Blood

- [Voiceover] A phased array transducer
with an abdomen exam type is used to evaluate
the chest cavity for the presence of fluid.
The procedure is best performed with the subject
in a sitting position, leaning slightly forward,
to allow access to the posterior chest cavity.
The patient is instructed to breathe normally.
And the transducer is placed in a long-axis orientation
over the posterior chest wall
at the eighth or ninth intercostal space,
in the posterior axillary line.
The orientation marker is directed to the patient's head.
The ribs are identified in the near field of the image
as a bright interface with a posterior shadow.
The pleural line is identified as a bright
hyperechoic line between the rib shadows.
The to and fro sliding movement of the visceral pleura
against the parietal pleura, with breathing,
generates the lung sliding sign.
The transducer is moved along the posterior axillary line
to identify the bright, hyperreflective diaphragm.
Fluid will appear as a dark anechoic area
in the dependent area of the chest cavity.
Identify the borders of the fluid collection
and the normal appearing lung.
A needle insertion site should be chosen
in the posterior chest,
in a dependent area of the fluid collection.
Adjust the transducer so it is located between two ribs.
The needle should be inserted just below
the center position of the transducer
to allow the needle to pass just superior
to the lower rib to avoid the neurovascular bundle,
which lies on the inferior surface of the rib.
Follow the needle entry by slowly sliding
the transducer in the direction of needle advancement.
The needle will appear as a small bright hyperechoic dot.
When the needle tip appears,
the transducer should be advanced a short distance distally
to follow the tip of the needle trajectory.
The needle is slowly advanced under direct
ultrasound visualization until the tip is seen
to indent and then puncture the parietal pleura.
The transducer should be moved slightly proximally
and distally to confirm that the needle tip lies
in the fluid collection in the chest cavity.

Brightcove ID

5733273235001

https://youtube.com/watch?v=x1XR4AOi8q0

3D How To: Ultrasound Guided Paracentesis

Read more about 3D How To: Ultrasound Guided Paracentesis

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3D animation demonstrating an ultrasound guided Paracentesis Procedure.

Applications

Cardiology

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How To Videos

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Subtitles

- [Voiceover] A curved array transducer
with an abdomen exam type
is used to perform an ultrasound guided paracentesis.
It is easier to perform this exam
when the bladder is not filled.
The patient is placed in a supine position.
The abdominal cavity is evaluated in two planes.
Place the transducer in a transverse position
with the orientation marker to the right.
The transducer is placed at the lateral border
of the rectus sheath at the level of the umbilicus.
To evaluate the abdominal cavity for free fluid,
sweep the transducer from an inferior to superior position.
Fluid will appear hypoechoic or anechoic
and accumulate in the lateral gutter
and between loops of bowel.
To obtain a long axis view,
rotate the transducer 90 degrees with the orientation marker
directed to the point of needle entry.
Sweep the transducer across the abdominal cavity
from left to right to evaluate the abdomen for free fluid.
A needle insertion site should be chosen
in the lateral abdominal area
in a dependent area of the fluid collection
which is clear from loops of bowel.
The needle should be inserted lateral to the rectus sheath
in a transverse fashion to avoid the epigastric artery.
Follow the needle entry by slowly sliding the transducer
in the direction of needle advancement.
The needle will appear as a small, bright hypoechoic dot.
When the needle tip appears,
the transducer should be advanced a short distance distally
to follow the tip of the needle trajectory.
The needle is slowly advanced
under direct ultrasound visualization
until the tip is seen to indent
and then puncture the parietal peritoneum.
The transducer should be moved slightly proximally
and distally to confirm location of the needle tip.

Brightcove ID

5508117950001

https://youtube.com/watch?v=LDIo6xQS7Hc

3D How To: Female Pelvis Exam

Read more about 3D How To: Female Pelvis Exam

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3D animation demonstrating a Female Pelvis ultrasound exam.

