Comprehensive Notes: Ultrasound-Associated Materials and Equipment (Table 16.1 and Related Content)

Introduction

• Purpose: Understand ultrasound-associated materials and equipment to support a successful Point-of-Cocus Ultrasound (POCUS) program.
• Key idea: Gel is the lifeline of ultrasound; many ancillary materials (barcodes, probe covers, IV catheters, etc.) improve efficiency and workflow.
• Objective focus:
  • Discuss importance of various ultrasound accessories.
  • Determine optimal level of accessories given budget and utilization.
  • Overview of basic options and costs for materials needed for ultrasound-guided procedures.
• Core takeaway: Use a comprehensive, cost-aware approach to stocking supplies; involve the supply chain manager early; tailor purchases to your program’s usage patterns.

Table of Contents Snapshot (Table 16.1) – Summary of ultrasound accoutrements

• Equipment and brands, approximate costs, suitable users, and notes:
  • Ultrasound gel: Brands Parker Labs Aquasonic 100, Medline, Dynarex; Approx cost per 250 mL bottle: $1-3$; Suitable for all programs.
  • Gel warmer: Brand Thermasonic (NEXT); Cost per warmer: $120-220$.
  • Aseptic/Probe covers:
  • Adhesive barriers (e.g., Tegaderm; CIVCO UltraDrape): $0.20-4.00$ per cover.
  • Sterile probe covers (non-adhesive): Brand ProTek (CIVCO et al.); Cost: $4-13$ per cover.
  • Endocavitary probe covers: Options include high-level disinfection pathway with products from Parker Labs Eclipse, generic condom-type covers; cost varies by product.
  • High-level disinfectant (HLD) options for transducers:
  • Nanosonics Trophon (automated HLD system): Initial cost $10{,}000-15{,}000$.
  • Tristel ULT foam (HLD foam) with wipes: Film/foam approach; cost per HLD cycle $3.15$.
  • Echogenic needles (enhanced ultrasound visibility): Brands B. Braun, BD, Pajunk, Havel’s, Cook; Cost per needle: $10-20$.
  • Micro-puncture kits: Brands Merit MAK, BD; Cost per kit $7-20$; includes needle, wire, catheter.
  • Peripheral IV catheters: Brand B. Braun; Cost per catheter $0.80-3.50$; some kits $8-30 per kit; catheters with guidewires $20-90$.
  • Needles and needle guides: Cost for needles varies; needle guides: cost varies (often not clearly costed).
  • Barcode reader: Jadak Flexpoint HS-1; Cost: $650-800$ per scanner; Spiral Wrap: $10-20$ per 100 ft; Generic brands available.
  • Cord protector / Cord suspension system / Plexiglass lock box: Costs per item given as per extension springs, cable ties, and lock boxes (see specifics below).
  • General storage and workflow aids: trays, bins, probe cover organization, carousels, and cord/drape management solutions.
• Note: Prices are approximate and vendor-specific. Always confirm current pricing with the supply chain manager.

Supply Chain and Institutional Purchases

• Primary step: Establish relationship with your department’s supply chain manager.
  • Role: Ordering, stocking, and storing equipment; can locate hospital/system stock and price products quickly.
  • Benefit: Simplifies procurement for items like nerve block needles by confirming availability within the hospital system.
  • Process: Use hospital supply chain software to search, price, and pull items efficiently.
• Practical implication: Early engagement reduces delays and helps tailor purchases to actual usage and inventory levels.

Machine Accessories and Workflow Enhancements

• Secondary idea: Most ultrasound machines in POCUS are mobile, cart-based and highly maneuverable.
• Storage optimization: Many carts include an attached storage bin to reduce unnecessary searching.
• Durability and longevity: Add protective measures to vulnerable areas of machines and probes.
• Example workflow improvements include better organization and easier access to supplies; aim for streamlined, repeatable setups.

