Artery

Case: Peripheral Venous Access - Part 2

Read more about Case: Peripheral Venous Access - Part 2

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Use ultrasound imaging to identify anatomy prior to intravenous catheter needle punctures, verify needle depth, and use dynamic techniques for attaining optimal needle guidance during deep vein cannulation & IV placement.

Applications

Cardiology

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

Case Study Videos

Media Library Tag

Subtitles

- Hello, my name is Phil Perera
and I'm the emergency ultra sound coordinator
at the New York Presbyterian hospital in New York City
and welcome to SoundBytes Cases.
In this SoundBytes module, entitled Ultrasound Guided
Cannulation of Arm Veins Part 2,
we'll look further into the techniques needed
to use ultrasonography to guide a IV into
one of the deep arm veins.
As we discussed in part one of this module,
we first want to map out the vein using both short
and long axis views and we'll employ a dynamic technique
for optimal guidance for the catheter down to the vein.
Want to use a longer angiocath for the procedure,
preferably 1.88 inch or longer
as we need a good amount of plastic catheter in the vein
to avoid extravasation of fluids or meds
during resuscitation of the patient.
This recent published study showed that it's crucial
to select the correct target vessel when deciding
to cannulate a deep arm IV.
169 patients were enrolled in the study
and it was determined that the size of the vessel
directly correlated with the success rate
of the cannulation procedure.
A vessel with a diameter less than three millimeters
correlated to a success rate of only 56%.
While a diameter greater than 6 millimeters correlated
to success rate of 92%.
That's showing that the diameter was directly correlating
to the success rate of placement of a deep arm IV.
Also the depth of the vessel was very important
as no vessel that was deeper than 1.6 centimeters
was successful cannulated.
A very nice study by Dr. Panebianco et al.
A academic emergency medicine, 2009.
Armed with the knowledge of the last study,
here we're going to measure the diameter of a brachial vein
prior to a puncture attempt.
Notice here, we've selected a brachial vain
and we're measure the diameter at 3.7 millimeters
by 4.3 millimeters.
Thus, this would correlate with a low likelihood
of success rate during a cannulation attempt.
Notice also we're measuring the depth of the vessel
and while the depth of the vessel is six millimeters
less than the 1.6 centimeters that correlated
to no successful outcomes of peripheral IV cannulation,
the diameter of the vessel would be very difficult
to cannulate.
Now let's take a look at a better target.
This is a basilic vessel and we can see here
that the diameter is much larger than the last
brachial vein and we measure it at 6.5 millimeters
by 6.7 millimeters.
Thus, this would have a very high success rate
in terms of cannulation with a ultrasound guided IV.
We can also see that the vessel depth is relatively
superficial, again making it more amenable
to a cannulation attempt.
Once we have selected a favorable target vessel
for cannulation, we can place the probe in a short axis
of side to side orientation.
Here we're using a q-tip coming in underneath the probe
at 45 degree angle to look for the ring down artificat
for guidance for placement of the IV in a side to side
or lateral orientation on the patients arm.
We can look for a finding know as the ring down artifact
on the ultrasound screen as shown here.
Notice we have a nice plump basilic vein in the middle
of the field here and we can see a dark mark
emanating from the surface directly down.
Which is the ring down artifact caused by pressure
from the q-tip.
Thus this would be the appropriate poke point
on the side to side orientation on the patients arm
for placement of the IV.
We can also localize a vessel using the long axis technique.
Notice here we have the probe oriented
in an up and down configuration on the patients arm
and are placing the q-tip underneath the distal aspect
again at a 45 degree angle
to look for that ring down artifact onto the vessel.
To increase the accuracy of an ultrasound guided IV,
it's important to know the course of the vessel
as it runs up and down the arm.
Here we see in the picture to the left
that we're localizing the vessel at one point
on the patients arm but it's not enough
to know only one point.
We need to know the course of the vessel
as it runs up and down the arm as show in the picture
here to the right.
Notice we're marking two points on the vessel.
We have the distal poke point as noted by the blue x
towards the outer part of the patients arm
and then we're moving the probe more up the arm
more proximally to mark a second point on the vessel.
A line drawn between these marks would identify
the trajectory that the IV should follow
once it comes in at the the distal poke point
to successfully cannulate the vessel.
This longer angiocath at 1.88 inches would be more
optimal for cannulation of a deep arm vein
using ultrasound guidance.
This schematic shows the reason
that we need a longer angiocath when cannulating
a deeper arm vein.
While the vein my only be one centimeter deep to the skin.
Notice that the needle is not going directly down,
it comes in at about a 45 degree angle
to cannulate the vessel.
So we need a longer aspect of the needle just
to make it down to the target vein.
Plus we also need an ample amount of catheter
to be within the vessel lumen