Publication Date

Thu, 05/05/2016 - 12:00

Media Library Type

How To Videos

Media Library Tag

Subtitles

- [Voiceover] A curved, or phased array transducer,
with a pelvis exam type,
is used to perform the pelvis ultrasound exam.
A full bladder is used as an acoustic window
to view the pelvic organs.
The pelvis is evaluated in two plains.
Place the transducer in a long axis position
with the orientation marker to the patient's head,
at the level of the symphysis pubis.
Angle the transducer inferiorly into the pelvis.
The bladder appears in the near-field of the image,
as a hypoechoic triangular structure.
The uterus is gray in appearance
and located either directly posterior
or superior to the bladder.
The endometrial stripe will appear as
a bright echogenic line from the fundus to the cervix.
The uterus does not always lay directly in the midline
so it may be necessary to slightly rotate the transducer
to view the entire length of the uterus.
Sweep the transducer from side to side
to see the entire uterus.
The ovaries may be seen by sweeping the transducer
to the lateral aspects of the pelvis.
They are almond-shaped and slightly hypoechoic structures.
Follicles may appear as multiple
hypoechoic, cystic structures within the ovaries.
Some follicles may be quite prominent,
depending upon the luteal stage.
To obtain a transverse view of the uterus,
rotate the transducer 90 degrees,
so the orientation marker is to the patient's right.
The bladder appears more rectangular in shape in this view.
Sweep the transducer superiorly
from the level of the cervix to the fundus
to see the entire uterus.
The ovaries will be seen on either side of the uterus
and can vary in location,
from a superior to inferior position.

Brightcove ID

5750473717001

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

3D How To: Abdominal Aorta Exam

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3D animation demonstrating an Aorta ultrasound exam.

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Subtitles

- [Voiceover] A curved or phased array transducer
with an abdomen exam type is used to perform
an aorta ultrasound exam.
The entire length of the aorta from
the level of the diaphragm
to the bifurcation of the iliac arteries
must be evaluated in two planes.
The examination begins with the transducer
placed transversely in the epigastric mid line,
with the marker directed to the patient's right.
The aorta is seen as a round, pulsatile structure,
anterior to the bright reflection of the vertebrae.
The vena cava is an oval structure
immediately to the left of the aorta on the screen,
which changes in caliber with compression
or deep inspiration.
The abdominal aorta will course gradually,
becoming more superficial as it progresses distally.
The transducer is slowly moved distally
to identify the celiac trunk,
renal arteries,
superior mesenteric artery,
and bifurcation to the iliac arteries.
Note the location of any change in size
of the aorta or iliac arteries,
and measure in long and short axis views
from outer wall to outer wall
to determine the true diameter.
The transducer is returned to the epigastric area
and rotated 90 degrees clockwise,
with the orientation marker to the patient's head.
The transducer is swept side to side
to identify the maximal diameter of the aorta.
The abdominal aorta will have proximal to distal taper.
The transducer is moved distally
to evaluate the walls of the aorta
for any change in the shape or size.
If the aorta is difficult to visualize
due to overlying bowel, gentle downward transducer pressure
may encourage peristalsis of the overlying bowel.
Alternatively, consider moving the patient
into a left lateral decubitus position
to re-position the bowel away from the field of view.

Brightcove ID

5508114778001

https://youtube.com/watch?v=NI-tU5w-gzg

3D How To: eFAST RUQ

Read more about 3D How To: eFAST RUQ

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3D animation demonstrating a Right Upper Quadrant (RUQ) view while performing the eFAST exam.

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Subtitles

- [Voiceover] A phased array transducer
with an abdomen exam type is used to perform
the right upper quadrant view of the FAST exam.
The orientation marker is directed
towards the patients head.
The transducer is placed in a long axis orientation
along the right mid-auxiliary line between
the 7th to 9th inter-costal space.
Rotation and oblique positioning of the transducer
will help eliminate rib shadows.
To evaluate the entire area of the hepatorenal recess
for free fluid sweep the transducer
from an anterior to posterior position.
If present, fluid will appear as a dark
or aniconic strip between the kidney and the liver.
If it is difficult to visualize the hepatorenal recess.
A deep inspiration will move the diaphragm
and other structures in this area
down and below the ribs for easier access.
Sliding the transducer upward will visualize
the diaphragm and plural interface.
Sliding the transducer downward will visualize
the inferior pole of the right kidney.

Brightcove ID

5508136019001

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

3D How To: eFAST Pelvis

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3D animation demonstrating the pelvis view while performing an eFAST exam.