Barcode Reader – Data Entry and Workflow Benefits

• Challenge: Manual entry of patient data on the ultrasound machine can slow workflows and introduce errors.
• Barcode reader advantages:
  • Faster workflow, reduces unidentified studies, improves ultrasound scans saved, decreases data-entry errors, optimizes workflow.
  • Setup: Small handheld device connected via USB to the ultrasound machine; reads hospital wristband barcodes.
  • Workflow integration: Can be configured to query DICOM modality worklists when wristband is scanned.
  • Flexibility: If no workflow system exists, the reader imports the patient identifier into the appropriate field on the patient info screen.
  • Field mapping: Different screen fields can be mapped to reports or PACS; clinician login IDs can be encoded into barcodes for easy identification.
• Compatibility: Most ultrasound machines accept a range of USB barcode scanners; verify compatibility with your machine manual.
• Practical tip: Coordinate with the IT department to ensure proper mapping and data flow.

Organization of Procedural Guidance Supplies

• Ultrasound-guided peripheral IV (USPIV) insertion is a core ED procedure.
• Organization goals:
  • Keep all supplies for procedures within easy reach of the cart.
  • Use clear containers or cups to store individual items for quick access.
• Rationale: Improves efficiency and reduces clinician frustration during high-demand ED shifts.

Probe Accessories – Non-sterile vs Sterile Covers

• Non-sterile/aseptic ultrasound-guided procedures (e.g., PIV placement, nerve blocks) require small sterile probe covers.
• Adhesive barrier options (convenient combinations):
  • Tegaderm (3M) covering the transducer; cost per unit $0.20-0.60$.
  • CIVCO UltraDrape (adhesive barrier placed on skin prior to IV insertion) with gel on top; may facilitate easier cleanup; cost per unit $2.50$ (example product #610-1419).
  • CIVCO Envision: cost per unit $3.12$ (product #H2O-001); similar to Tegaderm but less adherent, with sterile saline liquid wipe that dries quickly.
  • Sheathes ADH-35-4: cost per unit $2.89$; similar to Tegaderm and Envision; FDA-cleared viral barrier with 20 nm pore size; easier to apply per clinician experience.
• Loading considerations: End users should determine preference based on ease of use, barrier properties, and potential transducer surface interaction.
• Note: For large sterile fields (e.g., central venous cannulation), ensure the probe cover length is at least 48 inches to cover the cord and allow sterile field manipulation.
• Sterile probe covers: Most kits include telescopically folded covers, a sterile gel packet, and two rubber bands (Fig. 16.4). Sizes differ by probe models.
• Telescoping designs (PullUp technology) simplify loading and cord coverage (Fig. 16.5).

Endocavitary Probe Covers and Transvaginal Coverage

• Transvaginal ultrasound uses disposable probe covers; two main types:
  • Condom-type covers (inexpensive latex-based covers; around $0.25$ per cover).
  • Pre-gelled, non-rolled covers (more expensive) with built-in gel; latex-free and typically around $0.80$ per cover.
• Condom-type covers: Low-cost option; widely available; may have higher breakage risk compared with specialized products.
• Non-rolled, pre-gelled covers: Gel already inside; dry quickly with minimal residue after procedure.
• In low-resource settings, condom-type covers or sterile gloves can substitute if necessary; sterile gloves preferred for durability and pinhole reduction.
• Note: Some programs select barrier systems based on ease of use and compatibility with the procedure type.
• Transducer sterilization considerations: For mucosal-contact exams (transvaginal, intra-oral), high-level disinfection (HLD) between uses is recommended.

High-Level Disinfection (HLD) Options – Transducer Care

• When mucosal contact occurs with endocavitary probes, HLD between uses is advised.
• Nanosonics Trophon (automatic HLD):
  • Provides HLD in about $7$ minutes per cycle.
  • Initial cost: $10{,}000-15{,}000$.
  • Practical barrier: Upfront capital expense; may require institutional agreement if radiology department handles HLD.
• Tristel ULT foam (HLD foam and wipes): FDA-cleared in 2023; provides HLD equivalent to traditional wipe methods but in a two-minute cycle per probe; cost per HLD cycle is $3.15$.
• Trade-off considerations:
  • Trophon offers automated, validated cycles with consistent outcomes but high upfront cost.
  • Tristel ULT provides a cheaper, rapid alternative with factory-validated capabilities; may suit low- to mid-volume settings.
• General infection-control approach: Use sterile gel for sterile procedures; maintain a cleaning protocol to reduce probe contamination risk; consider wiping exterior surfaces between exams with approved cleaning solutions.

