Catheter

12 months, Zero Iatrogenic Pneumothoraces

Read more about 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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Cardiology

Testimonial

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Other Videos

Subtitles

- If my wife or one of my children
needed a central line, I would ask two questions.
I would need to know the experience
of the individual who's placing the line
and whether or not he or she is using ultrasound.
And if they're not using ultrasound,
I would find another doctor.
(lively music)
- [Man] When I came to Houston and Memorial Hermann,
I became aware that ultrasound
wasn't being used for central line insertion.
Either in our hospitals
or in the general medical community.
- It is just like driving blindly
on the road versus driving with your total vision, right?
It gives you total confidence
and certainty about what you're doing.
And what is happening with the patient
which is the most important thing.
- I presented the results
of the use of ultrasound at Cedar Sinai
and also results in the literature
from around the world.
Showing that the injuries
from central line insertion can be reduced
if not eliminated with ultrasound guidance.
- You cannot achieve the kind of numbers
that have been achieved nation wide
without using ultrasound.
But in our way we say
central lines should not cause pneumothoraces.
It should be a rarity rather than the acceptability.
And that's where we're doing in this hospital.
Trying to show that you can do a lot of lines
without doing pneumothorax.
And we have been able to do so so far.
- In fact, for two of our hospitals,
they've reported over a year's worth
of practice in the hospital
without the occurrence of a single iatrogenic pneumothorax.
- These are considered never events certainly
by Medicare and probably will be never events
by insurance companies.
And probably will be never events
from the legal system.
So that's really three good reasons
other than intellectually wanting
to do the right thing.
- We've actually created a new award
for hospitals that are achieving zero
iatrogenic pneumothoraces for a whole year.
We're goin' for zero.
This amazing?
And actually, I didn't even mention it
but we, our emergency departments.
We have nine of 'em, busy, we saw over 400,000
visits last year.
They placed a lot of central lines.
They use ultrasound and it is amazing
but we had no iatrogenic pnuumothorax
for the whole year.
(lively music)
We're talkin' about emergencies.
We're talkin' about level one trauma.
I mean this is pretty amazing.
(lively music)
- A few weeks back I have a patient
in the ICU, almost 350 or 380 pounds.
Blood pressure was in 60s.
Neck was barely visible.
Groin we can not access.
And we got the ultrasound.
Was able to look at thigh jay
and we put the line in.
And that was the best thing
because it was made out of night almost
and we need a line.
And we got it.
Patient did very well
and eventually she got out of ICU.

Brightcove ID

5508114147001

https://youtube.com/watch?v=5BVf6PHrRrI

Body

M-Turbo: Catheter in IJV Short Axis.

Read more about M-Turbo: Catheter in IJV Short Axis.

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M-Turbo: Catheter in IJV Short Axis.

Applications

Cardiology

Clinical Specialties

FP/GP

Media Library Type

Image

M-Turbo: Catheter in IJV Long Axis

Read more about M-Turbo: Catheter in IJV Long Axis

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M-Turbo: Catheter in IJV Long Axis.

Applications

Cardiology

Media Library Type

Image

How to: Internal Jugular Vein Needle Insertion

Read more about 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.

Applications

Cardiology

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

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: Peripheral Arm Veins for Vascular Access

Read more about How to: Peripheral Arm Veins for Vascular Access

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An overview of ultrasound landmarks and scanning techniques used for peripheral arm vein access.

Applications

Cardiology

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Media Library Tag

Subtitles

- Ultrasound can be a great adjunct
for peripheral vein access.
Normally, our nurses can get pretty good access
to the peripheral vein through standard palpations,
but sometimes the patient may have an edematous arm,
their arm may be obese,
you may not be able to feel an antecubital vein easily.
In addition, if the antecubital veins cannot be accessed,
we may want to access deeper veins of the arm,
those being the basilic and brachial veins.
Ultrasound provides great visualization
of all of those veins.
We're gonna go ahead and choose the linear array transducer.
This is going to allow high-frequency imaging
to give us really good image quality
for superficial structures.
Remember, these veins are superficial
so we're gonna to want to get as good image as possible.
I'm gonna go ahead and choose the exam type.
Once I've chosen this transducer,
I do have different exam types I can choose from.
I'm gonna use the Exam button
to choose the Venous preset,
hit Select.
I've already got some gel at the antecubital fossa.
I already have a tourniquet up.
So let me now take a look at his antecubital fossa
and see what veins we can identify.
Here we have the transducer marker here,
I'm gonna put it to the patient's right.
Again, it doesn't really matter when we do vascular access
if it's to the right or left,
as long as the target vein is in the center.
First thing I notice is
that I can probably decrease my Depth a little bit.
So I'm going to go ahead and do that.
I'm going to turn my Gain up a little bit.
And I notice here, right in the center of the screen,
is an an anechoic structure, that is easily collapsible.
And as you can see, with simple pressure with my hand,
this vessel easily collapses.
There's no pulsatile motion and it easily collapses.
It is also quite superficial.
If you look at the marks here
on the right hand of the screen,
this is a half centimeter mark,
this is a one centimeter mark.
This vein is only about four to five millimeters deep.
So it'd be very easy to access.
If I'm looking at the screen right now,
and I put the vein directly in the center,
that vein will be directly in the center
of the transducer below the skin.
If you can not find anything in the antecubital veins,
you may want to take a look at the deeper veins of the arm.
So now let's take a look at the brachial
and the basilic veins.
I'm gonna put a little gel, a little more medial
of the elbow, and a little bit more proximal.
I'm gonna scan transversely across the arm.
I see a large vein,
here in the center of the screen,
which is collapsible.
In fact, I see multiple veins.
You can put a pretty large catheter into here.
You can easily place a 14 or a 16 gauge catheter.
I will recommend you use a two inch catheter
in all of these cannulations.
If you use a standard angiocath, you will get a flashback.
But unfortunately, most likely the catheter will dislodge.
So this, this is a good vein here.
If you look around a little bit more laterally,
we can see other veins,
and we can see the artery as well.
Here in the center of the screen,
you see a pulsatile structure, which represents the artery.
If you're unsure, if it's a very small vessel,
is arterial venous, you can put the color flow on.
And we see classic color flow profile
of an arterial structure.
So we're now scanning just above the antecubital fossa,
a little bit medially.
We have a pretty good image here,
just above the antecubital fossa, a little bit medially.
And we see a few structures here I want to point out.
We can see an artery, here in the center.
Again, when I put a little compression on it,
you can see pulsatile flow.
Adjacent to that,
you can see a vessel which easily collapses.
This represents a venous structure,
which could be cannulated,
but it doesn't look like it's in a great location
because it sits right adjacent to the artery.
In addition, on the other side of it,
is a slightly hypoechoic structure.
This represents a nerve.
So if I was choosing a location for venous access,
I would not choose this vein,
given the proximity both to the artery and the nerve.

Brightcove ID

5508134285001

https://youtube.com/watch?v=Pga4SAD-J9U