to avoid extravasation of fluids or medications.
For this reason, 1.88 inch or longer is essential
for cannulation of a deep arm vein.
Now we're ready to cannulate a vessel
using ultrasound guidance.
We'll begin using the short axis or side to side orientation
of the probe with the probe maker
orientated towards the left
as we stand in front of the patient.
This will correlate with the ultrasound screen indicator
dot which is towards the left of the screen.
Generally I want to go and place the IV at a 45 degree angle
underneath the patients skin and then I'll place
the probe over the area of the IV to guide the IV
directly into the vein.
This phantom shows why using the short axis technique
can be an excellent starting point for guiding
the IV directly down to the vein under ultrasound guidance.
Here we can see a target vessel and note we see
the echogenic tip of the needle going
through the anterior wall of the vessel
and permeating into the vessel lumen.
So the short axis technique is optimal
for viewing lateral needle orientation
across the patients arm and guiding the IV directly
down into the venous lumen.
When using the short axis technique,
one must keep in mind the effect of probe slice
on visualization of the needle.
Note here, the probe is position more proximally
along the course of the needle and even though the needle
tip is securely within the vessel lumen,
we're only visualizing the needle to be above the vessel.
Notice the schematic view here towards the left
and we can see the probe is more proximal along
the course of the needle and the ultrasound view
towards the right and even thought the tip of the needle
is securely within the lumen of the vessel,
we're only visualizing the needle above the vein
and may get a false determination of where the tip
of the needle is.
Therefore, when using the short axis technique
when cannulating a deep arm vessel,
it's important to move the probe along the course
of the vessel to stay in plane with the tip
of the needle as you advance the needle under the skin
and into the vessel lumen.
Here we see we've moved the probe more distally along
the course of the vessel and now we're more
in plane with the tip of the needle.
We see the schematic view to left
and the ultrasound view towards the right
showing successful cannulation of the vessel
and the tip of the needle right within the vein lumen.
This video clip shows successful cannulation
of a brachial vein using the short axis technique.
Notice here we see the vessel and notice
we see the echogenic tip of the needle coming down
from the surface and permeating the anterior wall
of the vessel
and there we can see the echogenic tip of the needle
right within the vessel lumen.
We can also use the long axis configuration
for cannulation of a deep arm IV.
Optimally, you want to place the probe in the configuration
of the vessel as it runs up and down the patients arm.
By tradition, we want to have the probe marker oriented
distal so that the distal aspect of the probe
will line up to the left of the ultrasound screen,
as shown here.
So distal on the screen will be to the left
and proximal to the right.
The IV would then enter underneath the probe
at that 45 degree angle.
While the short axis configuration gives
a lot of information about side to side
or lateral orientation of the needle,
the long axis configuration gives a lot of information
with regard to vertical needle depth.
Here we see a needle coming from the left
and permeating into the vein lumen.
Notice here we can get an accurate determination
of the optimal depth of the needle
in relation to the venous lumen for cannulation
of the vessel.
Here's a real cannulation of a brachial vein
in a long axis configuration.
We see the vein stretching out in a long axis configuration
as a tubular structure running from left to right
along the screen and we see the needle coming
in from the left to the right moving up and down
and cannulating within the venous lumen.
So at this point, we're ready to thread the catheter.
This video clip captures a long axis cannualtion
of a deep arm vein and we can see the needle coming
in from left to right and we can see the needle tip
permeating through the vessel lumen.
Now we can see the actual threading of the plastic catheter.
So again we'll look at the needle coming in from left
to right and now we'll go ahead and freeze it
so we can see the actual plastic catheter
securely within the lumen of the vessel
and it's nice to visualize the catheter
within the vessel lumen to ensure
that there's enough catheter there to give a good amount
of medications and fluids with extravasation
of either of these liquids into the patients arm.
In conclusion, thanks for tuning in to this SoundBytes
module going over part 2 of ultrasound guided
cannulation of arm veins.
Ultrasound guidance for peripheral IV insertion
is an extremely helpful technique
and optimally you want to choose a target vessel
greater than six millimeter in diameter
and at a depth of less than 1.6 centimeters
to optimize our cannulation success.
We want also pick a longer catheter so we have
enough needle and plastic catheter to get into
these deep arm vessels.
We use a combination of short and long axis views
to dynamically guide the angiocath into the vein
and just bear with it because there is a steep learning
curve for these ultrasound guided IVs.
So you'll get it with time so don't give up
and practice practice practice.
So I hope to see you back in the future
as we SoundBytes continues.

