<p begin="00:00:13.365" end="00:00:14.804" style="s2">- [Voiceover] This is Dr. Phil Perera</p>
<p begin="00:00:14.804" end="00:00:17.627" style="s2">and welcome to SoundBytes.</p>
<p begin="00:00:17.627" end="00:00:20.300" style="s2">In this module we're gonna<br />go over how to use ultrasound</p>
<p begin="00:00:20.300" end="00:00:22.912" style="s2">to guide us for the<br />supraclavicular subclavian</p>
<p begin="00:00:22.912" end="00:00:24.329" style="s2">vein cannulation.</p>
<p begin="00:00:25.967" end="00:00:28.460" style="s2">The supraclavicular approach<br />to the subclavian vein</p>
<p begin="00:00:28.460" end="00:00:31.681" style="s2">is a great alternative to the<br />traditional infraclavicular</p>
<p begin="00:00:31.681" end="00:00:34.094" style="s2">approach that's been<br />emphasized over the years</p>
<p begin="00:00:34.094" end="00:00:37.608" style="s2">in medical and surgical training.</p>
<p begin="00:00:37.608" end="00:00:39.978" style="s2">For this approach, the<br />catheter is placed into the</p>
<p begin="00:00:39.978" end="00:00:43.591" style="s2">subclavian vein above the<br />clavicle either very close to,</p>
<p begin="00:00:43.591" end="00:00:46.014" style="s2">or at the junction with<br />the internal jugular vein</p>
<p begin="00:00:46.014" end="00:00:49.320" style="s2">at the confluence of the<br />brachiocephalic vein.</p>
<p begin="00:00:49.320" end="00:00:52.095" style="s2">Advantages of this approach<br />include a relatively short</p>
<p begin="00:00:52.095" end="00:00:55.192" style="s2">distance to the vein and<br />less wire kinking than with</p>
<p begin="00:00:55.192" end="00:00:57.573" style="s2">the infraclavicular approach.</p>
<p begin="00:00:57.573" end="00:01:00.109" style="s2">A nice article that goes<br />over this approach was in</p>
<p begin="00:01:00.109" end="00:01:03.585" style="s2">the Western Journal of<br />Emergency Medicine in 2009 by</p>
<p begin="00:01:03.585" end="00:01:07.685" style="s2">the authors listed below in the reference.</p>
<p begin="00:01:07.685" end="00:01:09.930" style="s2">Let's take a moment to<br />review the upper extremity</p>
<p begin="00:01:09.930" end="00:01:12.009" style="s2">venous anatomy that we'll<br />need to know to perform</p>
<p begin="00:01:12.009" end="00:01:14.904" style="s2">supraclavicular subclavian cannulation.</p>
<p begin="00:01:14.904" end="00:01:17.558" style="s2">The first landmark is the<br />clavicle, and remember,</p>
<p begin="00:01:17.558" end="00:01:20.826" style="s2">as the subclavian vein passes<br />lateral to the clavicle</p>
<p begin="00:01:20.826" end="00:01:23.093" style="s2">it becomes the axillary vein.</p>
<p begin="00:01:23.093" end="00:01:26.071" style="s2">We can see the subclavian<br />artery and vein running</p>
<p begin="00:01:26.071" end="00:01:29.180" style="s2">above and below the clavicle.</p>
<p begin="00:01:29.180" end="00:01:31.270" style="s2">We can also see the internal jugular vein</p>
<p begin="00:01:31.270" end="00:01:34.817" style="s2">and carotid artery going<br />up and down the neck.</p>
<p begin="00:01:34.817" end="00:01:38.457" style="s2">We can see the confluence<br />of the internal jugular vein</p>
<p begin="00:01:38.457" end="00:01:42.213" style="s2">and the subclavian vein to<br />form the brachiocephalic veins.</p>
<p begin="00:01:42.213" end="00:01:45.125" style="s2">In effect, we're aiming<br />at the confluence here,</p>
<p begin="00:01:45.125" end="00:01:48.225" style="s2">the brachiocephalic vein for<br />placement of the catheter.</p>
<p begin="00:01:48.225" end="00:01:50.559" style="s2">And we can see that the<br />brachiocephalic veins join</p>
<p begin="00:01:50.559" end="00:01:52.887" style="s2">to become the superior vena cava</p>
<p begin="00:01:52.887" end="00:01:54.607" style="s2">going into the right atrium.</p>
<p begin="00:01:54.607" end="00:01:58.653" style="s2">And that's where we want to<br />place the tip of the catheter.</p>
<p begin="00:01:58.653" end="00:02:01.253" style="s2">Now let's take a look<br />at the essential anatomy</p>
<p begin="00:02:01.253" end="00:02:03.047" style="s2">from a lateral approach.</p>
<p begin="00:02:03.047" end="00:02:06.142" style="s2">We again note the clavicle<br />here forming the boundary</p>
<p begin="00:02:06.142" end="00:02:08.553" style="s2">between the subclavian artery and vein</p>
<p begin="00:02:08.553" end="00:02:10.964" style="s2">and the axillary artery and vein.</p>
<p begin="00:02:10.964" end="00:02:13.700" style="s2">We see the subclavian<br />artery and vein arching</p>
<p begin="00:02:13.700" end="00:02:16.025" style="s2">above and below the clavicle.</p>
<p begin="00:02:16.025" end="00:02:18.676" style="s2">And we see the internal<br />jugular vein and carotid artery</p>
<p begin="00:02:18.676" end="00:02:20.634" style="s2">going up and down the neck.</p>
<p begin="00:02:20.634" end="00:02:23.529" style="s2">Notice again the confluence<br />of the subclavian vein</p>
<p begin="00:02:23.529" end="00:02:27.407" style="s2">and the internal jugular vein<br />at the brachiocephalic vein.</p>
<p begin="00:02:27.407" end="00:02:30.427" style="s2">And again, that's where we'll<br />be aiming with our needle.</p>
<p begin="00:02:30.427" end="00:02:32.431" style="s2">Notice the brachiocephalic<br />vein joining in the</p>
<p begin="00:02:32.431" end="00:02:36.838" style="s2">superior vena cava and<br />down into the heart.</p>
<p begin="00:02:36.838" end="00:02:39.646" style="s2">Now let's take a moment to<br />talk about ultrasound guidance</p>
<p begin="00:02:39.646" end="00:02:42.249" style="s2">for this approach to the subclavian vein.</p>
<p begin="00:02:42.249" end="00:02:44.579" style="s2">Traditionally it's been thought<br />to be difficult to image</p>
<p begin="00:02:44.579" end="00:02:47.145" style="s2">this portion of the<br />subclavian vein as it arches</p>
<p begin="00:02:47.145" end="00:02:48.980" style="s2">above the clavicle.</p>
<p begin="00:02:48.980" end="00:02:51.712" style="s2">However, the supraclavicular<br />portion of the subclavian</p>
<p begin="00:02:51.712" end="00:02:55.262" style="s2">vein can be well visualized by<br />placing the ultrasound probe</p>
<p begin="00:02:55.262" end="00:02:58.486" style="s2">in a medial position just<br />above the clavicle and angling</p>
<p begin="00:02:58.486" end="00:03:00.605" style="s2">it down into the chest.</p>
<p begin="00:03:00.605" end="00:03:03.780" style="s2">To visual the subclavian<br />vein just anterior</p>
<p begin="00:03:03.780" end="00:03:06.006" style="s2">to the subclavian artery.</p>
<p begin="00:03:06.006" end="00:03:08.728" style="s2">In this illustration, we<br />see the probe placed above</p>
