Cannulation

12 months, Zero Iatrogenic Pneumothoraces

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In this video we highlight Memorial Hermann Southeast Hospital for achieving 12 consecutive months of iatrogenic pneumothorax prevention by using Sonosite Point-of-Care ultrasound to guide central line placement.

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M-Turbo: Catheter in IJV Short Axis.

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M-Turbo: Catheter in IJV Short Axis.

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M-Turbo: Catheter in IJV Long Axis

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M-Turbo: Catheter in IJV Long Axis.

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How to: Internal Jugular Vein Needle Insertion

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An overview of ultrasound landmarks and scanning techniques for internal jugular vein access including a demonstration on an ultrasound phantom.

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Subtitles

- Ultrasound guided central lines are rapidly
becoming standard to care.
Ultrasound allows us to do this procedure much safer
than a standard blind landmark approach.
In this segment I'm gonna take you through how we can map
the jugular vein for the procedure of an intrajugular line
using the central approach.
So let me show you how to position our ultrasound.
We have our model here, lying down.
I normally would be at the head of the bed
and if you look at his neck,
you can actually see the two heads
of his general cleidomastoid.
We see a sternal head and the clavicular head
that usually form a triangle.
Normally in a blind landmark approach,
our needle would be going to the apex of the triangle.
We're now gonna use ultrasound to localize the vein.
We're gonna now find the vein
and make the needle insertion so much safer.
We're gonna go ahead and choose our system
which is gonna be placed just to the right of the patient.
We're gonna use a linear transducer.
We're gonna go ahead and set up our examination type.
I'm gonna hit exam, I'm gonna click on venous,
select, and we're gonna be ready to start scanning.
We're going to also use a little trick to put
the transducer marker actually to the patient's left.
The reason I do this is to maintain the orientation
from the head of the bed so the vein and the artery
are in the normal anatomic positions,
so it's not to create more confusion when you're using
ultrasound for guidance of a procedure.
I'm gonna go ahead and put a little bit of gel
on this transducer.
And now let's take a look at his neck in the normal place
that we would normally have put our needle.
So if we're looking at the screen, in the center
of the screen is a very large anechoic structure.
And you can see that it easily collapses.
This is the jugular vein.
Just adjacent to this,
to the left of the screen and below the vein is the artery.
That is what we want to avoid and just a little bit more
to the left of that is the thyroid.
So the ultrasound allows us to easily find the vein.
We can track it along its entire course.
First thing we can identify, is the vein patent?
You might have a patient who has had a previous cannulation
and the vein itself may not be a good candidate.
The second thing, once we've identified the vein,
we can map the skin and actually put marks on the skin,
and we can also look at the side of the ultrasound image
to see how deep the vein is.
And in this case it's about one centimeter deep.
I'm gonna show you how to use ultrasound
to actually guide your needle into the intrajugular vein.
As you can see we have a Blue Phantom here.
We're gonna be able to take a look at the vein,
first with ultrasound,
and then I'm gonna use the ultrasound transducer
to actually guide my needle toward the vein.
I'm gonna go ahead and place a little bit of gel
onto the neck where I expect the jugular vein to lie.
And then I'm gonna use my transducer
to identify this vein.
And you can see on this image,
we can see what is supposed to be a vein here in the center.
And it's compressible; it's about a centimeter deep or so.
So I can use ultrasound guidance.
I can now place this needle into the vein.
Normally this whole setup will be under sterile procedure,
the transducer will be covered with a sterile sheet,
I'll be in full sterile prep, and the needle
and the rest of the equipment all will be sterile.
But for the purposes of this demonstration
I think you'll recognize how I'm placing the needle
and how we're cannulating the vein.
So I put the target in the center of the image,
so this would be the jugular vein in the center
and we know that the jugular vein's about
a centimeter and a half deep in this case.
I'm now gonna show you how you can actually follow
the needle tip as you slowly march toward the vein.
I have the jugular vein centered in the image,
I can see it's compressible, we're sure it's the vein.
Now I take my needle and put it right adjacent
to the transducer in the mid part
and we can see the needle tip,
and I'm gonna slowly advance,
but while I'm advancing I'm angling the transducer
away from the needle and toward the needle tip
so I always have the needle tip in the field of view.
And when I do that I can always keep track
of how far I've gone, and then I do this nice and slow.
And you can see I'm getting closer to the vein now.
And I've actually hit the vein.
And if you can get a close look here, you can actually see
a little bit of blue liquid here,
which demonstrates that I've actually hit the vein.

