Axillary Brachial Plexus Block

M-Turbo: Axillary Nerve Post Injection

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M-Turbo: Axillary Nerve Post Injection.

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Case: Axillary Vein Cannulation

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Discussion on helpful scanning techniques and anatomy landmarks used to perform an ultrasound guided cannulation. Topics: patient and transducer position, identification of structures near the vein, vein depth, & insertion technique.

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Cardiology

Clinical Specialties

Anesthesiology (Regional)

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Case Study Videos

Subtitles

- [Voiceover] Welcome back to SoundBytes Cases.
This is Phil Perera, and in this module we'll discuss
cannulation of the axillary vein using ultrasound guidance.
So why, you might ask, would I want to use
ultrasound to cannulate the axillary vein,
when in effect, the axillary vein is an alternative approach
to cannulation of the subclavian vein on the chest wall?
The axillary vein is a continuation of the brachial vein
onto the chest wall, and becomes a subclavian vein,
as it passes medially under the first rib.
The axillary vein can be well visualized
using ultrasound at this lateral position on the chest wall,
and that's in contrast to the subclavian vein,
where the presence of the bony clavical
makes imaging of the infraclavicular portion
of the subclavian vein difficult.
So in effect, this is a lateral puncture
of the subclavian vein relaying into the axillary vein,
if you're gonna use the right anatomical terminology.
Ultrasound guidance of Axillary Vein cannulation
is now well documented in the medical literature,
although many clinicians remain unaware
that ultrasound can be integrated into this approach.
Two studies document utility
of ultrasound guidance for axillary vein cannulation
with a decreased complication rate,
and the studies are shown below,
the first in 2004 and the more recent in 2012,
both from our colleagues in Great Britain.
In 2011 the CDC came out
with some guidelines for the prevention
of intravascular catheter related infections.
Their recommendations included
using a subclavian vein site, if possible,
rather than internal jugular vein or femoral vein sites,
in adult patients, to minimize the risk of infection,
with a non-tunneled catheter.
They did say to avoid the subclavian site in hemodialysis
and advanced kidney disease patients, to decrease
the risk of subclavian vein stenosis.
They also advocated the use
of ultrasound guidance, if available.
Now let's review the relevant
upper extremity venous anatomy,
that we'll need to know,
to perform successful cannulation of the axillary vein.
Here we see the axillary vein and the axillary artery,
lateral on the patient's chest wall.
Notice here the clavical and the first rib.
As these structures move medially past the first rib,
they become the subclavian vein and artery.
We can see these arteries and veins here,
more medially located on the patient's chest.
Notice also,
we see the internal jugular vein and carotid artery,
moving up and down the patient's neck,
and coming together with the subclavian vessels.
We see the brachiocephalic vein,
which is the confluence of all of these vessels,
as they move down towards the heart,
to become the superior vena cava,
and we remember that, optimally,
we want to place the tip of the catheter,
when performing central venous cannulation,
in the superior vena cava,
and not into the right atrium.
Here's another anatomical image,
showing a perspective from a more lateral orientation
on the patient's chest wall.
Here, we see the axillary vein and axillary artery,
and notice that the normal orientation
of the vein and the artery
is that the artery should be superior to the vein,
although occasionally we have seen some variation,
and it's not unusual for the vein
to be overlapped by the artery, or vice versa.
We see the continuation of the axillary vein and artery,
onto the patient's chest wall, medially,
to become the subclavian vein and artery,
as the vessels pass medial to the first rib.
We also see the internal jugular vein and carotid artery,
and the superior vena cava.
To best image the axillary vein using ultrasound
we'll place the probe on the lateral chest wall.
Here we see the probe applied,