<p begin="00:03:08.728" end="00:03:11.057" style="s2">the subclavian vein able to image it</p>
<p begin="00:03:11.057" end="00:03:13.421" style="s2">in a long axis orientation.</p>
<p begin="00:03:13.421" end="00:03:16.200" style="s2">For this application we'll<br />want to use the high frequency</p>
<p begin="00:03:16.200" end="00:03:19.014" style="s2">10 megahertz linear array type probe.</p>
<p begin="00:03:19.014" end="00:03:22.077" style="s2">And notice that we have<br />the probe angled anterior</p>
<p begin="00:03:22.077" end="00:03:25.069" style="s2">to pick up the vein which<br />will be located anterior</p>
<p begin="00:03:25.069" end="00:03:27.438" style="s2">to the subclavian artery.</p>
<p begin="00:03:27.438" end="00:03:29.971" style="s2">Thus, cannulation of the<br />vessel will be performed</p>
<p begin="00:03:29.971" end="00:03:34.138" style="s2">in a long axis approach<br />using ultrasound guidance.</p>
<p begin="00:03:35.530" end="00:03:38.264" style="s2">An alternative approach to<br />find the subclavian vein</p>
<p begin="00:03:38.264" end="00:03:40.876" style="s2">and the brachiocephalic vein<br />is to follow the internal</p>
<p begin="00:03:40.876" end="00:03:43.214" style="s2">jugular vein inferiorly down the neck.</p>
<p begin="00:03:43.214" end="00:03:46.024" style="s2">We then will visualize the<br />subclavian vein as it joins</p>
<p begin="00:03:46.024" end="00:03:49.329" style="s2">with the internal jugular<br />vein at the confluence</p>
<p begin="00:03:49.329" end="00:03:50.997" style="s2">of the brachiocephalic vein.</p>
<p begin="00:03:50.997" end="00:03:53.620" style="s2">And we can use color Doppler<br />flow imaging as shown</p>
<p begin="00:03:53.620" end="00:03:57.070" style="s2">in the video box to the<br />upper right to differentiate</p>
<p begin="00:03:57.070" end="00:03:58.465" style="s2">vein from artery.</p>
<p begin="00:03:58.465" end="00:04:01.525" style="s2">Notice the characteristic<br />pulsations of the artery</p>
<p begin="00:04:01.525" end="00:04:06.192" style="s2">versus the constant phasic<br />respiratory hum of the vein.</p>
<p begin="00:04:06.192" end="00:04:09.410" style="s2">To use ultrasound guidance for<br />the supraclavicular approach</p>
<p begin="00:04:09.410" end="00:04:12.440" style="s2">we'll want to place the probe<br />in a long axis orientation</p>
<p begin="00:04:12.440" end="00:04:14.888" style="s2">in the supraclavicular fossa.</p>
<p begin="00:04:14.888" end="00:04:16.980" style="s2">As noted here in the<br />picture to the upper right,</p>
<p begin="00:04:16.980" end="00:04:21.041" style="s2">we can see the probe placed<br />over the top of the clavicle.</p>
<p begin="00:04:21.041" end="00:04:23.613" style="s2">There's not a lot of space<br />in the supraclavicular fossa</p>
<p begin="00:04:23.613" end="00:04:25.618" style="s2">and that's why it's easier<br />to place the probe in a</p>
<p begin="00:04:25.618" end="00:04:29.166" style="s2">long axis orientation rather<br />than a short axis approach.</p>
<p begin="00:04:29.166" end="00:04:31.895" style="s2">We'll be using the high<br />frequency linear array type probe</p>
<p begin="00:04:31.895" end="00:04:34.512" style="s2">for this application and<br />because we want to use dynamic</p>
<p begin="00:04:34.512" end="00:04:37.125" style="s2">or real time guidance, we're<br />going to use a sterile sheath</p>
<p begin="00:04:37.125" end="00:04:38.375" style="s2">over the probe.</p>
<p begin="00:04:39.790" end="00:04:41.908" style="s2">Now let's go over how to<br />use ultrasound to visualize</p>
<p begin="00:04:41.908" end="00:04:43.626" style="s2">the subclavian vein.</p>
<p begin="00:04:43.626" end="00:04:45.750" style="s2">We'll begin by running<br />the probe down the neck</p>
<p begin="00:04:45.750" end="00:04:47.990" style="s2">to identify the internal<br />jugular vein lateral</p>
<p begin="00:04:47.990" end="00:04:49.822" style="s2">to the carotid artery.</p>
<p begin="00:04:49.822" end="00:04:51.619" style="s2">We can push down with the<br />probe to differentiate</p>
<p begin="00:04:51.619" end="00:04:53.943" style="s2">vein from artery as the vein<br />should completely compress</p>
<p begin="00:04:53.943" end="00:04:57.123" style="s2">as long as there's no thrombosis present.</p>
<p begin="00:04:57.123" end="00:04:59.325" style="s2">We can also use Doppler<br />flow to differentiate</p>
<p begin="00:04:59.325" end="00:05:00.658" style="s2">the two vessels.</p>
<p begin="00:05:02.588" end="00:05:05.781" style="s2">After we identify the internal<br />jugular vein within the neck</p>
<p begin="00:05:05.781" end="00:05:09.206" style="s2">we'll run the probe even<br />further inferiorly down the neck</p>
<p begin="00:05:09.206" end="00:05:11.529" style="s2">and angle it down into the chest.</p>
<p begin="00:05:11.529" end="00:05:15.166" style="s2">Now, note here that we're<br />seeing the subclavian artery</p>
<p begin="00:05:15.166" end="00:05:16.965" style="s2">and the carotid artery and the confluence</p>
<p begin="00:05:16.965" end="00:05:18.723" style="s2">of the two vessels.</p>
<p begin="00:05:18.723" end="00:05:20.971" style="s2">And remember that the<br />subclavian artery is going to be</p>
<p begin="00:05:20.971" end="00:05:24.500" style="s2">located posterior to the subclavian vein.</p>
<p begin="00:05:24.500" end="00:05:26.947" style="s2">Next we're gonna orient the<br />probe even more anteriorly</p>
<p begin="00:05:26.947" end="00:05:29.480" style="s2">watching internal jugular<br />vein go down into the chest</p>
<p begin="00:05:29.480" end="00:05:31.931" style="s2">and join with the subclavian<br />vein at the confluence</p>
<p begin="00:05:31.931" end="00:05:34.144" style="s2">of the brachiocephalic vein.</p>
<p begin="00:05:34.144" end="00:05:36.472" style="s2">And we remember that the<br />subclavian vein will be located</p>
<p begin="00:05:36.472" end="00:05:40.139" style="s2">more anteriorly than<br />the subclavian artery.</p>
<p begin="00:05:40.139" end="00:05:42.347" style="s2">Now let's take a look at some<br />ultrasound images showing</p>
<p begin="00:05:42.347" end="00:05:45.208" style="s2">the internal jugular vein<br />running down the neck and joining</p>
<p begin="00:05:45.208" end="00:05:49.014" style="s2">with the subclavian vein at<br />the brachiocephalic confluence.</p>
<p begin="00:05:49.014" end="00:05:52.572" style="s2">And we can see the subclavian<br />vein arching from the lateral</p>
<p begin="00:05:52.572" end="00:05:55.594" style="s2">aspect to the left of the image, here,</p>
<p begin="00:05:55.594" end="00:05:58.900" style="s2">and joining with the<br />brachiocephalic vein medially.</p>
