Cannulation

Clinical Specialties

Media Library Type

Subtitles

- [Voiceover] A linear array transducer
with a vascular exam type,
is used to perform an ultrasound guided insertion
of a femoral artery catheter via a transverse approach.
The patient is in a supine position,
with the operator at the right side.
The transducer is placed transversely,
just inferior to the inguinal crease,
with the orientation marker direction
to the patient's right at a 9 o'clock position.
The superficial femoral artery
is seen as a dark, anechoic, pulsatile, circular structure
in the mid-portion of the ultrasound image.
Deeper, and slightly to the right of the image,
the femoral vein will appear
as a dark, anechoic, elliptical shape
that is compressible with transducer pressure.
Adjust the transducer so it is centered
over the femoral artery, lateral to the vein.
Follow the needle entry by slowing sliding the transducer
in the direction of needle advancement.
The needle will appear as a small, bright dot.
When the needle tip appears,
the transducer should be advanced a short distance distally,
to follow the tip of the needle trajectory
and stay in advance of the needle entry.
The needle is slowly advanced
under direct ultrasound visualization,
until the tip is seen to puncture the femoral artery.
The transducer should be moved slightly
proximally and distally to confirm that the needle tip
lies in the mid-portion of the artery.

Brightcove ID

5508128530001

https://youtube.com/watch?v=n7knHl9pSas

3D How To: Radial Artery Catheterization

Read more about 3D How To: Radial Artery Catheterization

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3D animation demonstrating an ultrasound guided radial artery catheterization transverse approach.

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Subtitles

- [Voiceover] Linear array transducer
with a vascular exam type,
is used to perform an ultrasound guided insertion
of a radial artery catheter via a transverse approach.
The patient is in a supine position,
with the arm abducted 45 degrees and externally rotated.
The wrist is extended by placing a small roll
beneath the wrist crease.
The transducer is placed transversely
just proximal to the wrist crease,
with the orientation marker directed to the patient's right.
The radial artery is superficial,
and is seen as a dark anechoic, round, pulsatile structure
on the lateral aspect of the wrist,
seen in the midst of static, echodense material.
There are often small venous vessels,
which accompany the radial artery,
which can be compressed with gentle transducer pressure.
The radius can be seen as an anechoic, dark structure,
approximately one centimeter below the radial artery.
Adjust the transducer so it is centered over the artery.
Follow the needle entry by slowing sliding the transducer
in the direction of needle advancement.
The needle will appear as a small, bright dot.
When the needle tip appears,
the transducer should be advanced a short distance distally
to follow the tip of the needle trajectory,
and stay in advance of the needle entry.
The needle is slowly advanced,
under direct ultrasound visualization,
until the tip is seen to puncture the radial artery.
The transducer should be moved slightly
proximally and distally to confirm the needle tip
lies in the mid-portion of the artery.

Brightcove ID

5508123545001

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

3D How To: Subclavian Vein Catheter Insertion

Read more about 3D How To: Subclavian Vein Catheter Insertion

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3D animation demonstrating an ultrasound guided insertion of a Subclavian Vein Catheter.

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Clinical Specialties

Media Library Type

Subtitles

- [Voiceover] A linear array transducer
with a venous exam type, is used to perform
an ultrasound guided insertion of a subclavian
vein catheter via an transverse approach.
The patient is in a supine position
with the head neutral.
The operator should stand to the patient's right side.
The transducer is placed transversely
just inferior to the mid portion of the clavicle,
with the orientation marker directed
to the patient's head at a 12 o'clock position.
The hyperechoic clavicle can be seen
in the superior portion of the ultrasound image.
The vein is dark, and anechoic,
just inferior and deep to the clavicle.
The transducer should be slowly moved one to two inches
toward the shoulder, with the face of the transducer
staying below the clavicle to obtain the best view
of the subclavian or axillary vein.
It is important to note that the lung lies directly
posterior to the vessel.
So, posterior wall puncture of the axillary vein
should be avoided.
Adjust the transducer so it is centered over the vein.
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,
and stay in advance of the needle entry.
The needle is slowly advanced
under direct ultrasound visualization
until the tip is seen to puncture the subclavian vein.
The probe should be moved slightly proximally and distally
to confirm that the needle tip lies
in the mid portion of the vein.