in a longitudinal or long axis orientation
over the top of the axillary vein.
We can image the vessel, using the long axis orientation,
to get a lot of information about the vessel,
but we can look in the short axis orientation,
by turning the probe so the probe indicator
will be towards the patient's right shoulder.
This will cut the vessel in cross section,
making it appear like a circle.
Before performance of the axillary vein cannulation,
we'll want to select the right ultrasound probe for the job.
For this application,
we'll be using a higher frequency 10 MHz linear array probe,
and because we're performing this procedure in a dynamic
or real-time guidance technique,
we'll want to put a sterile sheet or barrier
over the probe, so as to maintain
sterile precautions throughout the procedure.
Note, in some of the upcoming pictures, we don't have
a sterile sheet over the probe, but if we were performing
this in real procedure, we'd want to make sure,
that we have that sterile sheet over the probe.
While someone will run through a pre-procedure checklist,
assessing for relative contraindications
to axillary vein cannulation,
as it's a relatively non-compressible vessel,
coagulopathy is a contraindication
to axillary vein cannulation.
Also, renal disease or need for dialysis
would be relative contraindications to cannulation
of the axillary vein.
We can also run through a more extensive checklist,
known as the 6 point bundle,
which is shown in the upper right,
which emphasizes the use of maximal sterile precautions
for both patient and clinician during the procedure.
Now let's specifically discuss
some of the ultrasound guided approaches
to axillary vein cannulation.
The axillary vein can be visualized
in both short and long axis orientations, using ultrasound.
Imaging of the needle during cannulation of the vein
can then be performed in either orientation,
and there are pluses and minuses of both these orientations,
for cannulation of the vessel.
I generally recommend to start
in the short axis orientation
to introduce the needle,
initially to advance the needle down to the vein.
One may successfully cannulate the vessel in short axis,
however, one thing that can be very helpful
is to flip the probe, once the needle is under the skin,
into the long axis orientation,
to be used to visualize the needle
as it approaches the vessel,
as a long axis orientation shows needle depth
better than the short axis orientation.
So, putting it altogether, here's the probe position
for cannulation of the axillary vein
in the long axis orientation.
Notice here, that the needle would be placed
in an orientation coming in
under the lateral aspect of the probe,
and moving more medially.
Thus we can image the full position of the needle
as it moves down to the axillary vein.
In the next few images,
we'll also show you the placement of the probe
for the short axis cannulation of the axillary vein,
so as to compare both long and short axis imaging.
Here's a few pictures showing the orientation of the probe,
and the placement of the probe
for cannulation of the axillary vein
in a short axis orientation.
Notice here, that we have the probe
in an up and down configuration,
with the indicator dot towards
the patient's right shoulder or superior.
Notice we're placing the needle roughly at about the
midway point underneath the probe.
Now there are some benefits
of starting with the short axis orientation,
namely that it's helpful in orienting the needle,
up or down, superior or inferior,
on the patient's chest wall,
to best aim it towards the axillary vein.
Here are some ultrasound images
of the axillary vein and artery,
taken from the short axis view.
We have the probe marker oriented
towards the patient's head,
thus to the left of the image is superior,
and to the right is inferior.
We notice the axillary artery, the smaller vessel,
superior or towards the left of the image.
We see the larger axillary vein
at about the three centimeter mark,
inferior or towards the right of the image.
Notice towards the back of the image,
we can actually see the lung
sliding up and down as the patient breathes,
at about the five centimeter mark.
Thus it's very important to cannulate the vessel carefully,
and not to pass the needle deep,
past the axillary vein or artery
to cause an inadvertent pneumothorax.
Here's another image of the axillary artery and vein,
taken from a short axis configuration.