<p begin="00:05:58.900" end="00:06:01.882" style="s2">Again, we'll be aiming the<br />needle for the confluence</p>
<p begin="00:06:01.882" end="00:06:05.325" style="s2">of the subclavian vein down<br />with the brachiocephalic vein.</p>
<p begin="00:06:05.325" end="00:06:08.146" style="s2">Now we can that the structure<br />is relatively superficial,</p>
<p begin="00:06:08.146" end="00:06:10.532" style="s2">we can see the depth<br />markers over to the right,</p>
<p begin="00:06:10.532" end="00:06:13.126" style="s2">and we note that the subclavian<br />vein is only at about</p>
<p begin="00:06:13.126" end="00:06:15.252" style="s2">one centimeter depth.</p>
<p begin="00:06:15.252" end="00:06:17.581" style="s2">In this ultrasound image we<br />first locate the internal</p>
<p begin="00:06:17.581" end="00:06:20.233" style="s2">jugular vein and then we<br />orient the probe a little bit</p>
<p begin="00:06:20.233" end="00:06:23.048" style="s2">more anteriorly to pick<br />up that subclavian vein</p>
<p begin="00:06:23.048" end="00:06:25.885" style="s2">and the confluence of<br />the brachiocephalic vein.</p>
<p begin="00:06:25.885" end="00:06:28.131" style="s2">So all we're doing is a<br />slight tilt anteriorly</p>
<p begin="00:06:28.131" end="00:06:31.390" style="s2">with the probe to visualize<br />the subclavian vein</p>
<p begin="00:06:31.390" end="00:06:33.951" style="s2">running into the brachiocephalic vein.</p>
<p begin="00:06:33.951" end="00:06:36.482" style="s2">And again, we can see the<br />depth markers over to the right</p>
<p begin="00:06:36.482" end="00:06:39.343" style="s2">there, and we notice that the<br />subclavian vein is located</p>
<p begin="00:06:39.343" end="00:06:41.630" style="s2">at about one to two centimeters.</p>
<p begin="00:06:41.630" end="00:06:45.018" style="s2">So again, it's a relatively<br />superficial structure.</p>
<p begin="00:06:45.018" end="00:06:47.345" style="s2">In this ultrasound image<br />we see the subclavian vein</p>
<p begin="00:06:47.345" end="00:06:49.918" style="s2">coming from lateral to<br />the left of the screen</p>
<p begin="00:06:49.918" end="00:06:52.446" style="s2">and joining with the<br />brachiocephalic vein medially.</p>
<p begin="00:06:52.446" end="00:06:54.164" style="s2">We can see a valve at the confluence</p>
<p begin="00:06:54.164" end="00:06:56.160" style="s2">between the two structures.</p>
<p begin="00:06:56.160" end="00:06:58.359" style="s2">Our needle would come in<br />from the lateral aspect</p>
<p begin="00:06:58.359" end="00:07:01.428" style="s2">and be aimed medially<br />towards that confluence</p>
<p begin="00:07:01.428" end="00:07:03.288" style="s2">and we can see that it would<br />have to come down about</p>
<p begin="00:07:03.288" end="00:07:07.169" style="s2">two centimeters to successfully<br />cannulate the vessel.</p>
<p begin="00:07:07.169" end="00:07:09.827" style="s2">In this illustration we'll<br />go over the surface anatomy</p>
<p begin="00:07:09.827" end="00:07:12.767" style="s2">for the supraclavicular<br />subclavian vein cannulation.</p>
<p begin="00:07:12.767" end="00:07:15.212" style="s2">The needle should be aimed<br />towards the subclavian vein</p>
<p begin="00:07:15.212" end="00:07:17.473" style="s2">at the confluence of the<br />internal jugular vein</p>
<p begin="00:07:17.473" end="00:07:19.476" style="s2">into the brachiocephalic vein.</p>
<p begin="00:07:19.476" end="00:07:21.680" style="s2">Generally we're gonna place<br />the needle up the back</p>
<p begin="00:07:21.680" end="00:07:25.943" style="s2">of the clavicular head of<br />the sternocleidomastoid.</p>
<p begin="00:07:25.943" end="00:07:28.799" style="s2">The needle should be aimed<br />towards the sternal notch.</p>
<p begin="00:07:28.799" end="00:07:31.772" style="s2">And again, it's a relatively<br />superficial stick.</p>
<p begin="00:07:31.772" end="00:07:34.095" style="s2">This video reviews the<br />middle triangle of the neck</p>
<p begin="00:07:34.095" end="00:07:35.685" style="s2">as framed by the divisions of the</p>
<p begin="00:07:35.685" end="00:07:37.564" style="s2">sternocleidomastoid muscle.</p>
<p begin="00:07:37.564" end="00:07:39.809" style="s2">Remember that the sternal<br />head will run medial</p>
<p begin="00:07:39.809" end="00:07:42.503" style="s2">and the clavicular head will run lateral.</p>
<p begin="00:07:42.503" end="00:07:45.370" style="s2">The clavicle will form the<br />inferior boundary of the middle</p>
<p begin="00:07:45.370" end="00:07:46.881" style="s2">triangle of the neck.</p>
<p begin="00:07:46.881" end="00:07:48.649" style="s2">And we can see the index finger placed</p>
<p begin="00:07:48.649" end="00:07:50.808" style="s2">within the middle triangle.</p>
<p begin="00:07:50.808" end="00:07:53.633" style="s2">Within this triangle will<br />run the internal jugular vein</p>
<p begin="00:07:53.633" end="00:07:55.509" style="s2">and the carotid artery.</p>
<p begin="00:07:55.509" end="00:07:58.322" style="s2">And that's where we want to be<br />first locating with the probe</p>
<p begin="00:07:58.322" end="00:08:01.710" style="s2">the internal jugular vein<br />as it runs down the neck.</p>
<p begin="00:08:01.710" end="00:08:04.120" style="s2">Here are the traditional surface<br />landmarks for cannulation</p>
<p begin="00:08:04.120" end="00:08:06.649" style="s2">of the supraclavicular subclavian vein.</p>
<p begin="00:08:06.649" end="00:08:08.611" style="s2">We want to identify the<br />clavicular head of the</p>
<p begin="00:08:08.611" end="00:08:11.510" style="s2">sternocleidomastoid laterally<br />and that's generally</p>
<p begin="00:08:11.510" end="00:08:13.436" style="s2">where we'll be placing our needle.</p>
<p begin="00:08:13.436" end="00:08:16.663" style="s2">The needle will be aimed towards<br />the sternal notch medially.</p>
<p begin="00:08:16.663" end="00:08:19.398" style="s2">And we can see that the needle<br />will be coming over the top</p>
<p begin="00:08:19.398" end="00:08:22.949" style="s2">of the clavicle aimed<br />into the subclavian vein.</p>
<p begin="00:08:22.949" end="00:08:25.487" style="s2">And this video clip will<br />simulate the correct placement</p>
<p begin="00:08:25.487" end="00:08:27.451" style="s2">of the needle for cannulation<br />of the subclavian vein</p>
<p begin="00:08:27.451" end="00:08:29.034" style="s2">above the clavicle.</p>
<p begin="00:08:29.900" end="00:08:31.859" style="s2">Here I'm just illustrating<br />where the subclavian vein</p>
<p begin="00:08:31.859" end="00:08:34.435" style="s2">should be running from lateral to medial.</p>
<p begin="00:08:34.435" end="00:08:36.870" style="s2">And note here, we'll place<br />the needle just lateral</p>
