Anesthesiology (Regional)

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Subtitles

- [Voiceover] A linear array transducer with a nerve
exam type, is used to perform an ultra sound
guided axillary regional nerve block.
The target depth is approximately one to two
centimeters in an 80 kilogram adult.
The patient is positioned supine with the arm
abducted 90 degrees, and the elbow bent 90 degrees.
The transducer is placed high as possible in the axilla,
with the orientation marker directed to the patient's head.
Slowly slide the transducer in a lateral to medial
direction to identify the axillary artery.
The axillary artery is a dark, round, pulsitile structure
with a hyperechoic wall.
The axilalry veins lie around the periphery of the artery
and are easily compressed.
Slide the transducer up the arm to a proximal
position, so the terrace major muscle,
which helps control the distribution of local
anesthetic during injection, is postero-medial
to the artery and nerves.
The biceps and coracobrachialis muscles, will appear
lateral to the artery.
The median, ulner, and radial nerves appear as
hyperechoic circles, with a honey comb appearance
surrounding the artery.
The nerve positions will vary around the artery.
The transducer is slowly moved laterally over
the biceps and corocobrachealis muscles.
The musculocutaneous nerve can be seen between
these muscles as a small, bright, hyperechoic circle
or triangle.
The needle is positioned one to two centimeters
lateral to the transducer, and advanced using
an in plane technique.
The needle path is directed through the biceps muscle,
toward the musculocutaneous nerve.
The initial end point for the needle is immediately
beside the musculocutaneous nerve, where three
to five CCs of anesthetic should be injected.
The needle is then advanced to a position immediately
post-terior to the artery.
As local anesthetic is injected, the terrace muscle
is pushed down, and the local anesthetic should
spread medial and lateral underneath the artery.
The needle can be advanced through hydrodisection
to facilitate appropriate spread of local anesthetic.
Finally, the needle is withdrawn and redirected anterior
to the artery.
Local anesthetic should be injected over the artery
to finish with a circumferential spread of local anesthetic
around the artery.

Brightcove ID

5765653161001

https://youtube.com/watch?v=3MBmUFMoH7w

3D How To: Parasternal Short Axis View

Read more about 3D How To: Parasternal Short Axis View

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3D animation demonstrating a Parasternal Short Axis view of the heart.

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Clinical Specialties

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- [Voiceover] A phased array transducer
with a cardiac exam type is used to perform
the parasternal short axis view of the heart.
If possible, place the patient in a left lateral
decubitus position to reduce any lung artifact
and to bring the heart closer to the anterior chest wall.
Place the transducer at the third or fourth
intercostal space immediately left of the sternum.
Move between the third and fourth intercostal space
and slide the transducer toward and away from the sternum
to identify the optimal scanning window.
Assuming the short axis of the heart to be positioned
on a plane from the patient's right shoulder
to the left hip.
Rotate the transducer to adjust
for the body habitus of the patient.
The orientation marker will be at approximately
the two o'clock position.
As an alternative approach, this exam may be performed
using an abdomen exam type with an orientation marker
to the patient's left side at approximately
the eight o'clock position.
The myocardium will appear gray
and the blood-filled chambers will appear hypoechoic.
The left ventricle will appear as a doughnut shape
in the center of the image.
The anterior, septal, inferior, and posterior
lateral walls of the ventricle can be identified.
The mitral valve will be seen in cross section.
From this position, the transducer can be tilted upward
to visualize the aortic valve in cross section.
End downward to visualize the myocardium
of the left ventricle.
Note the wall motion of the myocardial segments
and function of the valves.

Brightcove ID

5752141722001

https://youtube.com/watch?v=EaLuCBXXINg

3D How To: Parasternal Long Axis View

Read more about 3D How To: Parasternal Long Axis View

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3D animation demonstrating a Parasternal Long Axis view of the heart.