Brightcove ID

5508134289001

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

Case: Peripheral Venous Access - Part 1

Read more about Case: Peripheral Venous Access - Part 1

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Use ultrasound imaging to help identify deep and nonpalpable veins that can accommodate the placement of an IV catheter. Doppler color flow is used to differentiate the brachial artery from other anatomical structures.

Applications

Cardiology

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

Case Study Videos

Media Library Tag

Subtitles

- [Voiceover] Hello, my name is Phil Perera,
and I'm the emergency ultrasound coordinator
at the New York Presbyterian Hospital in New York City,
and welcome to SoundBytes Cases.
It's today's module, we'll look at the use
of bedside ultrasound to help us place peripheral IVs.
Specifically, we'll look at ultrasound guidance
for cannulation of deep arm veins.
Ultrasound can allow us to cannulate nonpalpable
arm veins, which have traditionally been off-limits
using traditional palpation techniques.
Thus we can avoid central venous access in those
with poor traditional access in whom we can get
a peripheral IV using ultrasound.
Ultrasound allows precise determination
of vascular anatomy prior to a puncture attempt,
and there's been a number of research studies
that have shown a decrease in number of attempts
and time to successful cannulation using ultrasound.
Here's an illustration showing the anatomy
of the arm veins: a long axis view to the right,
and a short axis view to the left.
Note here on the long axis view,
the brachial artery running down the arm,
and adjacent to the brachial artery,
we can see here the brachial vein.
Notice that the brachial vein is composed of
two major veins: the basilic vein, which is the
larger vein located more superficially and medially,
and the deep brachial veins found
adjacent to the brachial artery,
in a deeper and more lateral position on the arm.
Let's look at the short axis view,
and here we can see well the brachial complex:
the brachial artery surrounded by
two deep brachial veins here, and the more superficial
and medial basilic vein, which is really
the preferred target for a deep ultrasound guided IV.
Note the median nerve lying on top of
the deep brachial vein, which must be avoided
during a puncture attempt on this structure.
Here's a picture showing the surface anatomy
of the veins of the upper arm.
Notice here the basilic vein in a more medial position
on the patient's arm, and the brachial vein complex,
which would be located more laterally
on the patient's arm.
And these are the positions over which
we should place the probe in order to
inspect the veins of the upper arm.
Here are the orientations in which we can
place the probe to inspect the vein
for vascular line placement.
We see the short axis view to the left.
And notice that we're placing the probe
perpendicular to the vein, and note that
the resulting ultrasound image of the vein
will appear as a circle, as the vascular structure,
the vein here, will be cut end on.
Note the long axis view to the right
in which the probe is placed in a longitudinal manner
along the course of the vein, and note
the resulting image of the vein,
which appears as a tubular structure
on the ultrasound screen.
Here's the high-frequency, linear type of ray probe
that we'll be using for vascular access.
And that line on the side is the indicator marker
on the probe.
Here's the high-frequency, linear type of ray probe
placed on the patient's upper arm.
Notice here that it's placed in a short axis,
or side-to-side configuration.
Here we have the probe positioned over
the more medial, basilic vein.
Notice also that the probe marker here
is towards our left as we stand in front of the patient,
and the reason for that is note on the screen
that the indicator dot is also located here to the left.
Therefore left on the probe lines up