Ultrasound Gel – Properties, Storage, and Handling

• Role: Gel acts as a coupling medium to transmit sound waves with minimal reflection loss; acoustic impedance close to dermis helps transmission.
• Composition: Water, propylene glycol, carbomer (thickening agent), biocide preservative; pH around 6.5–7.0; some gels may contain dye or scented oils.
• Preferred gel: Parker Aquasonic 100 Ultrasound Transmission Gel; characteristics to consider:
  • Acoustic efficiency (transmits a broad range of sound waves with minimal loss).
  • High viscosity to enable layering on the patient and minimize run-off.
  • Bacteriostatic and hypoallergenic properties to reduce infection risk and adverse reactions.
• Packaging and cost:
  • 250 mL bottle: Approx cost $1.00-3.00$.
  • 5 L container: Approx cost $20.00$; cost per 250 mL bottle reduces to $1.00$; effectively halves the cost relative to smaller bottles if used to completion.
  • 5-L containers contain 20 × 250 mL portions; cost per bottle becomes $\frac{20}{20} = 1.$ per 250 mL bottle.
• Shelf life and opening rules:
  • Per Joint Commission guidance, ultrasound gel should be discarded 28 days after opening or by the expiration date, whichever comes first: $28 ext{ days}$ after opening.
  • Refill practices for reusable bottles should follow manufacturer instructions to minimize contamination.
• Single-use packets:
  • 20 mL single-use sterile gel packets; box quantity typically 100 packs; price per box $35-70$.
  • Sterile gel is preferred for sterile procedures; non-sterile gel may be used in non-sterile settings.
• Contamination considerations:
  • Cases of skin dermatitis linked to propylene glycol and Euxyl K 400 have been reported; propylene glycol and Euxyl K 400 are often implicated.
  • Bacterial contamination of gel, gel caps, and gel bottles has been observed with reported incidences 2.5 ext{-}6 ext{%} in some studies.
  • Wiping the exterior surface of gel containers with isopropyl alcohol or approved wipes between examinations can reduce contamination risk.
  • Refilling reusable gel bottles should follow manufacturer guidelines to prevent contamination.
• Gel pads – gel-free alternatives for near-field visualization:
  • Aquaflex gel pad (Parker Labs): 2 cm thick, 9 cm diameter; disposable standoff pad for near-field visualization; cost around $7.00$ per pad.
  • Hill Laboratories gel pad: slightly thinner, reusable; cost around $3.00$ per pad.

Gel Warmers and Gel Handling – Low-Resource and Portable Settings

• Gel warmers improve patient comfort by warming gel closer to body temperature; devices can be mounted on walls or placed on counters and typically hold 1–3 bottles.
• Price range for gel warmers: $120-220$ per warmer.
• Mounting solutions for handheld devices and gel storage:
  • Mounting solutions (adjustable brackets, arm mounts, wall mounts) improve positioning in space-constrained settings (e.g., ED, OR).
• Gel-warming in handheld setups:
  • Portable gel warmers can be less convenient in large departments if stations are not dedicated; integration into workflow improves patient satisfaction akin to radiology norms.
• Gel handling in low-resource settings:
  • Locally available substitutes for gel exist (olive oil, mineral oil, water-salt-cornstarch or cassava-based paste). For example, cassava root-based gel in Africa cost about $0.09$ per 500 mL bottle, illustrating substantial cost reductions in resource-limited settings.
• Gel supply considerations:
  • In areas with limited resources, consider using multi-dose containers to reduce waste, while ensuring contamination control and according to manufacturer guidelines.