<p begin="00:08:36.870" end="00:08:39.635" style="s2">to the clavicular head of<br />the sternocleidomastoid</p>
<p begin="00:08:39.635" end="00:08:42.594" style="s2">with an orientation<br />towards the sternal notch</p>
<p begin="00:08:42.594" end="00:08:43.844" style="s2">of the sternum.</p>
<p begin="00:08:44.797" end="00:08:46.899" style="s2">Next we'll add ultrasound into the mix</p>
<p begin="00:08:46.899" end="00:08:49.518" style="s2">and here we're placing the high<br />frequency linear array probe</p>
<p begin="00:08:49.518" end="00:08:51.603" style="s2">into the supraclavicular fossa,</p>
<p begin="00:08:51.603" end="00:08:54.251" style="s2">just above the subclavian vein.</p>
<p begin="00:08:54.251" end="00:08:56.905" style="s2">So we'd be placing the<br />needle on the lateral aspect</p>
<p begin="00:08:56.905" end="00:08:59.877" style="s2">of the probe so that<br />we can watch the needle</p>
<p begin="00:08:59.877" end="00:09:02.004" style="s2">come down into the vessel.</p>
<p begin="00:09:02.004" end="00:09:05.073" style="s2">And again, I'm just emphasizing<br />the standard trajectory</p>
<p begin="00:09:05.073" end="00:09:08.297" style="s2">of the needle from that lateral<br />aspect of the clavicular</p>
<p begin="00:09:08.297" end="00:09:12.520" style="s2">head of the sternocleidomastoid<br />towards the sternal notch.</p>
<p begin="00:09:12.520" end="00:09:14.273" style="s2">Here we get a different<br />perspective for the placement</p>
<p begin="00:09:14.273" end="00:09:16.930" style="s2">of the probe in the long<br />axis configuration in the</p>
<p begin="00:09:16.930" end="00:09:18.687" style="s2">supraclavicular fossa.</p>
<p begin="00:09:18.687" end="00:09:20.677" style="s2">And we see here that that<br />needle should be oriented off</p>
<p begin="00:09:20.677" end="00:09:23.962" style="s2">the back of the probe<br />or lateral to the probe.</p>
<p begin="00:09:23.962" end="00:09:26.939" style="s2">We'll be placing the needle<br />directly underneath the probe</p>
<p begin="00:09:26.939" end="00:09:30.688" style="s2">so we can watch it all times<br />as it goes down to the vessel</p>
<p begin="00:09:30.688" end="00:09:33.478" style="s2">to correctly cannulate<br />the subclavian vein.</p>
<p begin="00:09:33.478" end="00:09:36.416" style="s2">And the needle should be aimed<br />towards that sternal notch.</p>
<p begin="00:09:36.416" end="00:09:38.152" style="s2">Here we're going to<br />successfully cannulate the</p>
<p begin="00:09:38.152" end="00:09:40.484" style="s2">subclavian vein using<br />the long axis approach</p>
<p begin="00:09:40.484" end="00:09:42.609" style="s2">under ultrasound guidance.</p>
<p begin="00:09:42.609" end="00:09:45.675" style="s2">And we can see the needle<br />coming in from lateral to medial</p>
<p begin="00:09:45.675" end="00:09:48.407" style="s2">successfully cannulating<br />the subclavian vein.</p>
<p begin="00:09:48.407" end="00:09:50.694" style="s2">Notice that the needle<br />has a bright or echogenic</p>
<p begin="00:09:50.694" end="00:09:53.080" style="s2">appearance on ultrasound.</p>
<p begin="00:09:53.080" end="00:09:55.286" style="s2">Here we'll stop the video<br />clip and we can see the tip</p>
<p begin="00:09:55.286" end="00:09:58.510" style="s2">of the needle centered<br />within the subclavian vein.</p>
<p begin="00:09:58.510" end="00:10:00.428" style="s2">We'll note the depth<br />markers over to the right</p>
<p begin="00:10:00.428" end="00:10:03.001" style="s2">of the ultrasound image,<br />here, and we can see that</p>
<p begin="00:10:03.001" end="00:10:06.594" style="s2">the subclavian vein is at<br />about one to two centimeters.</p>
<p begin="00:10:06.594" end="00:10:09.146" style="s2">And we need to keep this in<br />mind as the dome of the lung</p>
<p begin="00:10:09.146" end="00:10:11.865" style="s2">is relatively close to<br />the subclavian and we want</p>
<p begin="00:10:11.865" end="00:10:15.009" style="s2">to keep that tip of the<br />needle relatively superficial.</p>
<p begin="00:10:15.009" end="00:10:17.253" style="s2">Once we've had a successful<br />cannulation of the vessel</p>
<p begin="00:10:17.253" end="00:10:19.190" style="s2">we can actually guide the guide-wire</p>
<p begin="00:10:19.190" end="00:10:21.109" style="s2">using ultrasound guidance.</p>
<p begin="00:10:21.109" end="00:10:23.640" style="s2">This is helpful as we want to<br />make sure that the guide-wire</p>
<p begin="00:10:23.640" end="00:10:27.538" style="s2">passes without obstruction<br />down into the vessel lumen.</p>
<p begin="00:10:27.538" end="00:10:30.584" style="s2">In this video clip we can<br />actually see the guide-wire</p>
<p begin="00:10:30.584" end="00:10:33.187" style="s2">advance through the catheter<br />into the subclavian vein</p>
<p begin="00:10:33.187" end="00:10:36.499" style="s2">laterally and being pushed<br />down the subclavian vein</p>
<p begin="00:10:36.499" end="00:10:39.509" style="s2">into the confluence with the<br />brachiocephalic vein medial</p>
<p begin="00:10:39.509" end="00:10:41.710" style="s2">and to the right.</p>
<p begin="00:10:41.710" end="00:10:43.913" style="s2">Next we can watch as the<br />guide-wires further advance</p>
<p begin="00:10:43.913" end="00:10:47.699" style="s2">down the brachiocephalic vein<br />into the superior vena cava.</p>
<p begin="00:10:47.699" end="00:10:49.989" style="s2">And here we can see the<br />echogenic guide-wire coming</p>
<p begin="00:10:49.989" end="00:10:53.045" style="s2">from left down the subclavian<br />into the brachiocephalic</p>
<p begin="00:10:53.045" end="00:10:55.002" style="s2">and into the superior vena cava.</p>
<p begin="00:10:55.002" end="00:10:56.883" style="s2">And remember that we want<br />to position the tip of the</p>
<p begin="00:10:56.883" end="00:10:59.907" style="s2">guide-wire and then the<br />resulting catheter within</p>
<p begin="00:10:59.907" end="00:11:02.521" style="s2">the superior vena cava so<br />that it doesn't enter into</p>
<p begin="00:11:02.521" end="00:11:03.748" style="s2">the right atrium.</p>
<p begin="00:11:03.748" end="00:11:05.914" style="s2">To summarize some of the<br />important parts of this module</p>
<p begin="00:11:05.914" end="00:11:08.441" style="s2">I want to emphasize that<br />the supraclavicular approach</p>
<p begin="00:11:08.441" end="00:11:10.806" style="s2">to subclavian vein is a<br />great alternative to the</p>
<p begin="00:11:10.806" end="00:11:13.786" style="s2">traditional infracavicular<br />approach and one in which</p>
<p begin="00:11:13.786" end="00:11:16.575" style="s2">ultrasound guidance can be<br />used dynamically or real time</p>