with left on the screen.
So now that we know the proper configuration
of the probe in the short axis view,
let's take a look at a typical appearance
of vascular structures cut end on.
Here we have the probe positioned over
the brachial complex, and we see here
the central brachial artery, surrounded by
two deep brachial veins.
So let's put that into video play here,
and notice with compression that
both of the veins compress completely,
helping us differentiate venus structures
from the artery in the center.
And notice that the artery has less distensible walls,
and stays open, even as we compress down with the probe.
We can further differentiate vascular structures
by applying color doppler flow.
Notice here as we apply doppler,
that we see arterial pulsations
in the central brachial artery.
However notice the absence here of any flow
within the deep brachial veins,
and that's because of the slightest flow
within those two vascular structures
as compared to the brisk arterial flow
in the central brachial artery.
So putting it all together, using doppler flow
and applying compression, notice here again
that the brachial artery in the center stays open
and has brisk arterial pulsations.
And notice that the two flanking
deep brachial veins compress completely
and have a lack of vascular flow with doppler interrogation.
Now let's look at a video clip that shows
all of the veins of the upper arm
in relation to one another.
Medial is to the right, and lateral is to the left.
Here we see the larger and more superficial basilic vein,
more medial and superficial to the brachial complex,
which is located here to the left.
And note the central brachial artery,
and two flanking deep brachial veins.
In this patient, the basilic vein would be
the preferred target for placement of a deep arm IV.
Here's a different patient.
Again, we're looking at the relation
of the basilic vein to the brachial complex.
Medial is to the left, and lateral is to the right.
We see here the superficial basilic vein,
and the deeper brachial complex.
Notice we apply pressure, that all of the venus structures-
the basilic vein, and the deep brachial veins,
all compress completely, helping us differentiate
venus from arterial vascular structures.
Here we're applying doppler flow,
and again we can differentiate the brachial artery
by its pulsations consistent with arterial flow.
And note the lack of significant flow
within the venus structures.
Specifically, the basilic vein.
Here's the high-frequency, linear type of ray probe
in a longitudinal, or long access orientation
over the patient's upper arm.
Here it's located over the more medial, basilic vein.
In this orientation, we have the probe marker
going distally, and this helps us line up the probe
with regard to the screen.
Notice the screen indicator dot here
is located towards the left, therefore,
distal on the screen would be over towards the left,
and the proximal on the screen
would be located over towards the right.
Here's a typical appearance of a venus structure
cut in a longitudinal, or long axis orientation.
Notice here that the vein has more of a tubular
appearance on the screen, and that the flow of blood here
is from the left, which is distal on the vein,
towards the right, which is proximal on the vein.
Looking in long axis gives complementary information
about the vein.
So thanks for tuning in to part one of
ultrasound guided peripheral IV insertion.
As we mentioned, ultrasound can be very helpful
in identifying deeper and nonpalpable veins
that can still allow placement of intravenous catheter.
We'll be looking at the vein in both short
and long axis views to determine the anatomy
prior to a puncture attempt.
And now that we have a good sense in terms
of how to look at a vein in both short and long axis,
we're ready to move directly to learning
how to cannulate the vein using ultrasound.
So I look forward to seeing you in part two
of peripheral venous access.