Brightcove ID

5508120188001

https://youtube.com/watch?v=IBmbc1ak5fY

3D How To: IJV Catheter Insertion (Transverse)

Read more about 3D How To: IJV Catheter Insertion (Transverse)

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3D animation demonstrating an ultrasound guided insertion of an internal jugular catheter (transverse).

Applications

Clinical Specialties

Media Library Type

Subtitles

- [Voiceover] A linear array transducer
with a venous exam type
is used to perform an ultrasound-guided insertion
of an internal jugular catheter via a transverse approach.
The patient is in a supine position
with the head slightly turned
toward the contralateral side.
The operator is positioned at the head of the bed.
The transducer is placed transversely
just below the apex
of the sternocleidomastoid muscle triangle,
with the orientation marker directed to the patient's left
at a 9:00 position.
The most superficial structure
identified in the ultrasound image
is the sternocleidomastoid muscle.
Deeper to this, the internal jugular vein
will appear as a dark anechoic elliptical shape,
and is compressible with transducer pressure.
The artery will be circular and pulsatile.
The thyroid gland lies medial to these structures,
and has a light gray echo signature.
Adjust the transducer so it is centered
over the internal jugular vein.
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,
and stay in advance of the needle entry.
The needle is slowly advanced
under direct ultrasound visualization
until the tip is seen to indent,
and then puncture the internal jugular vein.
The transducer should be moved
slightly proximally and distally
to confirm that the needle tip lies
in the mid-portion of the jugular vein.

Brightcove ID

5742626540001

https://youtube.com/watch?v=eesN9rGoXFM

3D How To: IJV Catheter Insertion (Long)

Read more about 3D How To: IJV Catheter Insertion (Long)

/sites/default/files/CentralVenous_IJ_Long_edu00472_thumbnail.jpg

3D animation demonstrating an ultrasound guided insertion of an Internal Jugular Catheter (Longitudinal).

Applications

Clinical Specialties

Media Library Type

Subtitles

Brightcove ID

5508120188001

https://youtube.com/watch?v=IBmbc1ak5fY

3D How To: Femoral Vein Catheter Insertion

Read more about 3D How To: Femoral Vein Catheter Insertion

/sites/default/files/CentralVenous_FemoralVein_edu00503_thumbnail.jpg

3D animation demonstrating an ultrasound guided insertion of a Femoral Vein Catheter.

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Clinical Specialties

Media Library Type

Subtitles

- [Voiceover] A linear array transducer
with a venous exam type is used to perform
an ultrasound guided insertion of a femoral vein catheter
via a transverse approach.
The patient is in a supine position
with the operator at the right side.
The transducer is placed transversely,
just inferior to the inguinal crease
with the orientation marker directed to the patient's right
at a 9 o'clock position.
The superficial femoral artery is seen as a dark
anechoic pulsatile circular structure
in the mid portion of the ultrasound image.
Deeper and slightly to the right of the image,
the femoral vein will appear as a
dark anechoic elliptical shape
that is compressible with transducer pressure.
Adjust the transducer so it is centered
over the femoral vein medial to the artery.
Follow the needle entry by slowly sliding the transducer
in the direction of needle advancement.
The needle will appear as a small bright 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 femoral vein.
The transducer should be moved slightly proximally
and distally to confirm that the needle tip
lies in the mid portion of the femoral vein.

Brightcove ID

5508120181001

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

Case: Central Line Bundle: Improving Patient Safety

Read more about Case: Central Line Bundle: Improving Patient Safety

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

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Case Study Videos

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

Brightcove ID

5508123477001

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

Case: Central Venous Access - Part 2

Read more about Case: Central Venous Access - Part 2

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This video (part 2 of 2) details how to use bedside ultrasound imaging to map the anatomy and orientation of the internal jugular vein, as well as determine puncture point, needle depth, and needle trajectory during central venous cannulation.