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- [Voiceover] A phased array transducer
with an abdomen exam type
is used to perform the pelvis view of the fast exam.
Place the transducer in a transverse position
with the orientation marker to the right
at the level of the symphysis pubis.
The pelvis is evaluated in two planes.
It is easier to perform this exam
when the bladder is filled.
The bladder is used as an acoustic window
to view the cul de sac
or retrovesicular space for free fluid.
To visualize the bladder,
angle the transducer inferiorly into the pelvis.
If it is difficult to visualize the bladder,
slide to the left or right of the symphysis pubis
to bring the bladder into view.
To evaluate the pelvis for free fluid,
sweep the transducer from an inferior to superior position.
Fluid will appear hyperechoic or anechoic
and accumulate posterior to the bladder,
posterior to the uterus, and between loops of bowel.
To obtain a long access view,
rotate the transducer 90 degrees
with the orientation marker
pointed toward the patient's head.
Sweep the transducer across the pelvis from left to right
to evaluate the pelvis for free fluid.

Brightcove ID

5508134284001

https://youtube.com/watch?v=pFtpx-yZfe0

Body

3D animation demonstrating the pelvis view while performing an eFAST exam.

3D How To: eFAST LUQ

Read more about 3D How To: eFAST LUQ

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3D animation demonstrating a Left Upper Quadrant (LUQ) view while performing the eFAST exam.

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- [Voiceover] A phased array transducer
with an abdomen exam type is used to perform
the left upper quadrant view of the FAST Exam.
The orientation marker is directed
toward the patient's head.
the transducer is placed in a long-access orientation
along the left-posterior axillary line
between the fifth to seventh intercostal spaces.
The sonographer's hand will touch the gurney
with the proper transducer position.
Rotation and oblique positioning of the transducer
will help eliminate rib shadows.
To evaluate the entire area of the spleenorenal recess
for free fluid, sweep the transducer
from an anterior to posterior position.
Carefully examine the spleenorenal recess
and subphrenic space.
Fluid will appear dark or anechoic.
If it is difficult to visualize the spreenorenal recess,
a deep inspiration will move the diaphragm
and other structures in this area
down and below the ribs for easier access.
Sliding the transducer in an upward direction
will visualize the diaphragm and plural interface.

Brightcove ID

5508120178001

https://youtube.com/watch?v=foyIEuUlgD0

Case: Ultrasound Guidance for Thoracentesis

Read more about Case: Ultrasound Guidance for Thoracentesis

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This video details how bedside ultrasound imaging can be used to guide thoracentesis, detect pleural fluid levels, and analyze patient anatomy. It also discusses patient positioning during the thoracentesis and probe placement.