Gel Handling in Low-Resource Settings – Practical Alternatives

• Local substitutes for gel where commercial gel is expensive or unavailable:
  • Olive oil, mineral oil, or a paste made from water, salt, and starch (e.g., cassava) has been used successfully as a gel substitute in some settings.
  • Example: Cassava root flour (8 parts) mixed with water (32 parts) and salt (1 part) produced acceptable gel for $0.09 USD per 500 mL bottle in certain studies.
• Practical implication: In settings with limited budgets or supply chains, alternative gels can provide functional performance at dramatically lower cost, though clinical workflow and imaging quality should be monitored.

Gel Pads and Gel Pad Usage

• Aquaflex Aquasonic gel pad: Parker Laboratories; 2 cm thick, 9 cm diameter; aqueous, bacteriostatic, disposable (stand-off pad) to improve visualization of near-field structures.
• Hill gel pad: slightly thinner, reusable; cost around $3.00$ per pad.
• Gel pad utility: improves visualization of near-field anatomy without direct skin contact or gel layering requirements, useful in difficult access scenarios.

Handheld Ultrasound Accessories and Organization

• Handheld ultrasound devices require dedicated accessories for optimal workflow and device management.
• OcuLine smartphone mount for Butterfly iQ+ (Fig. 16.16): Enables mounting a smartphone to the ultrasound probe; price around $99.00$ per unit.
• Charging/storage solutions:
  • Charging carts for handheld devices provide secure storage and charging, capacity up to 35 devices; cost range $200-400$ per cart.
• Operational benefits: Ergonomic positioning, single-handed scanning, and efficient device management across multiple patients.

Procedural Guidance Accessories – Echogenicity, Needle Handling, and Safety

• Needle echogenicity:
  • Echogenic needles improve needle tip visualization under ultrasound; available from B. Braun, BD, Pajunk, Havel’s, Cook; typical needle cost: $10-20$ each.
  • Havel’s EchoBlock needle is a cost-effective echogenic needle (about $7-10$) with varying length and calibration markings; Pajunk needles often preferred in studies for tip clarity.
• Needle engagement and nerve blocks:
  • For many ED nerve blocks, a 22-gauge needle is preferred for balance between rigidity and patient comfort.
  • For comprehensive nerve block programs, consider purchasing two lengths (e.g., 50 mm and 100 mm) to cover different depths.
• Nerve stimulation: Some regional anesthesia needles include nerve stimulation capability; this is not routinely required for ED nerve blocks but should be considered when ordering depending on your program.
• Control syringes:
  • A control syringe with three finger holes (two on barrel, one on plunger) provides improved control during injection; cost around $1.50$ per syringe.
• Needle guides:
  • Needle guides are disposable adapters that attach to the probe and help with fixed needle orientation for in-plane or out-of-plane approaches.
  • They are mainly useful for deep biopsies; for many ED vascular access procedures, there is limited additional benefit.
• Practical takeaway: Echogenic needles and control syringes can improve procedural safety and accuracy, especially for dynamic GUIDED procedures; evaluate whether added cost aligns with your program’s case mix.

Ultrasound-Guided Peripheral IV Catheters (USGPIV) – Design and Catheter Characteristics

• USGPIV cannulation targets deeper veins (basilic, brachial, cephalic) in the upper arm vs palpated, superficial veins in the forearm.
• Catheter length considerations:
  • Depth of target vessel dictates catheter length; very shallow veins in infants may require as short as 1.25" (~3.2 cm); deeper veins in adolescents/adults typically require ≥2" (≈5 cm) length; adult recommendations often ≥2.5".
• Catheter gauge:
  • Gauge should be at least comparable to those used in pediatric patients and typically 18-20 gauge for adolescents and adults (due to Bernoulli effect and flow needs).
• Catheter examples and features:
  • B. Braun Introcan Safety 18G 2.5" catheter: approx $2.50$ per catheter.
  • BD Insyte Autoguard Shielded IV Catheter 20G 1.88": approx $3.50$ per catheter.
  • B. Braun Introcan Safety IV Catheter 1.75"; Exel IV Catheter 2"; Terumo SurFlo IV Catheter: approx $1.25$ per catheter.
  • AccuCath: length 2.25"; ARROW radial artery cannulation set: 1.75" catheter; integrated guidewire systems that facilitate rapid access (Seldinger technique).
• Integrated systems for rapid cannulation:
  • AccuCath and ARROW kits include an integrated wire to speed up Seldinger technique; available in 22G, 20G, and 18G variants.
  • These systems are more expensive than standard long catheters but can reduce procedural time and improve success in difficult IV access cases.
• Practical implications:
  • In ED, when selecting US-guided peripheral IV catheters, balance catheter length, gauge, and presence of integrated wires against cost and expected procedural volume.
  • For nerve blocks and central line procedures, plan for complementary equipment (e.g., needle guides, larger catheter kits) as needed.