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Case Study Videos

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- 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 entitled part two
of Ultrasound Guided Central Venous Access
we'll look further onto the use of bedside ultrasound
to make a more precise puncture attempt
on the internal jugular vein
during central venous cannulation.
As we discussed in part one, we first wanna map out
the anatomy of the internal jugular vein
by orienting the probe
in both short and long axis configurations
to fully investigate the orientation of the vessel.
We want to use the dynamic technique for real time guidance
of the needle into the vein lumen
and for this we'll need to place the probe
into a sterile sheath barrier to observe sterile precautions
during the puncture attempt.
Here's the needle coming in underneath the probe
in a short axis configuration.
Notice that the sheath needle is coming in
underneath the probe at a 45-degree angle.
And notice that we're using the sheath needle
to first determine the location of the internal jugular vein
by the ring down artifact.
We would use the same approach for the cannulating needle
coming in underneath the probe at a 45-degree angle.
As we discussed prior, the probe should be oriented
in a side-to-side orientation
with the marker down towards our left
as we stand at the head of the bed
so it orients directly to the screen indicator dot
which will be oriented towards the left
of the ultrasound screen.
Here we're localizing the internal jugular vein
using the short axis configuration.
We're coming in underneath the probe with a sheath needle
at that 45-degree plane, pushing in underneath,
and notice the ring down artifact coming in
directly on top of that internal jugular vein
telling us this is the correct puncture point.
This video clip shows why a short axis orientation
is an excellent starting point for cannulation
of an internal jugular vein.
Here we see the echogenic tip of the needle coming down
and permeating the anterior wall of the vessel
and we then note the echogenic tip of the needle
squarely inside the lumen of the vessel.
And we can see how using the short axis orientation
can guide us in a side-to-side orientation
on the patient's neck in terms of lateral needle orientation
with regard to the surface down to the vessel lumen.
When using the short axis orientation
it's important to remember the affect of probe slice
on visualization of the needle tip.
Here we see the probe position one proximally
along the needle shaft
and note in the schematic view towards the left
we see the needle with the tip
squarely inside the venous lumen.
However, the ultrasound probe is positioned more proximally
along the shaft of the needle
and thus on the ultrasound view to the right
all we visualize is the needle above the vessel
even though the needle tip
is squarely right within the vessel lumen.
So we get a false determination of the tip of the needle.
In order to accurately determine
the location of the needle tip
we need to move the probe more distally
as we advance the needle into the patient's neck
along the course of the vessel.
Here we see the probe position more distally
now in plane with the needle tip
in the schematic view towards the left.
And there we can see we can get an accurate determination
of the location of the needle tip
with regard to the venous lumen.
We see the ultrasound view towards the right,
and now we'll be able to see the echogenic tip of the needle
accurately positioned within the vessel lumen.
A second pitfall that must be avoided
when cannulating the internal jugular vein
under ultrasound guidance is to make sure
that the needle tip does not angle to the side of the vein
during a cannulation attempt.
Even though we know the orientation of the vessel
with regard to the skin,
if we don't orient the cannulating needle
along the course of the vessel
it can veer to the side of the vessel
as shown in trajectory's one and two here.
Now if we know the course of the vessel
we can accurately position the needle
so that it goes along the course of the vessel
following trajectory three into the venous lumen.
The solution to avoiding this pitfall
is to know the course of the vessel
as it runs up and down the neck.
We can do this in two ways, the first of which
is to mark two points on the vessel
using the short axis configuration.
The needle would then enter at that distal mark
and aim towards the proximal mark
passing along the course of the internal jugular vein.
We can effectively do the same thing
by passing the probe in the long axis configuration
and knowing how the needle should pass
from the top of the neck down towards the chest.
Here we use a simulation model to show the correct approach
for a short axis cannulation of the internal jugular vein.
Notice here we have the probe in a side-to-side
or short axis orientation and the needle coming in
at a 45-degree angle underneath the probe.
Now remember that we must move the probe distally
to stay in plane with the needle tip
as we advance it underneath the skin
and into the internal jugular vein.
And as we do that
we notice that we've successfully cannulated
the internal jugular vein as shown by the red flow of blood.
And here we see a side orientation of the needle
with regard to the probe.