Again, we have the probe marker indicator
towards the patient's head.
Superior to the left, inferior to the right.
Thus we see the smaller axillery artery
to the left or superior, and the larger axillery vein
inferior toward the right of the image.
Notice that as we apply probe pressure
down onto the patient's chest wall,
we can actually compress the axillary vein ,
and this is one way of telling vein from artery,
as normally the vein should compress,
as long as there's no thrombus inside it,
and the artery will stay open.
We can see the lung sliding
towards the deeper aspect of the image.
In this ultrasound image,
again taken from a short axis configuration,
we'll use Color Flow Doppler to further differentiate
the axillary artery from the axillary vein.
We note again, that superior is to the left,
and inferior is to the right.
We can see the smaller axillery artery,
with pulsations indicating arterial flow within the lumen.
Notice here, we also see phasic respitory flow
within the axillary vein, corresponding to
inhalation and exhalation by the patient.
Thus, another way of differentiating the axillary artery
from the axillary vein.
Here are some images showing the appropriate positioning
of the probe for long axis cannulation of the axillary vein.
Again we notice that we have a high frequency linear array
probe positioned over the lateral chest wall,
directly over the axillary vein.
We have the needle coming in,
under the long axis of the probe.
Now, I like to have the probe positioned
so that the marker on the probe is oriented lateral.
Thus, the needle will come in underneath the indicator
and progress directly underneath the probe
as it courses from the skin down to the axillery vein.
It's important to keep the needle and plane
underneath the probe at all times,
so that it can be visualized as it goes down to the vessel.
Here's a long access ultrasound image of the axillary vein
as it courses from lateral to the left of the image
to medial to the right of the image.
Notice that the axillary vein appears
as a tubular structure, at about the three centimeter mark.
Now let's take a look at the axillery artery
using B-mode or greyscale sonography.
We can see the axillary artery
arching from lateral to medial
across the patient's chest wall,
and we note the pulsations within the lumen,
indicative of an arterial structure.
We can also see the thoracoacromial trunk
coming off medially off the axillery artery.
Next, we'll use Color Flow Doppler
to further differentiate venous structures from arterial.
This will be the axillary vein and we can tell this,
as it does not have that constant arterial pulsations
within the lumen.
Notice that rather,
it has the phasic respitory variation of flow
within its lumen, as indicative of a venous structure.
We can also see the thoracoacromial trunk
coming off medially.
Let's contrast that last ultrasound clip with
this one, showing the axillary artery, using
Color Power Flow Doppler.
Color Power Flow Doppler shows amplitude of flow,
and we can see that fast flow is very yellow,
we can see the faster flow within the inner part of the
lumen of the vessel.
But notice that we have here
the characteristic arterial pulsations,
that differentiate from venous pulsations.
Now let's discuss the micropuncture technique
for central venous cannulation.
The micropuncture technique has a lot of advocates
when talking about cannulation of the axillary vein,
as it utilizes a smaller 21 gauge needle
for the initial puncture of the axillary vein.
This is in contrast to a traditional central line kit,
which uses and 18 gauge needle, a much larger needle,
for that initial vessel cannulation.
One can then use
this smaller 21 gauge needle to cannulate the vessel,
and place a guidewire into the vessel.
A larger catheter can then be inserted
over the guidewire into the vessel.
Using these smaller diameter needles
is potentially safer for deeper puncture
of vessels like the axillary vein
to avoid potential complications.
In this video clip, we'll watch cannulation
of a vessel using a short axis approach.
This is a phantom which simulates the human body
and we can see that as we place the probe
in the short axis orientation,
the vessel appears as circular end-on.
Notice here, that we can see the echogenic tip of the needle
coming down to the vessel, permeating the interior wall,
and entering into the lumen of the vessel.
So the short axis plane allows