Needle Guides and Their Role in Ultrasound-Guided Procedures

• Needle guides are disposable attachments that help maintain a fixed needle orientation relative to the probe to support in-plane or out-of-plane planning.
• Pros:
  • Helpful for deep biopsies or interventional radiology contexts where precise needle trajectory is critical.
• Cons:
  • For ED-based vascular access and many US-guided peripheral procedures, the benefit is often limited after clinicians gain familiarity with in-plane/out-of-plane techniques.
• Decision point: Consider needle guides if your program frequently performs deep biopsies or where needle trajectory control is a recurring challenge.

Final Points – Practical Recommendations and Pricing Orientation

• Attend trade shows and exhibit halls to learn about current and newer products.
• Engage with peers across hospital departments (anesthesia, radiology) to learn about equipment and usage patterns.
• Explore with ultrasound program directors in other institutions to identify ideal equipment for your department.
• Key option set for US-guided peripheral IVs with guidewires: AccuCath, ARROW radial artery cannulation set, and midline catheter sets; these systems provide integrated wires and vary in availability and cost.
• Summary of key recommendations:
  1) Be familiar with accessories that improve workflow, device durability, and procedural guidance.
  2) Research and obtain pricing before purchasing to ensure fit with budget.
  3) Do not purchase materials unlikely to be utilized by your program.
  4) Know your supply chain manager and leverage their expertise.

Final Takeaway – How to Build a Comprehensive, Cost-Effective Inventory

• Start with core items essential to your POCUS program (gel, gel warmers, basic sterile covers, basic US-guided procedural needs).
• Map out typical procedures (PIV, nerve blocks, thoracentesis, paracentesis, central line attempts) to prioritize accessories.
• Layer sophistication as volumes justify (e.g., echogenic needles, needle guides, integrated IV catheter systems).
• Build a cost-accessible plan for infection control (HLD vs non-HLD options) and gel usage strategies (multi-dose vs single-use packets).
• Maintain an ongoing dialogue with the supply chain manager and IT department for barcode integration and inventory management.

Appendix: Quick Reference (Key Numbers)

• 250 mL gel bottle: $1.00$ per bottle (approx) when using 5 L container pricing.
• 5 L gel container: approx $20.00$; equivalent to $1.00$ per 250 mL bottle.
• Gel packet: 20 mL single-use packets; box price: $35-70$.
• Gel openness: discard 28 days after opening; $28$ days.
• Trophon (HLD) initial cost: $10{,}000-15{,}000$.
• HLD cycle (Tristel ULT foam): $3.15$ per cycle.
• Echogenic needles: $10-20$ per needle.
• Micro-puncture kit: $7-20$ per kit.
• Peripheral IV catheters: basic $0.80-3.50$; with guidewires $20-90$.
• Long catheters for USGPIV: typical lengths 2"–2.5"; depth-based decisions.
• Barcode scanner (Jadak Flexpoint HS-1): $650-800$ per scanner.
• Spiral Wrap: $10-20$ per 100 ft.
• Cord accessories: extension spring $3.00$; Velcro cable ties $5.00$ for 25 ties; lock box $20-200$ per box.
• Smartphone mounting (OcuLine for Butterfly iQ+): $99.00$ per unit.
• Charging cart capacity: up to 35 devices; $200-400$ per cart.