<p begin="00:11:16.575" end="00:11:19.266" style="s2">to guide the needle down into the vein,</p>
<p begin="00:11:19.266" end="00:11:21.365" style="s2">hopefully to decrease<br />the risk of complications</p>
<p begin="00:11:21.365" end="00:11:23.770" style="s2">to our patient during the procedure.</p>
<p begin="00:11:23.770" end="00:11:26.263" style="s2">As we discussed, the<br />subclavian vein cannulation</p>
<p begin="00:11:26.263" end="00:11:28.434" style="s2">is performed with the<br />ultrasound probe held in the</p>
<p begin="00:11:28.434" end="00:11:31.855" style="s2">long axis orientation in<br />the supraclavicular fossa</p>
<p begin="00:11:31.855" end="00:11:34.425" style="s2">so that the needle will enter<br />off the back of the probe</p>
<p begin="00:11:34.425" end="00:11:37.406" style="s2">laterally and be advanced<br />in a long axis view down</p>
<p begin="00:11:37.406" end="00:11:39.127" style="s2">into the vein.</p>
<p begin="00:11:39.127" end="00:11:40.757" style="s2">Let's finish here with a<br />discussion of some of the</p>
<p begin="00:11:40.757" end="00:11:43.452" style="s2">potential complications of this approach,</p>
<p begin="00:11:43.452" end="00:11:46.557" style="s2">the first of which is<br />inadvertent pneumothorax.</p>
<p begin="00:11:46.557" end="00:11:49.457" style="s2">Now the subclavian vein is<br />relatively close to the lung,</p>
<p begin="00:11:49.457" end="00:11:51.017" style="s2">the dome of the lung, and for that reason,</p>
<p begin="00:11:51.017" end="00:11:53.181" style="s2">we'll traditionally go on<br />the right side where the</p>
<p begin="00:11:53.181" end="00:11:55.303" style="s2">right side of the lung is<br />a little lower at the dome</p>
<p begin="00:11:55.303" end="00:11:57.313" style="s2">than on the left side.</p>
<p begin="00:11:57.313" end="00:11:59.169" style="s2">We could actually visualize<br />the dome of the lung</p>
<p begin="00:11:59.169" end="00:12:02.001" style="s2">on ultrasound as seen in the<br />video box to the upper right.</p>
<p begin="00:12:02.001" end="00:12:04.250" style="s2">We can see the pleural<br />surfaces moving back and forth</p>
<p begin="00:12:04.250" end="00:12:07.393" style="s2">as the patient breathes and<br />this is called lung sliding.</p>
<p begin="00:12:07.393" end="00:12:10.004" style="s2">So we can visualize the lung and avoid it.</p>
<p begin="00:12:10.004" end="00:12:12.095" style="s2">We want to avoid deep<br />punctures with the needle</p>
<p begin="00:12:12.095" end="00:12:14.464" style="s2">and keep that needle tip<br />visualized at all times</p>
<p begin="00:12:14.464" end="00:12:17.283" style="s2">as we advance it down into the vein.</p>
<p begin="00:12:17.283" end="00:12:19.696" style="s2">The second potential complication<br />is inadvertent puncture</p>
<p begin="00:12:19.696" end="00:12:23.119" style="s2">of the subclavian artery during<br />the cannulation procedure.</p>
<p begin="00:12:23.119" end="00:12:25.769" style="s2">Remember that the subclavian<br />vein lies anterior</p>
<p begin="00:12:25.769" end="00:12:28.627" style="s2">to the subclavian artery<br />and we can actually identify</p>
<p begin="00:12:28.627" end="00:12:32.144" style="s2">both structures prior to puncture<br />attempts using ultrasound.</p>
<p begin="00:12:32.144" end="00:12:35.361" style="s2">We can use color flow Doppler<br />imaging to differentiate</p>
<p begin="00:12:35.361" end="00:12:37.963" style="s2">the artery from the vein and<br />as seen in the mini boxes</p>
<p begin="00:12:37.963" end="00:12:40.232" style="s2">to the upper part of the video here,</p>
<p begin="00:12:40.232" end="00:12:43.152" style="s2">we can see to the left<br />the pulsations within</p>
<p begin="00:12:43.152" end="00:12:46.366" style="s2">the subclavian artery and<br />the venous hum to the right,</p>
<p begin="00:12:46.366" end="00:12:49.588" style="s2">there, within the subclavian vein.</p>
<p begin="00:12:49.588" end="00:12:52.771" style="s2">We want to aim that needle<br />anteriorly at all times to avoid</p>
<p begin="00:12:52.771" end="00:12:55.926" style="s2">the subclavian artery so as<br />not to inadvertently puncture</p>
<p begin="00:12:55.926" end="00:12:58.619" style="s2">it during the cannulation procedure.</p>
<p begin="00:12:58.619" end="00:13:00.414" style="s2">So while it's important<br />to discuss the potential</p>
<p begin="00:13:00.414" end="00:13:02.463" style="s2">complications of this approach,</p>
<p begin="00:13:02.463" end="00:13:04.663" style="s2">I feel that this is a<br />great line in clinical use</p>
<p begin="00:13:04.663" end="00:13:07.507" style="s2">and one that's actually better<br />or safer for our patients</p>
<p begin="00:13:07.507" end="00:13:10.655" style="s2">than the traditional blind<br />landmark-based infraclavicular</p>
<p begin="00:13:10.655" end="00:13:12.628" style="s2">approach to the subclavian vein.</p>
<p begin="00:13:12.628" end="00:13:14.548" style="s2">So I hope it's something<br />that you'll give a try in</p>
<p begin="00:13:14.548" end="00:13:17.277" style="s2">the clinical areas using<br />ultrasound guidance.</p>
<p begin="00:13:17.277" end="00:13:19.771" style="s2">And I look forward to seeing<br />you back in the future</p>
<p begin="00:13:19.771" end="00:13:21.771" style="s2">as SoundBytes continues.</p>

<p begin="00:00:07.403" end="00:00:09.316" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.316" end="00:00:10.984" style="s2">with a vascular exam type,</p>
<p begin="00:00:10.984" end="00:00:13.876" style="s2">is used to perform an<br />ultrasound guided insertion</p>
<p begin="00:00:13.876" end="00:00:17.790" style="s2">of a femoral artery catheter<br />via a transverse approach.</p>
<p begin="00:00:17.790" end="00:00:19.896" style="s2">The patient is in a supine position,</p>
<p begin="00:00:19.896" end="00:00:22.611" style="s2">with the operator at the right side.</p>
<p begin="00:00:22.611" end="00:00:24.986" style="s2">The transducer is placed transversely,</p>
<p begin="00:00:24.986" end="00:00:27.338" style="s2">just inferior to the inguinal crease,</p>
<p begin="00:00:27.338" end="00:00:29.254" style="s2">with the orientation marker direction</p>
<p begin="00:00:29.254" end="00:00:32.996" style="s2">to the patient's right<br />at a 9 o'clock position.</p>
<p begin="00:00:32.996" end="00:00:35.117" style="s2">The superficial femoral artery</p>
<p begin="00:00:35.117" end="00:00:38.847" style="s2">is seen as a dark, anechoic,<br />pulsatile, circular structure</p>
<p begin="00:00:38.847" end="00:00:41.307" style="s2">in the mid-portion of<br />the ultrasound image.</p>