Brightcove ID

5769198966001

https://youtube.com/watch?v=lREUPXCpK8Y

How to: Infraclavicular Brachial Plexus Nerve Block

Read more about How to: Infraclavicular Brachial Plexus Nerve Block

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Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block .

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

- The infraclavicular block is used for surgery
below the mid-humerus.
Any surgery of the elbow, forearm, wrist or hand
can be performed under a properly executed
infraclavicular block.
Many people use curvilinear, low-frequency
or mid-frequency probe to do the infraclavicular block.
With proper positioning
you can do a infraclavicular block
with a basic linear probe.
I'm gonna demonstrate the infraclavicular block
with a basic linear probe
because most people have a linear probe
in their ultrasound repertoire.
Proper positioning for
the infraclavicular block is important.
We usually keep the patient supine
for infraclavicular block.
We also move the patient completely to the other side
of the bed of the site to be blocked.
Abduction of the arm moves the clavicle down
and out of the way of your needle.
If the arm is down by the side
our needle approach is gonna bump into the clavicle.
Usual depth settings
for infraclavicular block in a normal patient
usually range between four to six centimeters total depth.
Ultrasound probe positioning in the infraclavicular region
is done in the parasagittal plane below the clavicle.
I will orient the probe
so the left side of the screen is caudal
and the right side of the screen is cranial.
This makes sense because if I bring
the needle from the cranial side on the screen
it will also come from the right side.
The first thing we see here
is the pectoralis major
and we also will see a pectoralis minor
if I move slightly lateral.
Here we now have identified both the axillary vein
and the axillary artery.
The vein is found more caudal than the artery.
The artery is found cranial.
Around the artery we now identify our nerves.
The nerves at this level
are the cords of the brachial plexus.
Traditionally the medial cord is described as being
approximately seven to ten o'clock
on the artery in this picture.
The posterior cord is described around
six o'clock on the artery
and the lateral cord is described between three
and six o'clock on this picture.
It's difficult to see individual nerves
because this is a deep block.
So the important thing is to surround the artery
with local anesthetic.
Now if we move more medially
we see some lung on the bottom left side of the screen here.
Lateral approaches to the infraclavicular block are safer
because the more lateral you are
the less likely you are to enter the lung with your needle.
Typically we use about 20 to 30 milliliters
of local anesthetic for infraclavicular block.
Our first injection of the artery
will be below the artery.
Some studies have described a single injection
resulting in a complete brachial plexus block
by depositing our entire local anesthetic below the artery.
Usually I do my first injection below the artery
and look at the spread.
If the spread is adequate I'll stop there.
If I need to position the needle in other places
I'll go either to the lateral cord
or approximately three o'clock
and then lastly at the medial cord
which would be about ten o'clock on the artery.
Complete spread of local anesthetic around the artery
will result in a good brachial plexus block.
In this image of the infraclavicular block
we see the local anesthetic being injected
cranial to the axillary artery.
Superficial we see the pectoralis major.
The pectoralis minor's not very visible on this picture.
Deep to the artery we see the subscapularis.
The needle has now injected on the cranial side
and is being advanced deep to the artery.
And you can see the injection there below the artery
getting local anesthetic around the posterior cord.
We continued to advance the needle
so it injects around the medial cord
on the more caudal side of the artery.

Brightcove ID

5508104662001

https://youtube.com/watch?v=1xTsXuiUNiw

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Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block .

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Case: Peripheral Venous Access - Part 2

Case: Peripheral Venous Access - Part 2

Case: Peripheral Venous Access - Part 1

Case: Peripheral Venous Access - Part 1

How to: Infraclavicular Brachial Plexus Nerve Block

How to: Infraclavicular Brachial Plexus Nerve Block

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