Brightcove ID

5743128737001

https://youtube.com/watch?v=21w4kuD0_gA

How To: Axillary Vein Cannulation

Read more about How To: 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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Axillary Vain

Axillary Vein Cannulation

Cannulation

Insertion

Vein

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

Body

Radial Vein With Compression

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Jugular Vein Thrombus

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Jugular Vein Color

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Case: Supraclavicular Approach to Subclavian Vein Cannulation

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3D animation demonstrating the Ultrasound Guided Insertion of a Subclavian Vein Catheter.

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Subtitles

- [Voiceover] This is Dr. Phil Perera
and welcome to SoundBytes.
In this module we're gonna go over how to use ultrasound
to guide us for the supraclavicular subclavian
vein cannulation.
The supraclavicular approach to the subclavian vein
is a great alternative to the traditional infraclavicular
approach that's been emphasized over the years
in medical and surgical training.
For this approach, the catheter is placed into the
subclavian vein above the clavicle either very close to,
or at the junction with the internal jugular vein
at the confluence of the brachiocephalic vein.
Advantages of this approach include a relatively short
distance to the vein and less wire kinking than with
the infraclavicular approach.
A nice article that goes over this approach was in
the Western Journal of Emergency Medicine in 2009 by
the authors listed below in the reference.
Let's take a moment to review the upper extremity
venous anatomy that we'll need to know to perform
supraclavicular subclavian cannulation.
The first landmark is the clavicle, and remember,
as the subclavian vein passes lateral to the clavicle
it becomes the axillary vein.
We can see the subclavian artery and vein running
above and below the clavicle.
We can also see the internal jugular vein
and carotid artery going up and down the neck.
We can see the confluence of the internal jugular vein
and the subclavian vein to form the brachiocephalic veins.
In effect, we're aiming at the confluence here,
the brachiocephalic vein for placement of the catheter.
And we can see that the brachiocephalic veins join
to become the superior vena cava
going into the right atrium.
And that's where we want to place the tip of the catheter.
Now let's take a look at the essential anatomy
from a lateral approach.
We again note the clavicle here forming the boundary
between the subclavian artery and vein
and the axillary artery and vein.
We see the subclavian artery and vein arching
above and below the clavicle.
And we see the internal jugular vein and carotid artery
going up and down the neck.
Notice again the confluence of the subclavian vein
and the internal jugular vein at the brachiocephalic vein.
And again, that's where we'll be aiming with our needle.
Notice the brachiocephalic vein joining in the
superior vena cava and down into the heart.
Now let's take a moment to talk about ultrasound guidance
for this approach to the subclavian vein.
Traditionally it's been thought to be difficult to image
this portion of the subclavian vein as it arches
above the clavicle.
However, the supraclavicular portion of the subclavian
vein can be well visualized by placing the ultrasound probe
in a medial position just above the clavicle and angling
it down into the chest.
To visual the subclavian vein just anterior
to the subclavian artery.
In this illustration, we see the probe placed above
the subclavian vein able to image it
in a long axis orientation.
For this application we'll want to use the high frequency
10 megahertz linear array type probe.
And notice that we have the probe angled anterior
to pick up the vein which will be located anterior
to the subclavian artery.
Thus, cannulation of the vessel will be performed
in a long axis approach using ultrasound guidance.
An alternative approach to find the subclavian vein
and the brachiocephalic vein is to follow the internal
jugular vein inferiorly down the neck.
We then will visualize the subclavian vein as it joins
with the internal jugular vein at the confluence
of the brachiocephalic vein.
And we can use color Doppler flow imaging as shown
in the video box to the upper right to differentiate
vein from artery.
Notice the characteristic pulsations of the artery
versus the constant phasic respiratory hum of the vein.
To use ultrasound guidance for the supraclavicular approach
we'll want to place the probe in a long axis orientation
in the supraclavicular fossa.
As noted here in the picture to the upper right,
we can see the probe placed over the top of the clavicle.
There's not a lot of space in the supraclavicular fossa