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Clinical Specialties

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Subtitles

- [Voiceover] A phased array transducer with a cardiac
exam type, is used to perform parasternal long axis
view of the heart.
If possible, place the patient in a left lateral
decubitus position to reduce any lung artifact,
and to bring the heart closer to the anterior chest wall.
Place the transducer at the third, or fourth, intercostal
space immediately left of the sternum.
Move between the third, and fourth intercostal space,
and slide the transducer toward, and away from the sternum
to identify the optimal scanning window.
Assuming the long axis of the heart to be positioned on a
plane from the patients right shoulder to left hip, rotate
the transducer to adjust for the body
habitus of the patient.
The orientation marker, will be at approximately
the 10 o'clock position.
As an alternative approach, this exam may be performed using
an abdomen exam type, with the orientation marker
to the patients right side at approximately
the 4 o'clock position.
They myocardium will appear gray, and the blood filled
chambers will appear hypoechoic.
The descending aorta is seen in cross section as a round
structure posterior to the atrioventricular junction.
This view is used to evaluate the right ventricle, left
ventricle outflow tract, and left ventricle.
Note overall activity of the heart.
Any wall motion abnormality, valve abnormalities,
and the presence of pericardial effusion.

Brightcove ID

5794989686001

https://youtube.com/watch?v=4qerzEW_ASU

3D How To: Apical 4-Chamber View

Read more about 3D How To: Apical 4-Chamber View

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3D animation demonstrating an Apical 4-Chamber view of the heart.

Applications

Clinical Specialties

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Subtitles

- [Voiceover] A phased array transducer
with a cardiac exam type is used to perform
the apical four chamber view of the heart.
If possible, place the patient
in a left-lateral decubitus position
to reduce any lung artifact and to bring the heart
closer to the anterior chest wall.
Place the transducer at the apex
or point of maximum impulse,
with the orientation marker to the patient's
left side at a three o'clock position.
As an alternative approach, this exam may be
performed using an abdomen exam type,
with the orientation marker to the patient's right side.
Aim to the right shoulder.
The apex of the heart is visualized
closest to the transducer.
The myocardium will appear gray,
and the blood-filled chambers will appear hypoechoic.
The ventricles are in the near field,
and the atria are in the far field of the image.
This view is used to compare the size of the right
and left ventricles and evaluate contractility.
The right side of the heart,
which is located on the left side of the screen,
should be smaller than the left.
Th apical, septal, and lateral walls
of the left ventricle are visualized in this view.

Brightcove ID

5508134322001

https://youtube.com/watch?v=_eHZz-OCc_M

3D How To: Saphenous Nerve Block

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3D animation demonstrating an ultrasound guided saphenous nerve block.

Clinical Specialties

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Media Library Tag

Subtitles

- [Voiceover] A linear array transducer
with a nerve exam type is used to perform
an ultrasound-guided saphenous nerve block.
The target depth is approximately
one to three centimeters in an 80 kilogram adult.
The patient is positioned in a supine position
with the leg slightly abducted and externally rotated.
The transducer is placed in the middle of the thigh
in a transverse plane, with the orientation marker
directed to the patient's right.
The leg is scanned medially to laterally
to identify the superficial femoral artery,
which lies underneath the sartorius muscle.
The saphenous nerve can lie either
anterior or posterior to the artery.
The saphenous nerve may not be visible.
If it is, it will appear as a bright,
hyperechoic oval or triangular structure.
The needle is positioned one to two centimeters lateral
to the transducer, and advanced under the transducer.
Local anesthetic is injected incrementally,
superficial and deep to the artery
to complete the saphenous nerve block.

Brightcove ID

5508114714001

https://youtube.com/watch?v=54VG2GhJ3w4

Body

3D animation demonstrating an ultrasound guided saphenous nerve block.

3D How To: Supraclavicular Nerve Block

Read more about 3D How To: Supraclavicular Nerve Block

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3D animation demonstrating an ultrasound guided Supraclavicular nerve block.