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Congested Heart Failure

Infection

Tumors

Increased Blood Pressure

Blocked Blood Vessels

Subtitles

- 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.
In this SoundBytes module I'd like to begin by discussing
the case of a patient who presented with worsening
shortness of breath
and had a chest X-ray which revealed this finding.
Notice here we have the presence of
an opacified left hemithorax
and notice here that the trachea is pushed away
from the left hemithorax
suggesting the presence of a very large pleural effusion
as the cause of our patient's dyspnea.
Now if in fact this was a large pleural effusion causing
our patient's shortness of breath
a therapeutic thoracentesis would be in order
to relieve her symptoms.
This leads into the topic for this SoundBytes module
which is the use of bedside ultrasound to perform the
thoracentesis procedure.
In this module I'd like to go through how sonography
can potentially make the thoracentesis procedure
a safer one for our patients
with a decrease in the inherent complications of the
procedure, such as pneumothorax or perforation
of the diaphragm.
Before a performance of a thoracentesis procedure
it's mandatory to look with sonography
to make sure that there's enough pleural fluid
amenable for a safe thoracentesis.
Notice here we have the patient positioned in
an upright position
so that the fluid will layer out above the level
of the diaphragm.
Notice here we note the diaphragm as shown by the red line
across the patient's anterior chest wall
Notice here we have the probe positioned along the lateral
aspect of the patient's chest with a marker dot towards
the patient's head.
We can angle the probe above the diaphragm
to look for a dark or anechoic collection of fluid
consistent with a pleural effusion.
This is the ultrasound image that corresponds to the
chest X-ray from the patient as we discussed in
the beginning of the module.
We have the probe positioned across the patient's left
side of the chest,
coming in with a probe marker toward the patient's head.
We can see here, superior towards the left and
inferior towards the right,
We note the spleen and the kidney,
inferior in the abdominal compartment
and we see the white line that is the diaphragm
moving up and down as the patient breathes.
We note above the diaphragm,
superior in the chest cavity,
the presence of a large, dark or anechoic
collection of fluid,
consistent with a very large pleural effusion,
and we fail to appreciate any lung within
this pleural effusion.
Just to emphasize the point that it's very important
to look with sonography, prior to performance of a
thoracentesis procedure,
we know this pleural effusion is taken from the right chest
we see the liver towards the inferior aspect of the patient
towards the right here,
and we note above the diaphragm here,
which is moving up and down as the patient breathes,
the presence of a dark or anechoic fluid collection,
but we also see here lung within the pleural effusion
and an attachment of the lung,
a fibrinous attachment,
that attaches the lung down to the diaphragm.
So this could be potentially a complicated performance
of a thoracentesis as the needle that goes into that
chest cavity could be pushed by that fibrinous attachment
up into the lung causing a pneumothorax.
This is the first traditional position of the patient
for the thoracentesis procedure.
This is the recumbent position in which we have the patient
lying down with the head of the bed elevated.
This will encourage the fluid to layer out above
the diaphragm,
and make it more amenable to a puncture attempt.
Here we see a pleural effusion within the left hemithorax,
note the effusion as denoted by the yellow liquid
around the red lung.
Here the black star indicates the appropriate position
for the needle for the puncture point for the thoracentesis.
When performing a thoracentesis procedure the needle should
be positioned above the level of the rib,
so as to avoid the neurovascular bundle,
which as shown in this illustration lies just below
to the rib.
Here I'm demonstrating the appropriate position of the probe
to investigate for the lateral approach to the thoracentesis
this time on the right chest.
Notice the positioning of the probe,
in this case the 3 MHz probe,
on the lateral chest wall,
right above the level of the diaphragm,
to look for a pleural effusion.
Here I'll indicate the orientation of the ribs
across the lateral chest wall,
and here's about the orientation of the diaphragm.
Now remember that that diaphragm will move up and down
as the patient breathes, so we want to place the probe
above the level of the diaphragm,
to look into the thoracic cavity
for a suitable collection of fluid.
Therefore here we note the position of the needle
for the appropriate positioning of the needle
for the lateral puncture approach
to the thoracentesis procedure.
And we note again that the level of the diaphragm,
on the lateral chest wall is shown by the red line,
and we note the needle above the diaphragm,
so that it can safely enter into the thoracic cavity
and not cause a complication such as puncture the diaphragm
during the thoracentesis procedure.
Here we note the second traditional positioning of
the patient for the thoracentesis procedure,
which is the standard upright position,
in which the needle would come in from a posterior approach.
And we note the patient bending forward over a stand
or a table.
Here we see a pleural effusion within the right chest
and we note here the patient has a puncture point
that would come in, into the pleural effusion,
below the scapula but above the layer of the diaphragm.
In this video clip I'll outline some of the surface anatomy
important for the posterior approach to the
thoracentesis procedure.