better lateral guide of the needle path,
and is a good starting position
for cannulation of an axillary vein.
In this video clip, we'll use the long axis approach
for cannulation of a central vein.
Here we're using some new technology,
known as MBE technology,
that is on a lot of the Sonosite machines.
What we see here is the tip of the needle
is much more echogenic.
We aim the needle towards the dotted line,
which is coming from right to left on the image here.
Now let's watch the needle coming in from left to right,
and we can see that,
as the needle is in plane with the probe
in the long axis approach,
we can see the full extent of the needle
as it travels from superficial down
to permeate the anterior wall of the vessel
and enter into the vessel lumen.
Thus the long access plane allows
a much better guide to needle depth
and allows you to gauge where the tip of the needle is
at all times.
That's why I generally start with a short axis approach
and then flip to long axis.
In this video clip, we'll look at a real-time
axillary vein cannulation in a real patient.
Here we see the needle coming down from left to right,
we're using the long axis view.
Notice that the images are not quite as crisp,
because the probe is slightly off-axis to the vessel.
What we can see here is the tip of the needle
as shown by a small arrow, coming down, pushing down
on that anterior wall of the axillary vein,
and then entering into the vessel lumen.
So in this case we were able to successfully cannulate
the axillary vein, although the images are
not quite as clear as in the phantom,
and this is one pitfall from using the long axis approach,
that you must be completely in plane with the needle
throughout its entire path down to the vessel.
Here's another clip in the long axis orientation,
showing a successful cannulation of an axillary vein.
We can see here the needle pushing down
on that anterior wall, and then entering
into the vessel lumen.
Now one potential pitfall is that, occasionally,
the vessel can be pushed down, the anterior wall can tent
towards the posterior wall, as you push the needle down.
So have patience, and occasionally,
a slight pull-back with the needle
will loosen that tissue, and allow you
to free the needle tip within the vessel lumen.
But again, the teaching point here
is that the long axis view is great
for assessment of needle depth at all times.
Another use of ultrasound and the long axis technique
which I find very helpful,
is to assess that the guidewire
is safely within the position,
within the lumen of the axillary vein.
Here we note the needle coming down from left to right,
and we can see the guidewire passing
through the tip of the needle,
moving down the axillary vein,
down towards the superior vena cava.
This can be very helpful in assessing that the guidewire
is indeed safely within the axillary vein,
prior to placement of the plastic catheter.
While standard practice would dictate
that after placement of a central line,
one would obtain a chest radiograph
to look for the placement of the tip of the catheter
in the superior vena cava.
A quick and easy way of assessing
that the catheter is indeed inside the superior vena cava
is to use a saline flush.
Here we're flushing the saline into the catheter
and we can note the presence of bubbles
within the right side of the heart,
indicating that the catheter is indeed
within the vessel lumen, so a quick and easy way,
right at the bedside, prior to obtaining a chest radiograph.
In conclusion, thanks for joining me
for this SoundBytes module,
going over ultrasound guided approaches
to axillary vein cannulation.
Ultrasound guidance of axillary vein cannulation
is now well supported in the medical literature,
and in fact, the CDC guidelines from 2011
advocate placement of central lines
within the axillary and subclavian veins,
to lower the incidence of bloodstream-associated infections.
As we discussed, the micropuncture technique,
using a smaller needle
for the initial cannulation of the axillary vein,
can be very helpful for this approach.
We can then place a guidewire and larger catheters
into the vessel more safely.
So clinicians should strongly consider
this alternative approach,
using ultrasound guided approaches into the axillary vein,
when determining the location
for central venous catheter placement in their patients.
So, I hope to see you back, as SoundBytes continues.