<p begin="00:00:41.307" end="00:00:43.629" style="s2">Deeper, and slightly to<br />the right of the image,</p>
<p begin="00:00:43.629" end="00:00:45.526" style="s2">the femoral vein will appear</p>
<p begin="00:00:45.526" end="00:00:48.165" style="s2">as a dark, anechoic, elliptical shape</p>
<p begin="00:00:48.165" end="00:00:50.972" style="s2">that is compressible<br />with transducer pressure.</p>
<p begin="00:00:50.972" end="00:00:53.170" style="s2">Adjust the transducer so it is centered</p>
<p begin="00:00:53.170" end="00:00:56.471" style="s2">over the femoral artery,<br />lateral to the vein.</p>
<p begin="00:00:56.471" end="00:00:59.547" style="s2">Follow the needle entry by<br />slowing sliding the transducer</p>
<p begin="00:00:59.547" end="00:01:01.993" style="s2">in the direction of needle advancement.</p>
<p begin="00:01:01.993" end="00:01:05.135" style="s2">The needle will appear<br />as a small, bright dot.</p>
<p begin="00:01:05.135" end="00:01:06.672" style="s2">When the needle tip appears,</p>
<p begin="00:01:06.672" end="00:01:10.067" style="s2">the transducer should be advanced<br />a short distance distally,</p>
<p begin="00:01:10.067" end="00:01:12.259" style="s2">to follow the tip of the needle trajectory</p>
<p begin="00:01:12.259" end="00:01:15.350" style="s2">and stay in advance of the needle entry.</p>
<p begin="00:01:15.350" end="00:01:16.591" style="s2">The needle is slowly advanced</p>
<p begin="00:01:16.591" end="00:01:19.257" style="s2">under direct ultrasound visualization,</p>
<p begin="00:01:19.257" end="00:01:23.008" style="s2">until the tip is seen to<br />puncture the femoral artery.</p>
<p begin="00:01:23.008" end="00:01:24.972" style="s2">The transducer should be moved slightly</p>
<p begin="00:01:24.972" end="00:01:28.121" style="s2">proximally and distally to<br />confirm that the needle tip</p>
<p begin="00:01:28.121" end="00:01:31.288" style="s2">lies in the mid-portion of the artery.</p>

<p begin="00:00:07.465" end="00:00:09.053" style="s2">- [Voiceover] A liner<br />array transducer with</p>
<p begin="00:00:09.053" end="00:00:11.160" style="s2">a venous exam type is used to preform</p>
<p begin="00:00:11.160" end="00:00:13.097" style="s2">an ultrasound guided insertion</p>
<p begin="00:00:13.097" end="00:00:15.733" style="s2">of a peripherally<br />inserted central catheter</p>
<p begin="00:00:15.733" end="00:00:18.144" style="s2">via a transverse approach.</p>
<p begin="00:00:18.144" end="00:00:19.835" style="s2">The patient is in a supine position</p>
<p begin="00:00:19.835" end="00:00:23.522" style="s2">with the arm extended 90<br />degrees at the patient's side</p>
<p begin="00:00:23.522" end="00:00:24.977" style="s2">and externally rotated.</p>
<p begin="00:00:24.977" end="00:00:27.961" style="s2">The transducer is placed<br />transversely just proximal</p>
<p begin="00:00:27.961" end="00:00:30.980" style="s2">to the medial condyle<br />in the bicipital groove</p>
<p begin="00:00:30.980" end="00:00:34.207" style="s2">with the orientation marker<br />directed to the patient's right.</p>
<p begin="00:00:34.207" end="00:00:37.505" style="s2">The basilic vein is seen as<br />a dark anechoic circular,</p>
<p begin="00:00:37.505" end="00:00:40.124" style="s2">compressible structure<br />in the mid-portion of</p>
<p begin="00:00:40.124" end="00:00:43.985" style="s2">the ultrasound image, between<br />the biceps and triceps muscle.</p>
<p begin="00:00:43.985" end="00:00:46.285" style="s2">Deeper, and slightly to<br />the right of the screen,</p>
<p begin="00:00:46.285" end="00:00:49.383" style="s2">the bright hyper-echoic<br />humerus can be seen.</p>
<p begin="00:00:49.383" end="00:00:51.365" style="s2">Adjust the transducer so it is</p>
<p begin="00:00:51.365" end="00:00:53.544" style="s2">centered over the basilic vein.</p>
<p begin="00:00:53.544" end="00:00:55.856" style="s2">Follow the needle entry by slowly sliding</p>
<p begin="00:00:55.856" end="00:00:58.889" style="s2">the transducer in the direction<br />of needle advancement.</p>
<p begin="00:00:58.889" end="00:01:01.720" style="s2">The needle will appear<br />as a small bright dot.</p>
<p begin="00:01:01.720" end="00:01:03.472" style="s2">When the needle tip appears,</p>
<p begin="00:01:03.472" end="00:01:06.443" style="s2">the transducer should be<br />advanced a short distance</p>
<p begin="00:01:06.443" end="00:01:08.519" style="s2">to follow the tip of the needle trajectory</p>
<p begin="00:01:08.519" end="00:01:11.159" style="s2">and stay in advance of the needle entry.</p>
<p begin="00:01:11.159" end="00:01:12.892" style="s2">The needle is slowly advanced under</p>
<p begin="00:01:12.892" end="00:01:15.533" style="s2">direct ultrasound<br />visualization until the tip</p>
<p begin="00:01:15.533" end="00:01:19.306" style="s2">is seen to indent and then<br />puncture the basilic vein.</p>
<p begin="00:01:19.306" end="00:01:21.919" style="s2">The transducer should be<br />moved slightly proximally</p>
<p begin="00:01:21.919" end="00:01:24.040" style="s2">and distally to confirm<br />that the needle tip</p>
<p begin="00:01:24.040" end="00:01:26.679" style="s2">lies in the mid portion<br />of the basilic vein.</p>
<p begin="00:01:26.679" end="00:01:28.592" style="s2">This technique can also be used</p>
<p begin="00:01:28.592" end="00:01:31.925" style="s2">with the deep brachial or cephalic vein.</p>

<p begin="00:00:07.010" end="00:00:09.026" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.026" end="00:00:11.485" style="s2">with a venous exam<br />type, is used to perform</p>
<p begin="00:00:11.485" end="00:00:14.424" style="s2">an ultrasound guided<br />insertion of a subclavian</p>
<p begin="00:00:14.424" end="00:00:17.250" style="s2">vein catheter via an transverse approach.</p>
<p begin="00:00:17.250" end="00:00:19.487" style="s2">The patient is in a supine position</p>
<p begin="00:00:19.487" end="00:00:21.144" style="s2">with the head neutral.</p>
<p begin="00:00:21.144" end="00:00:24.198" style="s2">The operator should stand<br />to the patient's right side.</p>
<p begin="00:00:24.198" end="00:00:26.531" style="s2">The transducer is placed transversely</p>
<p begin="00:00:26.531" end="00:00:29.380" style="s2">just inferior to the mid<br />portion of the clavicle,</p>
<p begin="00:00:29.380" end="00:00:31.338" style="s2">with the orientation marker directed</p>
<p begin="00:00:31.338" end="00:00:34.428" style="s2">to the patient's head at<br />a 12 o'clock position.</p>
<p begin="00:00:34.428" end="00:00:36.407" style="s2">The hyperechoic clavicle can be seen</p>
<p begin="00:00:36.407" end="00:00:39.304" style="s2">in the superior portion<br />of the ultrasound image.</p>