Clinical Specialties

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Media Library Tag

Subtitles

- [Voiceover] A linear array transducer with
a nerve exam type is used to perform an ultrasound guided
supraclavicular regional nerve block.
The target depth is approximately one to three centimeters
in an 80 kilogram adult.
The patient is positioned in a 45 degree
reclining position with a pillow under their head
and the neck exposed on the operative side.
The patient's head is rotated toward the contralateral side.
The examination begins by finding the supraclavicular region
of the brachial plexus as a landmark technique.
The transducer is placed posterior
to the midpoint of the clavicle at an acute angle
with the orientation marker directed
to the patient's right at a ten o'clock position
with the transducer aimed into the thorax.
The subclavian artery is seen as a round pulsal tile
structure superior to the bright reflection
of the first rib.
The plura is seen as a bright hyperechoic reflection
deep two, or at the same depth as the first rib.
The nerves of the brachial plexus are posterior
or superior to the subclavian artery.
The nerve trunks appear as hypoechoic dark circles
within the bright hyperechoic fascia of the brachial plexus.
Colored doppler imaging may be used
to identify smaller arterial branches
running through the brachial plexus
or lying in the path of needle advancement.
The needle is positioned one to two centimeters
lateral to the transducer, and advanced
using an in plane technique.
The initial end point of the needle
is just posterior to the artery
immediately above the first rib.
It is important to distinguish the plura
from the first rib to avoid a pneumothorax.
The local anesthetic is injected
incrementally close to the nerves.
The needle can be redirected towards
the upper trunks of the brachial plexus
if the spread of local anesthetic is not deemed adequate.

Brightcove ID

5750031878001

https://youtube.com/watch?v=9vW1uo7mKDc

Body

3D animation demonstrating an ultrasound guided Supraclavicular nerve block.

Case: Central Line Bundle: Improving Patient Safety

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Video case study covering the 6-point central line bundle.