Brightcove ID

5508139234001

https://youtube.com/watch?v=zxmkrrq1P3M

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3D How To: Axillary Nerve Block

Read more about 3D How To: Axillary Nerve Block

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3D animation demonstrating an ultrasound guided axillary nerve block.

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

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

How to: Axillary 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

- Axillary nerve blocks are used for surgery,
usually below the elbow.
If properly executed, axillary nerve block
can be performed by identifying individual nerves
or just in depositing local anesthetic
below the artery and above the axillary artery.
Axillary nerve blocks under ultrasound
can improve safety because you can view
many of the small arteries and veins in the axilla,
and avoid intravascular injection.
To properly position for the axillary nerve block,
we have moved our patient to the opposite side of the bed,
and we will now abduct the arm 90 degrees.
For the axillary nerve block,
we usually use a linear probe.
Usually axillary nerve blocks are very shallow,
so I've put my initial depth setting
to about two and a half to three centimeters.
Usually, I also set the frequency settings
to general or resolution for the axillary nerve block.
To do a properly executed axillary nerve block,
identification of the artery and vein is important.
If you find the artery,
injection below and above the axillary artery
usually results in a good nerve block.
We initially place the probe in the axilla,
and identify a pulsating artery in the axilla.
This is your axillary artery.
Now, as you can see, the pulsating artery,
there is no vein in my initial picture.
This is because the vein is collapsed
with light pressure of the probe.
It is very important to identify the axillary vein,
so you do not inject into the axillary vein.
As I let up some pressure,
you can now see the axillary vein
superficial to my pulsating artery.
Other structures visualized in this shot
include the biceps and coracobrachialis
on the right side of the screen,
and either the latissimus dorsi,
or the triceps, on the left side of the screen,
depending on what level I am at.
Our needle approach to the axillary block
is always cranial to caudal in this direction.
The reason we come cranial to caudal
is for two reasons:
the axillary vein, as you see on the picture,
usually lies caudal,
and we do not wanna puncture the axillary vein
with a needle approach from the caudal side.
Also, it's much cleaner to go through the deltoid
or the biceps, rather than the axilla.
My initial needle insertion point
will direct the needle below the artery.
If you inject below the artery,
local anesthetic can spread backwards
along the latissimus dorsi, or triceps muscle,
to get to the radial and ulnar nerves.
Here, we can see the needle,
advancing through the biceps muscle.
Our first injection is gonna be below the artery,
and you can see the needle advancing to that area.
You can see the axillary artery, and the axillary vein.
The radial nerve is located deep to the axillary artery.
The ulnar nerve is located between the artery and vein,
and the median nerve is located at nine o'clock
on the axillary artery.
Now we see the needle being advanced above the artery.
You can see the local anesthetic has already been injected
deep to the artery,
and now the median nerve is sitting on top of the artery,
at twelve o'clock.
The needle is now pushing the artery down
and injecting local anesthetic all around the artery
and the median nerve.
We then advance the needle towards the ulnar nerve,
which is now directly in front of the needle.
Our goal is to get local anesthetic
around the ulnar nerve here.
Total volume injected appears to be large,
but it is only 20 milliliters so far.
Now the ulnar nerve is visible,
floating in the local anesthetic,
in the median on top of the artery.
Next, I would like to identify the musculocutaneous nerve.
The musculocutaneous nerve is the fourth nerve
of a properly executed axillary block.
I find the musculocutaneous nerve by moving slightly distal
along the arm.
I also wanna increase the depth,
and look for a hyperechoic nerve
within the biceps or coracobrachialis muscle.
Traditionally, the musculocutaneous nerve
can be oval or triangular.
The musculocutaneous nerve is one of the brightest,
or most hyperechoic nerves in the body,
and it's easily blocked with local anesthetic
in the realm of three to five milliliters.
Here we see a hyperechoic musculocutaneous nerve
surrounded by a hyperechoic fascia.
Our needle is being advanced to the lateral portion.
The local anesthetic is now being injected
below the musculocutaneous nerve,
and now above the musculocutaneous nerve,
to give complete surrounding of that nerve.
The needle is being advanced to the biceps muscle.
You can see the pulsatile axillary artery medial as well.

Brightcove ID

5765651694001

https://youtube.com/watch?v=rG7PXuXrqbU

Body

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

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Axillary Brachial Plexus Block

M-Turbo: Axillary Nerve Post Injection

M-Turbo: Axillary Nerve Post Injection

Case: Axillary Vein Cannulation

Case: Axillary Vein Cannulation

3D How To: Axillary Nerve Block

3D How To: Axillary Nerve Block

How to: Axillary Nerve Block

How to: Axillary Nerve Block

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