<p begin="00:00:39.304" end="00:00:41.387" style="s2">The vein is dark, and anechoic,</p>
<p begin="00:00:41.387" end="00:00:43.977" style="s2">just inferior and deep to the clavicle.</p>
<p begin="00:00:43.977" end="00:00:47.219" style="s2">The transducer should be<br />slowly moved one to two inches</p>
<p begin="00:00:47.219" end="00:00:49.877" style="s2">toward the shoulder, with<br />the face of the transducer</p>
<p begin="00:00:49.877" end="00:00:52.685" style="s2">staying below the clavicle<br />to obtain the best view</p>
<p begin="00:00:52.685" end="00:00:55.397" style="s2">of the subclavian or axillary vein.</p>
<p begin="00:00:55.397" end="00:00:58.063" style="s2">It is important to note<br />that the lung lies directly</p>
<p begin="00:00:58.063" end="00:00:59.861" style="s2">posterior to the vessel.</p>
<p begin="00:00:59.861" end="00:01:02.691" style="s2">So, posterior wall puncture<br />of the axillary vein</p>
<p begin="00:01:02.691" end="00:01:04.214" style="s2">should be avoided.</p>
<p begin="00:01:04.214" end="00:01:07.472" style="s2">Adjust the transducer so it<br />is centered over the vein.</p>
<p begin="00:01:07.472" end="00:01:10.469" style="s2">Follow the needle entry by<br />slowly sliding the transducer</p>
<p begin="00:01:10.469" end="00:01:12.943" style="s2">in the direction of needle advancement.</p>
<p begin="00:01:12.943" end="00:01:16.832" style="s2">The needle will appear as a<br />small, bright, hyperechoic dot.</p>
<p begin="00:01:16.832" end="00:01:19.415" style="s2">When the needle tip<br />appears, the transducer</p>
<p begin="00:01:19.415" end="00:01:21.964" style="s2">should be advanced a<br />short distance distally</p>
<p begin="00:01:21.964" end="00:01:24.265" style="s2">to follow the tip of<br />the needle trajectory,</p>
<p begin="00:01:24.265" end="00:01:26.819" style="s2">and stay in advance of the needle entry.</p>
<p begin="00:01:26.819" end="00:01:28.455" style="s2">The needle is slowly advanced</p>
<p begin="00:01:28.455" end="00:01:30.590" style="s2">under direct ultrasound visualization</p>
<p begin="00:01:30.590" end="00:01:34.266" style="s2">until the tip is seen to<br />puncture the subclavian vein.</p>
<p begin="00:01:34.266" end="00:01:37.399" style="s2">The probe should be moved<br />slightly proximally and distally</p>
<p begin="00:01:37.399" end="00:01:39.357" style="s2">to confirm that the needle tip lies</p>
<p begin="00:01:39.357" end="00:01:41.940" style="s2">in the mid portion of the vein.</p>

<p begin="00:00:07.397" end="00:00:09.087" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.087" end="00:00:10.710" style="s2">with a venous exam type</p>
<p begin="00:00:10.710" end="00:00:13.822" style="s2">is used to perform an<br />ultrasound-guided insertion</p>
<p begin="00:00:13.822" end="00:00:17.827" style="s2">of an internal jugular catheter<br />via a transverse approach.</p>
<p begin="00:00:17.827" end="00:00:19.996" style="s2">The patient is in a supine position</p>
<p begin="00:00:19.996" end="00:00:21.420" style="s2">with the head slightly turned</p>
<p begin="00:00:21.420" end="00:00:23.431" style="s2">toward the contralateral side.</p>
<p begin="00:00:23.431" end="00:00:26.331" style="s2">The operator is positioned<br />at the head of the bed.</p>
<p begin="00:00:26.331" end="00:00:28.712" style="s2">The transducer is placed transversely</p>
<p begin="00:00:28.712" end="00:00:29.970" style="s2">just below the apex</p>
<p begin="00:00:29.970" end="00:00:32.663" style="s2">of the sternocleidomastoid<br />muscle triangle,</p>
<p begin="00:00:32.663" end="00:00:35.671" style="s2">with the orientation marker<br />directed to the patient's left</p>
<p begin="00:00:35.671" end="00:00:37.655" style="s2">at a 9:00 position.</p>
<p begin="00:00:37.655" end="00:00:39.098" style="s2">The most superficial structure</p>
<p begin="00:00:39.098" end="00:00:41.086" style="s2">identified in the ultrasound image</p>
<p begin="00:00:41.086" end="00:00:43.548" style="s2">is the sternocleidomastoid muscle.</p>
<p begin="00:00:43.548" end="00:00:46.077" style="s2">Deeper to this, the internal jugular vein</p>
<p begin="00:00:46.077" end="00:00:49.080" style="s2">will appear as a dark<br />anechoic elliptical shape,</p>
<p begin="00:00:49.080" end="00:00:51.990" style="s2">and is compressible with<br />transducer pressure.</p>
<p begin="00:00:51.990" end="00:00:55.354" style="s2">The artery will be circular and pulsatile.</p>
<p begin="00:00:55.354" end="00:00:58.421" style="s2">The thyroid gland lies<br />medial to these structures,</p>
<p begin="00:00:58.421" end="00:01:01.367" style="s2">and has a light gray echo signature.</p>
<p begin="00:01:01.367" end="00:01:03.420" style="s2">Adjust the transducer so it is centered</p>
<p begin="00:01:03.420" end="00:01:05.804" style="s2">over the internal jugular vein.</p>
<p begin="00:01:05.804" end="00:01:08.867" style="s2">Follow the needle entry by<br />slowly sliding the transducer</p>
<p begin="00:01:08.867" end="00:01:11.272" style="s2">in the direction of needle advancement.</p>
<p begin="00:01:11.272" end="00:01:15.230" style="s2">The needle will appear as a<br />small bright hyperechoic dot.</p>
<p begin="00:01:15.230" end="00:01:16.923" style="s2">When the needle tip appears,</p>
<p begin="00:01:16.923" end="00:01:20.067" style="s2">the transducer should be advanced<br />a short distance distally</p>
<p begin="00:01:20.067" end="00:01:22.537" style="s2">to follow the tip of<br />the needle trajectory,</p>
<p begin="00:01:22.537" end="00:01:25.144" style="s2">and stay in advance of the needle entry.</p>
<p begin="00:01:25.144" end="00:01:26.523" style="s2">The needle is slowly advanced</p>
<p begin="00:01:26.523" end="00:01:28.724" style="s2">under direct ultrasound visualization</p>
<p begin="00:01:28.724" end="00:01:30.616" style="s2">until the tip is seen to indent,</p>
<p begin="00:01:30.616" end="00:01:33.391" style="s2">and then puncture the<br />internal jugular vein.</p>
<p begin="00:01:33.391" end="00:01:34.837" style="s2">The transducer should be moved</p>
<p begin="00:01:34.837" end="00:01:36.859" style="s2">slightly proximally and distally</p>
<p begin="00:01:36.859" end="00:01:38.740" style="s2">to confirm that the needle tip lies</p>
<p begin="00:01:38.740" end="00:01:41.990" style="s2">in the mid-portion of the jugular vein.</p>

<p begin="00:00:07.010" end="00:00:09.026" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.026" end="00:00:11.485" style="s2">with a venous exam<br />type, is used to perform</p>
<p begin="00:00:11.485" end="00:00:14.424" style="s2">an ultrasound guided<br />insertion of a subclavian</p>
<p begin="00:00:14.424" end="00:00:17.250" style="s2">vein catheter via an transverse approach.</p>