Here's about the level of the scapula on the
posterior chest wall,
and this is about the level of the diaphragm,
so the appropriate positioning for the needle for
the thoracentesis procedure
would be about the level of my finger here.
And we'll just freeze that down,
there's the scapula,
and here's about the level of the diaphragm.
Notice my finger safely above the diaphragm,
so as not to puncture through the diaphragm
into the abdominal cavity.
As shown by the black star this would be the appropriate
positioning of the needle for the thoracentesis procedure.
Prior to the thoracentesis procedure
we'll investigate the pleural effusion using a 3 MHz probe.
Notice the 3 MHz probe is placed along the
posterior chest wall,
at first with the probe marker on the long axis trajectory
with the orientation of the marker towards
the patient's head.
We can then swivel the probe into the lateral orientation,
with the probe marker lateral to further investigate
above the diaphragm,
for a suitable collection of pleural effusion amenable
to a thoracentesis procedure.
A clinical pearl that can be very helpful in further
delineating the pleural effusion with regard to the
patient's anatomy is to look further with a
10 MHz high frequency linear array type probe
prior to the thoracentesis puncture.
Notice here we're placing the high frequency probe along the
posterior chest wall in the long axis configuration with the
probe marker swiveled toward the patient's head.
We can also orient the probe in between the patient's ribs
in the lateral orientation as well,
to further investigate the anatomy.
This illustration shows what the anatomy of a pleural
effusion will look like using a high frequency 10 MHz probe.
In this illustration the probe is configured in the
long axis orientation.
So we have superior to the left and inferior to the right.
We see anteriorly the chest wall and we see the
superior rib to the left and the inferior rib to the right.
We know that the parietal pleura,
that white line just deep to the ribs,
and below the parietal pleura we can see the darker
anechoic pleural effusion.
In this illustration we're actually showing here
the visceral pleura, that coats the outside of the lung,
and we can actually see the distance between the pleura
layers, the parietal pleura and the visceral pleura,
which would be the full extent of the pleural effusion.
This would be your safety zone,
or the area in which it would be safe to place a needle.
It would be not safe to place a needle any deeper
than that safety zone,
as a needle could puncture through the visceral pleura
and into the lung, causing a pneumothorax.
Here's an ultrasound image showing a very large pleural
effusion as taken with a high frequency 10 MHz probe.
Superior towards the left, inferior towards the right.
We can see the hyperechoic, or bright bone tables of the rib
both superior and inferior,
which will show us the areas of the rib to avoid
during the thoracentesis procedure.
We'd actually want to come in over the top of the inferior
rib to avoid the neurovascular bundle.
We can see here the white line making up the parietal pleura
and deep to the parietal pleura we note a large amount of
pleural effusion.
We note here the absence of a lung in the pleural effusion
so we can place the needle pretty deeply here
without causing a pneumothorax.
This ultrasound image is again taken with a high frequency
10 MHz probe,
but in this orientation the probe is configured between
the ribs in the lateral orientation.
So, all we see is the chest wall, anteriorly,
we see the parietal pleura, that white line deep to the
chest wall,
and just deep to the parietal pleura we can see the
pleural effusion as made up by the darker anechoic
collection of fluid.
Now, note here that we also see the lungs sliding
back and forth as the patient breathes,
and we can see the full extent of the pleural effusion,
or the safety zone for performance of
the thoracentesis procedure.
In this ultrasound image,
again taken with a 10 MHz high frequency probe,
we can see the diaphragm moving back and forth as
the patient breathes,
defining the lower aspect of the thoracic cavity.
Thus, it would probably be unsafe to perform a
thoracentesis at this level of the chest wall,
because we might go through the diaphragm and into
the spleen with a needle.
So, it's important to look first to ascertain
the level of the diaphragm,
and make sure that the thoracentesis needle is going
safely above the diaphragm so as not to puncture
into the abdominal compartment.
In this video clip we'll first place the
high frequency 10 MHz probe along the posterior
aspect of the chest wall to define the proper
orientation for the puncture for the posterior approach
to thoracentesis procedure.
The needle can then come in directly underneath the probe
as shown here.
Now, I'll show a wide angle shot here and note this is
the proper position for the thoracentesis needle,
as definied by sonography from the posterior approach
to thoracentesis.
In conclusion, thanks for tuning in for this SoundBytes
module going over ultrasound guidance for the
thoracentesis procedure.
Sonography can potentially make the procedure a safer one
for our patients with a decrease in the complication rate,
such as pneumothorax or perforation of the diaphragm.
We'll want to use both the 3 MHz and higher frequency 10 MHz
probes to fully evaluate the effusion in relation to
the patient's anatomy, prior to a puncture attempt.
We can either use the static technique where we position
the patient appropriately and then mark off the
puncture spot with sonography,
prior to the thoracentesis procedure.
Or, we can use a dynamic technique,
where we place the probe in a sterile sheet
and watch the needle in real-time go into the chest cavity.
So, I hope to see you back in the future
as SoundBytes continues.

