Carotid Artery

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

Cardiology

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

Case Study Videos

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.
Today's module is going to look at the use of bedside
ultrasound for placement of central venous catheters,
specifically the internal jugular vein in the neck.
So the question is,
why use ultrasound for central venous access
and why not just use the traditional landmark technique?
Well, interestingly, multiple research studies now show
a decreased number of puncture attempts
are needed using ultrasound guidance
and there's also a lower complication rate
such as lowering the risk of pneumothorax and hematoma.
The US Agency for Health Care Research, the AHRQ,
recommends ultrasound guidance for central lines
right up there in the top 10 patient safety practices.
Ultrasound will allow precise determination
of the anatomy of the vascular structures in the neck
prior to a puncture attempt.
Here's the middle triangle of the neck
that serves as the standard approach for cannulation
of the internal jugular vein.
We see here the branches of the sternomastoid muscle,
the sternal head medially,
and the clavicular head laterally.
Here we're putting our finger into the triangle of the neck
and this indentation between the muscle heads
would be the standard approach for placement of the needle.
We see here that the clavicle forms the inferior
boundary of the middle triangle of the neck.
Within the middle triangle of the neck
run two very important vascular structures
and as per the textbook orientation of the carotid artery
to the internal jugular vein,
we see in the image here that the carotid artery
should run medial to the internal jugular vein
which lies lateral to the artery.
However, unfortunately, there's great variability
in human anatomy and many times the internal jugular vein
can overlap the carotid artery as shown in the drawing here.
Notice the variation in location
of the internal jugular vein to the carotid artery
and many times the internal jugular vein
is located on top of the carotid artery,
making it difficult to cannulate.
Thus, it's important to look with ultrasound
before cannulation attempts to avoid puncture
to the carotid artery.
Here's the high-frequency linear type array probe
that we'll be using to best map out
the internal jugular vein before puncture attempts.
Notice the probe marker there to the side of the probe.
Here are the orientations that we can place
the high-frequency probe in relation to the
internal jugular vein for vascular line placement.
Here to the left, we see the short axis configuration
with the probe perpendicular to the vessel
and notice that the vessel will appear on the ultrasound
screen as a circle, as the vessel will be cut end on.
To the right, we see the long axis configuration
and note the probe placed along
the long axis course of the vessel.
The vessel therefore on the screen will appear
as a tubular structure as shown here
in the image to the right.
Here's the high-frequency linear type array probe
placed over the middle triangle of the neck
over the internal jugular vein and carotid artery.
Now, I like to have the probe positioned
in a side-to-side orientation,
with the marker dot oriented towards my left
as I stand at the head of the bed.
The reason for that is then the orientation
of the probe marker will line up to the orientation
of the screen indicator dot,
which we see here is orientated towards the left
on the ultrasound screen.
Thus the left side of the probe
will orient directly to the left side of the screen,
and this will allow us to orient ourselves
as we place the needle underneath the patient's neck
and cannulate the vein.
Here's a typical appearance of the internal jugular vein
and carotid artery in a short axis configuration,
taken with a B mode or gray scale image.
Note lateral here towards the left and medial to the right.
Here we notice the internal jugular vein in a location
more lateral and superficial to the carotid artery,
which lies deeper and medial to the vein.
We can see the depth markers to the side
and we note the internal jugular vein
at about 1.5 centimeters depth.
Now we can apply Doppler sonography to further
differentiate the two structures
and here again we notice the internal jugular vein
lying lateral and superficial to the carotid artery.
We note the Doppler sonography steady pulsations
of the internal jugular vein that
vary with respiratory pattern
and we can also see the carotid artery
with the pulsations with each heart beat
differentiating the two structures.
We can also press down with the probe
to differentiate the two structures.
The internal jugular vein should compress completely,
while the more muscular outer walls of the carotid artery
should keep it open with compression of the probe.
Here's another video clip showing the internal jugular vein
and carotid artery in a short axis configuration.
Notice here that this internal jugular vein
is much more distended than in the last patient.
Here we see that the internal jugular vein
is located more superficially at about 0.5 centimeters
and that it overlaps the carotid artery medially.
Highlighting the fact that there's great variability
in the course of the internal jugular vein
in relation to the carotid artery,
even within the same patient,
we're running the probe from a position high within the neck
in which the internal jugular vein is seen more laterally,
to a position more inferiorly in which the internal
jugular vein comes to rest more medially
on top of the carotid artery.
Here's a different patient in which the internal jugular
vein is seen smack on top of the carotid artery.
Notice here, we'll place Doppler flow to confirm
the carotid artery shown here deeper to the
more superficial internal jugular vein.
In this patient, it would be extremely difficult
to cannulate the internal jugular vein
without puncturing the carotid artery.
Best to attempt cannulation in another area of the body.
One pearl that can be used to further distend the internal
jugular vein and make it a better target for a cannulation
attempt is to have the patient Valsalva or hum.
Notice here in the image to the left,
the patient is bearing down and notice that the
internal jugular vein becomes much bigger
as the patient pushes down.
In the image to the right, note the relatively small
caliber of the internal jugular vein.
Notice that it's almost as big here as the carotid artery,
but that it becomes much more distended
as the patient bears down.
Using the Valsalva technique can make it a much better
target for placement of the large cannulation needle.
Here's the high-frequency probe placed in a
longitudinal or long axis manner on the patient's neck.
Notice here that it's running along the course of the
internal jugular vein as it runs
up and down the patient's neck.
By convention here, I like to have the probe marker
towards the patient's head.
Therefore, I know where it lines up
on the ultrasound screen.
Notice here as a screen indicator dot is towards the left
that superior on the internal jugular vein
will be located towards the left of the screen
and inferior will be located
towards the right of the screen.
Here's a long axis view of an internal jugular vein.
I have the probe marker going more distally
or superior within the neck
so to the left is distal and to the right is proximal.
Notice the internal jugular vein that appears like
a tubular structure on the ultrasound screen
and we see the blood flowing here from left to right.
Here's a video clip, again a long axis configuration
in a different patient and here we see a much more
distended internal jugular vein that's lying on top
of the carotid artery.
Notice the swirls of blood in the internal jugular vein
showing the course of the blood flow
from high within the neck to the left,
low within the neck here to the right.
In conclusion, thanks for tuning in for part one
of Ultrasound Guided Central Venous Access.
I hope I've been able to score the point
that ultrasound is very helpful in determining
the relative anatomy of the internal jugular vein
and carotid artery prior to an invasive procedure
as a textbook anatomy of the vein to artery
is often incorrect and it's best to use a combination
of short and long axis views prior to a puncture attempt
to best define the anatomy.
So I hope to see you back in the future
as SonoAccess continues and we return
in central venous access part two.

Brightcove ID

5743132351001

https://youtube.com/watch?v=_RHRy64jQ6s

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Case: Central Venous Access - Part 1

Case: Central Venous Access - Part 1

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