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Clinical Specialties

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Case Study Videos

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- [Voiceover] In this Soundbytes module, we'll discuss
how we can improve patient safety through a concept
known as a central line bundle.
Now the central line bundle is a six step checklist
of initiatives that can decrease both the infectious,
and mechanical complications of central line placement.
Let's begin this module by going over some of the
potential patient benefits of central venous access.
Central venous access allows more secure
vascular access in our sickest patients,
and gives us the ability to deliver
high flow infusions in these patients.
Central venous access is also a safer administration route
of vasopressors as opposed to the peripheral route.
A central line allows for better hemodynamic monitoring
of our patients, allowing you to monitor
central venous pressure, or CVP, and also
mixed venous oxygen saturation.
However there are some serious patient risks involved
with placement of a central venous catheter.
The two main groups of complications are the mechanical,
and the infectious.
Those included under mechanical complications are
pneumothorax formation, hemothorax formation,
and inadvertent arterial puncture with hematoma formation.
The second main category are the infectious complications
and central associated bloodstream infections
are increasingly recognized cause of increased
morbidity and mortality in our sickest patients.
Because of these recognized complications of
central line placement, bedside ultrasound has stepped up
to help us lower the complication rate.
Bedside ultrasound dramatically decreases
the mechanical complications of central line placement,
allowing real time guidance of the cannulating needle
into the central vein.
Bedside ultrasound is now recommended by
governmental agencies and multiple medical societies
as an aid in placement of central lines.
And over recent years there's been increasing momentum
in initiatives to decrease
central line associated infections.
Two major initiatives were the IHI 100,000 Lives Campaign
which came out in 2005, with the aim to improve
patient safety in all USA hospitals.
Also in 2006, the Joint Commissions, JCAHO
came out with the Six National Safety Goals,
also with the aim of reducing risk of
health care associated infections.
The Institute for Health Care Improvement, or IHI
recommendations for central venous access include
five major initiatives.
The first is increasing attention to hand hygiene.
Number two, adequate skin antisepsis,
number three, maximal barrier precautions,
number four, catheter site selection,
and number five, daily review of the need
for a central line.
If one adds ultrasound guidance of line placement
to the five point IHI recommendations of hand hygiene,
skin antisepsis, maximal barrier precautions,
catheter site selection, and daily review of the need
for central line, one gets to the central line
six point bundle, the current standard
for decreasing complications of central line placement.
Before performing central venous access,
it's mandatory to perform a checklist prior to the procedure
to decrease the complication rate.
The first thing one should do is to review
the patient charts for those increased procedural risks
to our patients, such as coagulopathy,
thrombocytopenia, the presence of a DVT
within the upper extremity or lower extremity veins,
or a known latex allergy.
One should obtain informed consent from our patients,
also performing a prescan ultrasound to look for a clot
in the targeted veins.
Last but not least, it's optimal and mandatory
to perform a time out procedure together
with the nursing staff.
Going through the IHI guidelines for decreasing
the complication rate for central venous access,
the first step is to wash your hands thoroughly
prior to the procedure.
As an alternative, one can consider application of
alcohol based, waterless hand cleansers which offer
additional disinfection benefit over conventional washing.
The second step for decreasing the complication rate
of central venous access, is adequate attention
to skin antisepsis.
For this initiative, Chlorhexidine is going to be optimal.
Chlorhexidine offers benefits over traditional
Povidine-iodine with regard to skin antisepsis,
and it's best to scrub the Chlorhexidine sponge
vigorously across your patient's skin for 20 seconds,
applying three Chlorhexidine scrubs sequentially
to a wide field area over the patient's skin.
The third step is adequate attention to
maximal barrier precautions during the
central venous placement procedure.
The operator and all assistants should wear a cap,
mask, sterile gown and sterile gloves
throughout the procedure.
It's important to place a wide field barrier
over the patient during the procedure
to decrease the infectious risk to our patient.
The patient should be covered from head to toe
with this wide field barrier, with only a small opening
for the insertion site of the central line.
The fourth main step within the IHI guidelines,
is adequate attention to site selection
for placement of a central venous catheter.
In general, high lines are preferred.
The internal jugular vein and subclavian vein
are associated with a decreased risk of
infectious complications to our patients.
In general, low lines are less preferred,
as placement of a catheter into the femoral vein
is associated with higher risk of infection,
and also a higher risk of DVT in our patients.
Critical actions following placement of a
central venous catheter include using sterile technique
to flush all lines of the catheter, and then putting
sterile catheter caps on all lumens.
We'll then place a sterile dressing,
like the Tegaderm shown in the picture to the upper right
over the access site, and obtain a chest radiograph
after all high lines, to look for placement
of the tip of the catheter,
and also to rule out a pneumothorax.
An optimal approach to facilitate compliance
with the central line bundle, is to create a
dedicated central line bundle cart that moves
to the patient during the actual procedure.
On this dedicated central line bundle cart,
can be included all the supplies essential
to central venous access, to facilitate easy compliance
with the steps.
In the cart can be included the chlorhexidine swabs,
all the sterile barrier supplies for the operator,
such as the cap, gown and sterile gloves,
the wide field barrier for our patient,
sterile caps to go onto the central venous catheter,
and the dressing cover, the Tegaderm to cover the site
after the procedure is completed.
One should also have the ultrasound probe
sterile sheath cover, to facilitate the use of
ultrasound in a sterile manner during the procedure.
A crucial step that's more relevant for the
critical care units, is a daily review of all
central venous lines to see if the line is truly needed.
All unessential lines should be immediately removed
from the patient, if not essential for optimal patient care,
to decrease the risk of infections to our patients.
So in conclusion, the central venous access six point bundle
can potentially decrease the complication rate
for our patients undergoing this procedure.
Remember that we get to the six point bundle
by adding ultrasound guidance of line placement
to the IHI five point recommendations as shown below.
Hand hygiene, skin antisepsis, maximal barrier precautions,
catheter site selection, going for those high lines
over the low lines, and a daily review of the
need for a central line.
Through adherence to the
central venous access six point bundle,
we can potentially make the central venous access procedure
a safer one for our patients.
Remember that, number one, we can potentially
lower the rate of mechanical complications
by using ultrasound guidance throughout the procedure.
And number two, we can potentially lower the rate of
infectious complications of the procedure,
by close adherence to the IHI guidelines.
In conclusion, hopefully we can make hospitalization
a potentially safer experience for the most ill
of our patients who are receiving central venous access,
for their treatments.
So I hope to see you back in the future,
as Soundbytes continues.

