation
marker
Image
optimisation
Exam type
System status
(charge/
memory)
Index’s of
tissue
heating
Depth
Marker
Maximum
selected
depth
On-screen control key
functions
Imaging mode and Exam Menu
 2D is the default mode, and is the
most frequently used
 Color is used to visualise the presence,
direction and velocity of flow
Exam menu
 Doppler records blood flow velocity
along the length of a beam
 M Mode uses a single beam of
ultrasound and projects the image over
time
 Exam – pressing this key displays the
exam type menu. The options depend
on the transducer attached(e.g. vascular,
nerve, abdomen). When using the
Hockey stick transducer, the default
exam type is ‘Venous’ (no need to
change this for vascular access).
Imaging
modes
Depth and Zoom Controls
 The up and down depth keys adjust the displayed
depth.
 The vertical depth scale will be marked in 0.5cm,
1cm and 5cm increments, depending on the
selected depth.
 The maximum selected depth will be displayed as
a number (in cm) in the lower right hand corner of
the screen.
 The ZOOM button magnifies the image 100%.
Press the zoom button – a box will appear on the
screen. Using the touchpad, move the box to the
region of interest. Press zoom to magnify this
region. To exit, press the zoom button again.
(Practically zoom needed only for small peripheral
vessels and always align box to the skin at the top.)
0.5cm
1cm
2cm
1.0cm
3cm
1.5cm
4cm
5cm
2.0cm
6cm
Gain controls
 Gain refers to the degree of amplification of returning
signals.
 Increasing the gain makes the image appear ‘whiter’. It
increases the noise on the displayed image. Adjusting the
gain may improve the ability to distinguish structures on
the screen.
 In each pair of gain keys, the left key decreases gain and the
right key increases gain.
 Near adjusts gain in the near field (upper half of the
image)
 Far adjust the gain in the far field (lower half of the
image)
 Gain adjusts the overall gain (entire image)
 Auto adjusts the gain automatically
• It is usually sufficient to change the overall gain or to use
the auto-gain.
Control keys with on-screen functions
Image optimisation
Res: best resolution
Gen: balance between resolution and penetration
Pen: best penetration
Dynamic
range/greyscale:
adjusts the number
of greys displayed
Brightness Orientation marker
adjustment
(see next slide)
Allows display of two
images
Multi-beam imaging: increases
resolution / enhances borders
(default: on)
Video clip
options
Scrolls
between Pages
1 and 2
The orientation marker
 The orientation
marker (green dot on
screen) corresponds to
the tip of the foot of
the hockey stick probe
or the raised dot on
the phased array
transducer.
Changing the orientation marker position
 The orientation of the on-screen image can be changed by
changing the position of the orientation marker.
 The options are Up/Right, Up/Left, Down/Left,
Down/Right (found on Page 2 of the on-screen control
keys).
A guide to the screen and controls
Orientation
marker
Exam type
and
transducer
Touchscreen
controls
Image
optimisation
Control
knob
System
status
Depth
Marker
On/Off
Maximum
selected
depth
Touchscreen
controls
Using the touchscreen controls
 The touchscreen controls are dynamic, and change
according to context.
 To select a control, tap it with your finger. The
following symbols identify how a control functions:
 (+) cycles through a list of settings
 () tapping the control displays/collapses a list
 () indicates that the setting is adjusted using the
control knob
Touchscreen controls – vertical group
Depth
Tap, then adjust with
control knob
Multi-beam imaging: increases
resolution/ enhances borders
(default: on)
Gain
Tap to select
Overall (‘Gain’),
Near or Far
gain, then
adjust with
control knob
Automatically
adjusts gain
Image optimisation
Res: best resolution
Gen: balance between
resolution and penetration
Pen: best penetration
Tap to
change
page
Zoom
Tap for box to
appear; slide
box to region of
interest. Tap
‘Box’ icon to
zoom.
Brightness
control of screen
not image
Reverts to
default gain
setting
Dotted line
down middle
of screen
Touchscreen controls – horizontal group
MODE
EXAM
Tap for menu, then select mode required.
Tap for menu, then select exam required.
The default setting is Vascular. Other exam
types are Venous, Musculoskeletal,
Superficial, and Nerve.
2D is the default mode, and is the most
frequently used.
Color is used to visualise the presence,
direction and velocity of flow.
M Mode uses a single beam of ultrasound
and projects the image over time.
System Defaults
Edge
NanoMaxx
When the Hockey stick transducer is
attached and the system is turned on, the
following default settings will be present:
When the system is turned on, the
following default settings will be present:
 Exam type:
Vascular
Resolution
 Image optimisation:
General
Up/Right
 Orientation marker:
Up/Left
 Exam type:
Venous
 Image optimisation:
 Orientation marker:
(fixed position)
 Image depth:
2.6cm
 Image depth:
2.6cm
 Multi-beam imaging: On
 Multi-beam imaging: On
System set-up for line insertion
After checking the default settings, the only adjustments that
may be required are:
 Depth
 Gain
 Orientation marker: may need to change this when using
the Hockey stick probe, depending on how the probe is held.
The position of the marker is fixed on the Nanomaxx.
 Image Optimisation: you may want to change this
depending on the depth of your target (Res, Gen or Pen).
Tips for use
 Whenever possible, connect the ultrasound machine to the power
outlet to prevent the machine from powering down during a
procedure.
 The operator should orient the transducer to match the medial-lateral
orientation of the patient. A quick check can be made by touching one
edge of the transducer, so the orientation on the patient corresponds to
that on the screen.
 Always use plenty of ultrasound gel in the probe cover, and make sure
there are no air pockets, which result in poor image quality.
 Using a generous amount of gel on the skin not only provides better
image quality, but also allows scanning with minimal pressure, which
avoids compression of vascular structures.
Ergonomics
 The patient, operator, ultrasound machine, and sterile tray should all
be arranged in an ergonomic position that allows for efficient
performance of the procedure.
 The ultrasound machine should be set up in such a way that the
operator can see both their needle and the screen without having to
turn their head. This avoids unnecessary movement, which may
compromise line insertion.
 The sterile tray/trolley should be positioned close enough to the
operator so that it eliminates the need to reach out for needle, lines and
other supplies.
NWTS Ultrasound Training
Cleaning – Machine cleaning / disinfection (switch off
– disconnect from power – non abrasive cleaners (soap and water) –
do not immerse - alcohol, glutaraldehyde, ammonia and per-acetic
acid based products are ok
- Probes (switch off – disconnect from power –
non abrasive cleaners (soap and water) – do not immerse
connection end (probe end ok) alcohol,
glutaraldehyde,ammonia and per-acetic acid based products
are ok
Storage –
Always place back on charge and switch
off the machine
Replace any sterile products used (Gel /Sheathes)