<p begin="00:00:17.250" end="00:00:19.487" style="s2">The patient is in a supine position</p>
<p begin="00:00:19.487" end="00:00:21.144" style="s2">with the head neutral.</p>
<p begin="00:00:21.144" end="00:00:24.198" style="s2">The operator should stand<br />to the patient's right side.</p>
<p begin="00:00:24.198" end="00:00:26.531" style="s2">The transducer is placed transversely</p>
<p begin="00:00:26.531" end="00:00:29.380" style="s2">just inferior to the mid<br />portion of the clavicle,</p>
<p begin="00:00:29.380" end="00:00:31.338" style="s2">with the orientation marker directed</p>
<p begin="00:00:31.338" end="00:00:34.428" style="s2">to the patient's head at<br />a 12 o'clock position.</p>
<p begin="00:00:34.428" end="00:00:36.407" style="s2">The hyperechoic clavicle can be seen</p>
<p begin="00:00:36.407" end="00:00:39.304" style="s2">in the superior portion<br />of the ultrasound image.</p>
<p begin="00:00:39.304" end="00:00:41.387" style="s2">The vein is dark, and anechoic,</p>
<p begin="00:00:41.387" end="00:00:43.977" style="s2">just inferior and deep to the clavicle.</p>
<p begin="00:00:43.977" end="00:00:47.219" style="s2">The transducer should be<br />slowly moved one to two inches</p>
<p begin="00:00:47.219" end="00:00:49.877" style="s2">toward the shoulder, with<br />the face of the transducer</p>
<p begin="00:00:49.877" end="00:00:52.685" style="s2">staying below the clavicle<br />to obtain the best view</p>
<p begin="00:00:52.685" end="00:00:55.397" style="s2">of the subclavian or axillary vein.</p>
<p begin="00:00:55.397" end="00:00:58.063" style="s2">It is important to note<br />that the lung lies directly</p>
<p begin="00:00:58.063" end="00:00:59.861" style="s2">posterior to the vessel.</p>
<p begin="00:00:59.861" end="00:01:02.691" style="s2">So, posterior wall puncture<br />of the axillary vein</p>
<p begin="00:01:02.691" end="00:01:04.214" style="s2">should be avoided.</p>
<p begin="00:01:04.214" end="00:01:07.472" style="s2">Adjust the transducer so it<br />is centered over the vein.</p>
<p begin="00:01:07.472" end="00:01:10.469" style="s2">Follow the needle entry by<br />slowly sliding the transducer</p>
<p begin="00:01:10.469" end="00:01:12.943" style="s2">in the direction of needle advancement.</p>
<p begin="00:01:12.943" end="00:01:16.832" style="s2">The needle will appear as a<br />small, bright, hyperechoic dot.</p>
<p begin="00:01:16.832" end="00:01:19.415" style="s2">When the needle tip<br />appears, the transducer</p>
<p begin="00:01:19.415" end="00:01:21.964" style="s2">should be advanced a<br />short distance distally</p>
<p begin="00:01:21.964" end="00:01:24.265" style="s2">to follow the tip of<br />the needle trajectory,</p>
<p begin="00:01:24.265" end="00:01:26.819" style="s2">and stay in advance of the needle entry.</p>
<p begin="00:01:26.819" end="00:01:28.455" style="s2">The needle is slowly advanced</p>
<p begin="00:01:28.455" end="00:01:30.590" style="s2">under direct ultrasound visualization</p>
<p begin="00:01:30.590" end="00:01:34.266" style="s2">until the tip is seen to<br />puncture the subclavian vein.</p>
<p begin="00:01:34.266" end="00:01:37.399" style="s2">The probe should be moved<br />slightly proximally and distally</p>
<p begin="00:01:37.399" end="00:01:39.357" style="s2">to confirm that the needle tip lies</p>
<p begin="00:01:39.357" end="00:01:41.940" style="s2">in the mid portion of the vein.</p>

<p begin="00:00:07.545" end="00:00:09.217" style="s2">- [Voiceover] A linear array transducer</p>
<p begin="00:00:09.217" end="00:00:11.689" style="s2">with a venous exam type is used to perform</p>
<p begin="00:00:11.689" end="00:00:15.584" style="s2">an ultrasound guided insertion<br />of a femoral vein catheter</p>
<p begin="00:00:15.584" end="00:00:17.953" style="s2">via a transverse approach.</p>
<p begin="00:00:17.953" end="00:00:20.153" style="s2">The patient is in a supine position</p>
<p begin="00:00:20.153" end="00:00:22.616" style="s2">with the operator at the right side.</p>
<p begin="00:00:22.616" end="00:00:24.913" style="s2">The transducer is placed transversely,</p>
<p begin="00:00:24.913" end="00:00:27.362" style="s2">just inferior to the inguinal crease</p>
<p begin="00:00:27.362" end="00:00:30.502" style="s2">with the orientation marker<br />directed to the patient's right</p>
<p begin="00:00:30.502" end="00:00:32.815" style="s2">at a 9 o'clock position.</p>
<p begin="00:00:32.815" end="00:00:35.934" style="s2">The superficial femoral<br />artery is seen as a dark</p>
<p begin="00:00:35.934" end="00:00:38.806" style="s2">anechoic pulsatile circular structure</p>
<p begin="00:00:38.806" end="00:00:41.503" style="s2">in the mid portion of<br />the ultrasound image.</p>
<p begin="00:00:41.503" end="00:00:44.022" style="s2">Deeper and slightly to<br />the right of the image,</p>
<p begin="00:00:44.022" end="00:00:45.838" style="s2">the femoral vein will appear as a</p>
<p begin="00:00:45.838" end="00:00:48.119" style="s2">dark anechoic elliptical shape</p>
<p begin="00:00:48.119" end="00:00:51.470" style="s2">that is compressible<br />with transducer pressure.</p>
<p begin="00:00:51.470" end="00:00:53.632" style="s2">Adjust the transducer so it is centered</p>
<p begin="00:00:53.632" end="00:00:57.199" style="s2">over the femoral vein<br />medial to the artery.</p>
<p begin="00:00:57.199" end="00:01:00.510" style="s2">Follow the needle entry by<br />slowly sliding the transducer</p>
<p begin="00:01:00.510" end="00:01:02.902" style="s2">in the direction of needle advancement.</p>
<p begin="00:01:02.902" end="00:01:06.317" style="s2">The needle will appear<br />as a small bright dot.</p>
<p begin="00:01:06.317" end="00:01:07.849" style="s2">When the needle tip appears,</p>
<p begin="00:01:07.849" end="00:01:11.318" style="s2">the transducer should be advanced<br />a short distance distally</p>
<p begin="00:01:11.318" end="00:01:14.038" style="s2">to follow the tip of<br />the needle trajectory.</p>
<p begin="00:01:14.038" end="00:01:15.838" style="s2">The needle is slowly advanced under</p>
<p begin="00:01:15.838" end="00:01:17.990" style="s2">direct ultrasound visualization</p>
<p begin="00:01:17.990" end="00:01:19.837" style="s2">until the tip is seen to indent</p>
<p begin="00:01:19.837" end="00:01:22.070" style="s2">and then puncture the femoral vein.</p>
<p begin="00:01:22.070" end="00:01:24.942" style="s2">The transducer should be<br />moved slightly proximally</p>
<p begin="00:01:24.942" end="00:01:27.510" style="s2">and distally to confirm<br />that the needle tip</p>
<p begin="00:01:27.510" end="00:01:31.177" style="s2">lies in the mid portion<br />of the femoral vein.</p>