and that's why it's easier to place the probe in a
long axis orientation rather than a short axis approach.
We'll be using the high frequency linear array type probe
for this application and because we want to use dynamic
or real time guidance, we're going to use a sterile sheath
over the probe.
Now let's go over how to use ultrasound to visualize
the subclavian vein.
We'll begin by running the probe down the neck
to identify the internal jugular vein lateral
to the carotid artery.
We can push down with the probe to differentiate
vein from artery as the vein should completely compress
as long as there's no thrombosis present.
We can also use Doppler flow to differentiate
the two vessels.
After we identify the internal jugular vein within the neck
we'll run the probe even further inferiorly down the neck
and angle it down into the chest.
Now, note here that we're seeing the subclavian artery
and the carotid artery and the confluence
of the two vessels.
And remember that the subclavian artery is going to be
located posterior to the subclavian vein.
Next we're gonna orient the probe even more anteriorly
watching internal jugular vein go down into the chest
and join with the subclavian vein at the confluence
of the brachiocephalic vein.
And we remember that the subclavian vein will be located
more anteriorly than the subclavian artery.
Now let's take a look at some ultrasound images showing
the internal jugular vein running down the neck and joining
with the subclavian vein at the brachiocephalic confluence.
And we can see the subclavian vein arching from the lateral
aspect to the left of the image, here,
and joining with the brachiocephalic vein medially.
Again, we'll be aiming the needle for the confluence
of the subclavian vein down with the brachiocephalic vein.
Now we can that the structure is relatively superficial,
we can see the depth markers over to the right,
and we note that the subclavian vein is only at about
one centimeter depth.
In this ultrasound image we first locate the internal
jugular vein and then we orient the probe a little bit
more anteriorly to pick up that subclavian vein
and the confluence of the brachiocephalic vein.
So all we're doing is a slight tilt anteriorly
with the probe to visualize the subclavian vein
running into the brachiocephalic vein.
And again, we can see the depth markers over to the right
there, and we notice that the subclavian vein is located
at about one to two centimeters.
So again, it's a relatively superficial structure.
In this ultrasound image we see the subclavian vein
coming from lateral to the left of the screen
and joining with the brachiocephalic vein medially.
We can see a valve at the confluence
between the two structures.
Our needle would come in from the lateral aspect
and be aimed medially towards that confluence
and we can see that it would have to come down about
two centimeters to successfully cannulate the vessel.
In this illustration we'll go over the surface anatomy
for the supraclavicular subclavian vein cannulation.
The needle should be aimed towards the subclavian vein
at the confluence of the internal jugular vein
into the brachiocephalic vein.
Generally we're gonna place the needle up the back
of the clavicular head of the sternocleidomastoid.
The needle should be aimed towards the sternal notch.
And again, it's a relatively superficial stick.
This video reviews the middle triangle of the neck
as framed by the divisions of the
sternocleidomastoid muscle.
Remember that the sternal head will run medial
and the clavicular head will run lateral.
The clavicle will form the inferior boundary of the middle
triangle of the neck.
And we can see the index finger placed
within the middle triangle.
Within this triangle will run the internal jugular vein
and the carotid artery.
And that's where we want to be first locating with the probe
the internal jugular vein as it runs down the neck.
Here are the traditional surface landmarks for cannulation
of the supraclavicular subclavian vein.
We want to identify the clavicular head of the
sternocleidomastoid laterally and that's generally
where we'll be placing our needle.
The needle will be aimed towards the sternal notch medially.
And we can see that the needle will be coming over the top
of the clavicle aimed into the subclavian vein.
And this video clip will simulate the correct placement
of the needle for cannulation of the subclavian vein
above the clavicle.
Here I'm just illustrating where the subclavian vein
should be running from lateral to medial.
And note here, we'll place the needle just lateral
to the clavicular head of the sternocleidomastoid
with an orientation towards the sternal notch
of the sternum.
Next we'll add ultrasound into the mix
and here we're placing the high frequency linear array probe
into the supraclavicular fossa,
just above the subclavian vein.
So we'd be placing the needle on the lateral aspect
of the probe so that we can watch the needle
come down into the vessel.