Brightcove ID

5733895862001

https://youtube.com/watch?v=6ThpUpgjSiM

Case: Ultrasound Guidance for Paracentesis

Read more about Case: Ultrasound Guidance for Paracentesis

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Using bedside ultrasound imaging when performing paracentesis, identifying ideal candidates for this procedure, mapping the internal jugular vein and ascites to determine an ideal puncture point, needle depth, and needle trajectory.

Media Library Type

Case Study Videos

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Subtitles

- Hello, my name is Phil Perera,
and I am the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City,
and welcome to Soundbytes.
In today's module we're going to focus in specifically
on the use of bedside ultrasound
for the paracentesis procedure.
Now, the use of bedside ultrasound for paracentesis
can actually lower your complication rate
and allow you to know who is a better candidate
for the actual procedure.
So, step number one, when you're deciding
if a paracentesis procedure is necessary,
is to determine if the patient actually has ascites
and if there's significant areas of fluid pockets
that are amendable to a drainage procedure.
The second step is to best mark the location
for the needle placement, using bedside ultrasound.
And the two techniques that have been used in the past
are the midline linea alba,
or the lateral gutter techniques.
And using bedside ultrasound can allow you to decide,
between the two, where is the best location
for the needle placement.
This illustration shows the preferred positions
for the paracentesis procedure.
The key concept here is, to avoid the epigastric vessels
during the puncture attempt,
note the location of the epigastric vessels,
just lateral to midline on the abdominal wall.
So we wanna use that 3 MHz probe,
and we can place the probe,
as shown in positions one and two,
in the traditional lateral gutter approaches
for the paracentesis procedure.
This would be above the anterior superior iliac crests.
And we can look for fluid within the lateral gutters
and plan for a puncture attempt
in either of these positions.
We can also place the probe in probe position three
as shown in the midline linea alba position.
We'd wanna place the probe below the umbilicus
in the midline, in a relatively avascular
midline linea alba position.
Now, we can also use the 10 MHz higher frequency probe
to get a better look at the abdominal wall
in relation to the bowel and the ascites fluid
prior to our puncture attempt.
In fact, this will give us a more detailed look
into the abdominal cavity, to better plan our approach
for the paracentesis procedure.
Here's the location of the probe to the lateral position
for the paracentesis procedure.
Note the placement of the high-frequency linear array probe
above the anterior superior iliac crests
along the lateral gutters of the patient.
Notice here, the location of the epigastric vessels
in relation to the lateral gutters,
and we want to avoid those epigastrics
during any puncture attempt.
Notice also the location of the bladder,
and we want to make sure that we decompress the bladder
prior to any puncture attempt for a paracentesis.
But we can see here that the probe
is safely lateral to most of these structures,
thus the paracentesis can be safely performed
from this position on the abdominal wall.
This video clip shows a small amount of ascites
as taken with a 3 MHz probe, and we can see here
a small amount of ascites is denoted
by that dark or anechoic fluid collection,
and we can see the intestine with anchoring mesentery
swaying back and forth within the ascites
as the patient breathes.
And this is known as gut sliding,
and it makes the intestine look almost like palm trees
swaying back and forth within the breeze.
So, from this location, it might be unsafe
to perform a paracentesis, as it could be difficult
to get a needle in between the areas of intestine
without puncturing through an area
of intestine or mesentery.
This video shows a moderate amount of ascites,
again taken with a 3 MHz probe.
And we note the intestine with anchoring mesentery
sliding back and forth as the patient breathes,
and we see a large collection of ascites,
that dark or anechoic fluid collection,
anterior to the intestine.
So this might be a good location to perform a paracentesis
as we could place the needle safely into that ascites
without going through into the intestine
or anchoring mesentery.
This video clip emphasizes the point
that using a higher-frequency 10 MHz probe
on the abdominal wall
gives a more detailed exam of the evaluation
of the ascites in relation to the intestine.
And we see the abdominal wall anteriorly,
and we can see the bowel floating within the ascites.
Here we can actually mark down and measure
the safety zone from in which a needle could safely go
through the abdominal wall, into the ascites,
without hitting bowel.
Note here, the safety zone is approximately two centimeters,
as marked out with the centimeter dots
towards the right of the image.
Another benefit of using the higher-frequency probe
prior to a paracentesis procedure
is to investigate the depth of the abdominal wall,
as a thick abdominal wall can frustrate attempts
at a paracentesis procedure.
Here we see the depth of the abdominal wall,
which measures 2.5 centimeters anteriorly,
and we can see the line,
which is the peritoneal lining there,
just deep to the abdominal wall.
Note the presence here of ascites,
the dark fluid collection,
just deep to the peritoneal lining
and we can see the gut sliding,
or bowel moving back and forth, deep within the ascites.
Note the two-centimeter safety zone
for placement of the needle into the ascites fluid,
but note here we'd need to use a longer needle,
a needle longer than 2.5 centimeters,
just to get through the abdominal wall
to get fluid from the abdominal cavity.