Brightcove ID

5508123477001

https://youtube.com/watch?v=hUH-B7qy-fc

How to: Stellate Ganglion Block

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This videos discusses some of the scanning techniques involved when performing a stellate ganglion nerve block under ultrasound guidance.

Clinical Specialties

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Subtitles

- Today I'm going to demonstrate the stellate ganglion block
performed under ultrasound guidance.
Traditionally this block was performed blindly,
without the use of any imaging modality.
Currently thoracoscopy is a preferred method,
however utilizing ultrasound such as this M Turbo system
utilizing the HFL 50 linear probe,
this can be done with less radiation
and avoidance of vascular structures
that might not otherwise be seen
under thoracoscopic guidance.
The C6 transverse process, Chassaignac's tubercle,
immediately inferior is the C7 body
and transverse process.
The probe is placed in a transverse orientation,
clearly identifying and avoiding the vertebral artery.
And the needle coming in contact with
the C7 transverse process.
To perform this particular block,
the following equipment is necessary.
The chlorhexidine prep,
one percent buffered lidocaine
with a one and one half inch 27 gauge needle,
a 25 gauge three and one half inch spinal needle,
a 10 cc syringe that will contain seven ccs
of one percent lidocaine with epinephrine,
or quarter percent bupivacaine with epinephrine.
The procedure is performed with the patient
in the supine position, with the chin up
and the following anatomic structures are identified.
The thyroid cartilage, the cricoid cartilage, and then,
the finger is placed in the groove next to the trachea,
and pressure applied until a bony protuberance is felt.
This is Chassaignac's tubercle or
the transverse process of C6.
Currently, the use of thoracoscopy
indicates use at the C7 level.
The reason for this is to provide
better sympathetic blockade while avoiding some
of the common side effects such as Horner's syndrome,
as well as recurrent pharyngeal nerve paralysis.
In this case, the HFL 50 probe will be utilized.
It provides a very high definition, high resolution view
of the subcutaneous structures.
Gel is placed at the formerly marked C6 level.
And the HFL 50 probe is placed on the skin
in a transverse arrangement.
The initial view is of the cricoid cartilage,
and then the probe is moved slightly cephalad
and then rotated slightly outward.
At this point the thyroid as well as the carotid artery
and Chassaignac's tubercle are clearly visible
as the hump located immediately in the center of the screen.
Since this is the C6 tubercle,
we will move slightly interior until it flattens out
and this becomes the C7 transverse process.
It's important to note at this point to utilize
the color flow Doppler which will indicate
vascular structures such as perforating thyroidal arteries
that are not to be violated,
as well as the carotid artery,
and the vertebral artery more laterally.
The structure of interest is the longus colli muscle.
At this point, local anesthetic
one percent lidocaine buffer is injected,
and a 25 gauge three and a half inch needle
is advanced through this track to contact the oss at C7.
The needle is backed off slightly and then the injection
of local anesthetic, preferably epinephrine
containing one percent lidocaine,
six to seven ccs is gently and slowly injected.
At this point, the probe is removed, the skin wiped
and cleaned, and if needed, a band aid placed
over the small puncture site.
This successfully concludes a stellate ganglion block
performed under ultrasound guidance.

Brightcove ID

5508120224001

https://youtube.com/watch?v=RrDOsfoOSuw

How To: Sacroiliac Injection

Read more about How To: Sacroiliac Injection

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This video discusses some of the scanning techniques when performing a sacroiliac injection under ultrasound guidance.