And again, I'm just emphasizing the standard trajectory
of the needle from that lateral aspect of the clavicular
head of the sternocleidomastoid towards the sternal notch.
Here we get a different perspective for the placement
of the probe in the long axis configuration in the
supraclavicular fossa.
And we see here that that needle should be oriented off
the back of the probe or lateral to the probe.
We'll be placing the needle directly underneath the probe
so we can watch it all times as it goes down to the vessel
to correctly cannulate the subclavian vein.
And the needle should be aimed towards that sternal notch.
Here we're going to successfully cannulate the
subclavian vein using the long axis approach
under ultrasound guidance.
And we can see the needle coming in from lateral to medial
successfully cannulating the subclavian vein.
Notice that the needle has a bright or echogenic
appearance on ultrasound.
Here we'll stop the video clip and we can see the tip
of the needle centered within the subclavian vein.
We'll note the depth markers over to the right
of the ultrasound image, here, and we can see that
the subclavian vein is at about one to two centimeters.
And we need to keep this in mind as the dome of the lung
is relatively close to the subclavian and we want
to keep that tip of the needle relatively superficial.
Once we've had a successful cannulation of the vessel
we can actually guide the guide-wire
using ultrasound guidance.
This is helpful as we want to make sure that the guide-wire
passes without obstruction down into the vessel lumen.
In this video clip we can actually see the guide-wire
advance through the catheter into the subclavian vein
laterally and being pushed down the subclavian vein
into the confluence with the brachiocephalic vein medial
and to the right.
Next we can watch as the guide-wires further advance
down the brachiocephalic vein into the superior vena cava.
And here we can see the echogenic guide-wire coming
from left down the subclavian into the brachiocephalic
and into the superior vena cava.
And remember that we want to position the tip of the
guide-wire and then the resulting catheter within
the superior vena cava so that it doesn't enter into
the right atrium.
To summarize some of the important parts of this module
I want to emphasize that the supraclavicular approach
to subclavian vein is a great alternative to the
traditional infracavicular approach and one in which
ultrasound guidance can be used dynamically or real time
to guide the needle down into the vein,
hopefully to decrease the risk of complications
to our patient during the procedure.
As we discussed, the subclavian vein cannulation
is performed with the ultrasound probe held in the
long axis orientation in the supraclavicular fossa
so that the needle will enter off the back of the probe
laterally and be advanced in a long axis view down
into the vein.
Let's finish here with a discussion of some of the
potential complications of this approach,
the first of which is inadvertent pneumothorax.
Now the subclavian vein is relatively close to the lung,
the dome of the lung, and for that reason,
we'll traditionally go on the right side where the
right side of the lung is a little lower at the dome
than on the left side.
We could actually visualize the dome of the lung
on ultrasound as seen in the video box to the upper right.
We can see the pleural surfaces moving back and forth
as the patient breathes and this is called lung sliding.
So we can visualize the lung and avoid it.
We want to avoid deep punctures with the needle
and keep that needle tip visualized at all times
as we advance it down into the vein.
The second potential complication is inadvertent puncture
of the subclavian artery during the cannulation procedure.
Remember that the subclavian vein lies anterior
to the subclavian artery and we can actually identify
both structures prior to puncture attempts using ultrasound.
We can use color flow Doppler imaging to differentiate
the artery from the vein and as seen in the mini boxes
to the upper part of the video here,
we can see to the left the pulsations within
the subclavian artery and the venous hum to the right,
there, within the subclavian vein.
We want to aim that needle anteriorly at all times to avoid
the subclavian artery so as not to inadvertently puncture
it during the cannulation procedure.
So while it's important to discuss the potential
complications of this approach,
I feel that this is a great line in clinical use
and one that's actually better or safer for our patients
than the traditional blind landmark-based infraclavicular
approach to the subclavian vein.
So I hope it's something that you'll give a try in
the clinical areas using ultrasound guidance.
And I look forward to seeing you back in the future
as SoundBytes continues.

Brightcove ID

5508120186001

https://youtube.com/watch?v=I3Jqbxa1_Ts

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