In this video clip, we've moved the probe slightly lateral
from the last position in the same patient.
Again, we note the deep abdominal wall,
at 2.5 centimeters, denoting that a longer needle
will be needed to get the ascites fluid.
But here we see a large collection of ascites,
and note here the absence of gut sliding,
denoting a larger pocket of ascites
and a more favorable position
for the paracentesis procedure.
So this is actually the position
in which we perform the paracentesis,
using a longer lumbar puncture needle
and we're safely able to get a paracentesis done
and get the ascites fluid out for evaluation in the lab.
In this video clip, we'll reemphasize the surface anatomy
for the lateral abdominal position for paracentesis.
Note we're coming with a cap needle
underneath the 10 MHz probe, at the lateral puncture point.
This would be the preferred position
for the lateral approach for paracentesis,
as shown by the black star.
Now, some of the surface anatomy that we can palpate
includes the iliac crest, and note here
we're about four to five centimeters
above the iliac crest there.
We also want to avoid
those all-important epigastric vessels,
which we can see medial to the puncture point
from the lateral paracentesis approach.
Using ultrasound guidance, we can map out
the best position on the abdominal wall
for the paracentesis approach,
and go either right or left-side
depending on the maximal pocket of ascites present.
We also want to ascertain the relative locations
of the liver and spleen, so as to avoid
iatrogenic injury to a solid organ.
And as we emphasized earlier in the video clips,
you want to look for that intestine
with anchoring mesentery,
so as to avoid intestinal puncture during the procedure.
While the lateral gutter approach to paracentesis
is commonly emphasized during medical training,
the midline linea alba position
can be a great location for a paracentesis procedure.
Note here the probe is placed along the midline linea alba
with a marker dot towards the patient's head.
And we see it placed along the midline,
just inferior to the umbilicus.
Here we'll further investigate
the midline linea alba position
for the paracentesis procedure.
Note the high-frequency probe,
placed along the midline linea alba,
and we're coming with a cap needle
at a 45-degree angle underneath the probe
looking for the ring down artifact
onto a suitable pocket of ascites.
Here's a different view point
from the same midline linea alba position.
Again, we're placing that probe along the midline.
And this would be about the appropriate position
for the paracentesis procedure.
And here we just place the needle right there,
directly inferior to the umbilicus.
And I'll indicate that with a black star.
Note here, we'd be coming through
the relatively avascular midline linea alba.
But recall that it's very, very important
from this position to not puncture
through the bladder, and we can see
the relative location of the bladder
in relation to the puncture point.
So we must have the patient void
or place a Foley catheter, prior to attempting
a paracentesis from the midline linea alba position.
Here's a video clip from the midline linea alba,
taken with a 3 MHz probe.
I have the probe oriented towards the patient's head
so the superior aspect is towards the left
and inferior's towards the right.
Note here, we see the bowels superiorly,
moving up and down within the ascites fluid,
which we see in the middle of the image here,
and note the bladder, relatively large,
towards the inferior aspect of the image here.
Now, we can see that this would be a pocket
amendable to paracentesis, but recall again,
to increase the safety of the procedure
from the midline linea alba approach,
we'd want to drain the bladder prior to a puncture attempt.
Here's a video clip taken from the same patient
after having him completely void.
And note now, we have the decompressed bladder,
making the ascites pocket much larger
and more amenable to a paracentesis puncture
from that midline linea alba technique.
And we can see here now, the pocket of ascites
as denoted by the dark or anechoic fluid collection,
between the bowel superior
and the decompressed bladder inferiorly.
In this video clip, we can see
how using the higher-frequency 10 MHz probe
can allow real-time guidance of the needle
down into the ascites pocket,
and we see the detection of the needle
coming in from left to right through the abdominal wall,
with the tip of the needle safely parked
within the ascites fluid.
Notice here that the bowel is distant
to the tip of the needle,
thereby we can minimize any puncture
through the bowel during the paracentesis procedure.
We need to put a sterile sheet over the probe
during this procedure.
So, in conclusion, thanks for tuning in
for ultrasound guidance of paracentesis.
Ultrasound guidance for this procedure
can potentially make the paracentesis procedure
a safer one for our patients, and using a combination
of both the three and 10 MHz probes
can fully evaluate the ascites prior to a procedure.
We can use either one of two techniques.
Either the static technique, we position the patient
and then mark off the puncture spot with ultrasound
prior to a procedure,
or we can actually use a dynamic technique
where we place the probe in a sterile sheet
and watch the needle in real-time
go through the abdominal wall into the ascites fluid.
Either of these techniques
can potentially decrease your complication rate,
so I hope in the future you'll consider
ultrasound guidance for paracentesis
during your next paracentesis procedure.

Brightcove ID

5508114740001

https://youtube.com/watch?v=bWxv_a9CkBs

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Case: Ultrasound Guidance for Thoracentesis

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Case: Ultrasound Guidance for Paracentesis

Case: Ultrasound Guidance for Paracentesis

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