Clinical Specialties

Media Library Type

Sacraliliac Joint Injection

Media Library Tag

S.I

Anesthetic Nerve Block

Subtitles

- Today I'm gonna demonstrate the sacroiliac joint injection
as facilitated by ultrasonography.
The anatomic considerations are the posterior superior
iliac spine, the sacrum, and the insertion formed
of the sacroiliac joint.
The C60 probe is placed in the transverse orientation.
After anesthetizing the skin the needle enters
out of plane into the joint, thusly performing the block.
The sacroiliac joint injection is useful specifically
to diagnose issues within the sacroiliac joint that might
be causing hip pain to the patient.
Typically on physical examination, there might be a positive
FABER or flexion abduction external rotation test,
also known as Patrick's sign,
or a positive Gaenslen's maneuver.
This can also occur when the patient has a pelvic tilt
or a leg-length discrepancy.
The injection is useful both diagnostically
and therapeutically.
Traditionally, fluoroscopy is utilized to place the needle
within the sacroiliac joint space.
The sacroiliac joint is a very complicated joint in that
it is a fibrous insertion superiorly and a traditional
articulating joint in the lower portion of it.
On fluoroscopy, issues arise such as parallax
and it is well-documented that sometimes the injection
is not placed within the joint but rather periarticularly
and, therefore, not providing the coverage
or the response that is expected.
To perform this particular block,
the following equipment is necessary.
Chlorhexidine for sterile technique.
Local anesthetic syringe containing 1% buffered lidocaine.
And then a syringe containing 5cc of bupivacaine,
one-half percent mixed with 5cc of one percent lidocaine.
And then 40-80 milligrams of triamcinolone kenalog
which is a particulate steroid.
A 3 1/2 inch, 25 gauge spinal needle will also be utilized
for the procedure.
There will be sterile 4 x 4s necessary to clean the area
at the conclusion.
And a simple band-aid will suffice to cover the wound.
The patient is placed in the traditional prone position.
There is a bolster within and under the abdomen
to facilitate opening of the sacroiliac joints.
And then I utilize the C60 probe with its curvy linear
structure to better visualize the interface between
the sacrum and the iliac crest.
The depth is usually set to 7 - 9 centimeters,
depending on the patient's habitus.
Additionally, I utilize the muscoloskeletal, or the MSK,
setting because it provides enhancement of the bony
structures and the enhancement of the joint space.
The probe is placed on the patient in the transverse
orientation approximately a centimeter or two above
the beginnings of the gluteal folds.
And I've found the anatomic midline by identifying
the spinous process of the sacral plate.
As I roll the probe laterally, the posterior superior
iliac spine comes into view very clearly at the top
of the screen, up here.
The space between the posterior superior iliac spine
and the shadow cast by the iliac crest and the sacrum
as it dives down represents the sacroiliac joint.
And you can see that in the center of the screen.
It's important to remember that the iliac crest and ilium
folds and cantilevers towards the sacrum.
Therefore, the needle angle needs to track from medial
to lateral into the space identified
in the center of the screen.
Local anesthetic is placed.
And as a finder needle, this injectate using hydrodissection
demonstrates the needle tip at all times.
The needle is going in the short axis, therefore,
it won't be completely visualized on the screen.
However, hydrodissection can help notice where
the tip is at all times.
Then I'll utilize the 3 1/2 inch spinal needle, 25 gauge,
and enter that track that I have placed
local anesthetic with it.
The needle tip will then be placed within that joint
identified in the center of the screen, right here.
At this point, I attach my syringe containing the local
anesthetic steroid and saline mix.
And then I could utilize color flow Doppler to actually
visualize perturbations of the liquid
as it enters the joint.
- [Voiceover] The view is in the short axis, therefore,
the needle is not visible.
The iliac crest is visible as the large hyperechoic
structure on the right of the screen.
The lateral crest of the sacrum is visible below.
The target is the void between the lateral crest
of the sacrum and the iliac crest.
This helps solidify understanding of the three-dimensional
structure of the sacroiliac joint.
- At this point the probe is removed.
I utilize the 4 x 4s to clean the area.
And a band-aid is placed over the wound.
This successfully completes the ultrasonographic
facilitation of a sacroiliac joint injection.

Brightcove ID

5734039824001

https://youtube.com/watch?v=7G56DN38mz8

SonoMBe On - Steep Femoral Nerve 4cm

Read more about SonoMBe On - Steep Femoral Nerve 4cm

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Clinical Specialties