Here's an actual cannulation of an internal jugular vein.
Notice that we see the deflection
of the anterior wall of the vessel
as the needle pushes down on that wall
followed by the appearance
of the echogenic tip of the needle
within the lumen of the vessel.
So let's watch that again.
Notice the deflection or pushing down of that anterior wall
and then as the needle permeates that anterior wall
we see the appearance of the echogenic tip of the needle
within the vessel.
Here's a different patient receiving a central line,
and notice in this clip we actually can visualize
the echogenic needle coming from the surface
and going all the way down through that anterior wall
of the internal jugular vein to park directly into the lumen
of the vessel.
This video sequence shows cannulation
of the internal jugular vein using the long axis trajectory.
Notice we swivel the probe into the long axis orientation
along the course of the internal jugular vein
as it runs up and down the patient's neck.
By convention again,
the probe marker should be oriented towards distally
or towards us as we stand at the head of the bed.
Notice the cannulating needle will come in
at a 45-degree angle under the distal aspect of the probe.
Remembering that the distal aspect of the probe
or the marker will orient
towards the left of the ultrasound screen,
we can then know to look towards the left of the screen
for the cannulating needle coming down to the vessel.
Here we're performing cannulation
of the internal jugular vein on a simulation model.
Notice here the probe is oriented
along the longitudinal or long axis course
of the internal jugular vein with the marker dot distal
or towards the patient's head.
Here we see the needle coming in at a 45-degree angle
underneath the distal aspect of the probe.
This will allow us to see the entire aspect of the needle
as it travels down from the surface
all the way down to the venous lumen
and cannulates the internal jugular vein.
Here we see the long axis approach
and the needle coming in from left to right
and we know here how the long axis orientation
is excellent for seeing vertical needle depth.
Note the needle coming through the anterior wall
of the vessel and now the needle tip
squarely within the vessel lumen.
Here we can see how the long axis orientation
allows us to plan the optimal depth for the needle tip
with regard to the venous lumen
to squarely secure a cannulation attempt.
Now this is in difference to the short axis orientation
which was better for lateral needle orientation
with regard to the vessel lumen.
So using a combination of short and long axis orientations
will allow you to see both lateral
and vertical needle orientations
with regard to the vessel lumen.
Here's a video clip in the long axis configuraiton
emphasizing the fact that the long axis view
is great for determining the needle depth.
And here we see a needle coming in from left to right
and notice how we can visualize the needle tip
smack within the vessel lumen.
Here's another long axis clip of a patient
who's receiving a central venous catheter
and we see the catheter coming in from left to right.
Notice here the needle tip
deflects the anterior wall of the vessel
pushing it down so that it almost meets the posterior wall.
Thus the needle could easily pass
through both walls of the vessel.
Using the long axis technique
one can best adjust the needle tip depth
and avoid puncturing the back wall of the vessel.
Here's another great use of the long axis technique.
Again, we're confirming that the needle tip
is located within the vessel lumen
and now we can watch as the guidewire
passes through the tip of the needle
and moves down inferiorly
down the patient's internal jugular vein.
This is a great way of confirming
that the guidewire is safely parked
within the lumen of the vessel
before threading the catheter.
Let's end this module with a possible pitfall
that can be avoided by first looking with ultrasound.
Here we have a patient who's had a prior central line
and we notice a thrombosed internal jugular vein
with echogenic material on top of the carotid artery.
When we push down with the probe
the internal jugular vein failed to compress.
In this patient it would be best
to look for an alternative area for puncture
of a central line.
In conclusion, thanks for tuning in for part two
of Ultrasound Guided Central Venous Access.
Using ultrasound for dynamic real time guidance
of the needle into the internal jugular vein
can potentially decrease the mechanical complications
of the cannulation procedure
making the procedure a safer one for our patients.
We can employ a combination
of both the short and long axis views
of the internal jugular vein for optimal results
for a cannulation attempt.
So I hope you'll consider ultrasound
during your next central line placement
and I hope to see you back as Soundbytes continues.

Brightcove ID

5743138573001

https://youtube.com/watch?v=zV3hw_QbgK4

Case: Central Venous Access - Part 1

Read more about Case: Central Venous Access - Part 1

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This video (part 1 of 2) details how the use of bedside ultrasound for placing central venous catheters can reduce the number of puncture attempts, increase patient safety, and increase procedural efficiency.

Applications

Clinical Specialties