Diagnostic

3D How To: Ultrasound Guided Paracentesis

Read more about 3D How To: Ultrasound Guided Paracentesis

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3D animation demonstrating an ultrasound guided Paracentesis Procedure.

Applications

Cardiology

Media Library Type

How To Videos

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Subtitles

- [Voiceover] A curved array transducer
with an abdomen exam type
is used to perform an ultrasound guided paracentesis.
It is easier to perform this exam
when the bladder is not filled.
The patient is placed in a supine position.
The abdominal cavity is evaluated in two planes.
Place the transducer in a transverse position
with the orientation marker to the right.
The transducer is placed at the lateral border
of the rectus sheath at the level of the umbilicus.
To evaluate the abdominal cavity for free fluid,
sweep the transducer from an inferior to superior position.
Fluid will appear hypoechoic or anechoic
and accumulate in the lateral gutter
and between loops of bowel.
To obtain a long axis view,
rotate the transducer 90 degrees with the orientation marker
directed to the point of needle entry.
Sweep the transducer across the abdominal cavity
from left to right to evaluate the abdomen for free fluid.
A needle insertion site should be chosen
in the lateral abdominal area
in a dependent area of the fluid collection
which is clear from loops of bowel.
The needle should be inserted lateral to the rectus sheath
in a transverse fashion to avoid the epigastric artery.
Follow the needle entry by slowly sliding the transducer
in the direction of needle advancement.
The needle will appear as a small, bright hypoechoic 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 parietal peritoneum.
The transducer should be moved slightly proximally
and distally to confirm location of the needle tip.

Brightcove ID

5508117950001

https://youtube.com/watch?v=LDIo6xQS7Hc

How To: Sacroiliac Injection

Read more about How To: Sacroiliac Injection

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This video discusses some of the scanning techniques when performing a sacroiliac injection under ultrasound guidance.

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

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S.I

Sacraliliac Joint Injection

Anesthetic Nerve Block

Subtitles

- Today I'm gonna demonstrate the sacroiliac joint injection
as facilitated by ultrasonography.
The anatomic considerations are the posterior superior
iliac spine, the sacrum, and the insertion formed
of the sacroiliac joint.
The C60 probe is placed in the transverse orientation.
After anesthetizing the skin the needle enters
out of plane into the joint, thusly performing the block.
The sacroiliac joint injection is useful specifically
to diagnose issues within the sacroiliac joint that might
be causing hip pain to the patient.
Typically on physical examination, there might be a positive
FABER or flexion abduction external rotation test,
also known as Patrick's sign,
or a positive Gaenslen's maneuver.
This can also occur when the patient has a pelvic tilt
or a leg-length discrepancy.
The injection is useful both diagnostically
and therapeutically.
Traditionally, fluoroscopy is utilized to place the needle
within the sacroiliac joint space.
The sacroiliac joint is a very complicated joint in that
it is a fibrous insertion superiorly and a traditional
articulating joint in the lower portion of it.
On fluoroscopy, issues arise such as parallax
and it is well-documented that sometimes the injection
is not placed within the joint but rather periarticularly
and, therefore, not providing the coverage
or the response that is expected.
To perform this particular block,
the following equipment is necessary.
Chlorhexidine for sterile technique.
Local anesthetic syringe containing 1% buffered lidocaine.
And then a syringe containing 5cc of bupivacaine,
one-half percent mixed with 5cc of one percent lidocaine.
And then 40-80 milligrams of triamcinolone kenalog
which is a particulate steroid.
A 3 1/2 inch, 25 gauge spinal needle will also be utilized
for the procedure.
There will be sterile 4 x 4s necessary to clean the area
at the conclusion.
And a simple band-aid will suffice to cover the wound.
The patient is placed in the traditional prone position.
There is a bolster within and under the abdomen
to facilitate opening of the sacroiliac joints.
And then I utilize the C60 probe with its curvy linear
structure to better visualize the interface between
the sacrum and the iliac crest.
The depth is usually set to 7 - 9 centimeters,
depending on the patient's habitus.
Additionally, I utilize the muscoloskeletal, or the MSK,
setting because it provides enhancement of the bony
structures and the enhancement of the joint space.
The probe is placed on the patient in the transverse
orientation approximately a centimeter or two above
the beginnings of the gluteal folds.
And I've found the anatomic midline by identifying
the spinous process of the sacral plate.
As I roll the probe laterally, the posterior superior
iliac spine comes into view very clearly at the top
of the screen, up here.
The space between the posterior superior iliac spine
and the shadow cast by the iliac crest and the sacrum
as it dives down represents the sacroiliac joint.
And you can see that in the center of the screen.
It's important to remember that the iliac crest and ilium
folds and cantilevers towards the sacrum.
Therefore, the needle angle needs to track from medial
to lateral into the space identified
in the center of the screen.
Local anesthetic is placed.
And as a finder needle, this injectate using hydrodissection
demonstrates the needle tip at all times.
The needle is going in the short axis, therefore,
it won't be completely visualized on the screen.
However, hydrodissection can help notice where
the tip is at all times.
Then I'll utilize the 3 1/2 inch spinal needle, 25 gauge,
and enter that track that I have placed
local anesthetic with it.
The needle tip will then be placed within that joint
identified in the center of the screen, right here.
At this point, I attach my syringe containing the local
anesthetic steroid and saline mix.
And then I could utilize color flow Doppler to actually
visualize perturbations of the liquid
as it enters the joint.
- [Voiceover] The view is in the short axis, therefore,
the needle is not visible.
The iliac crest is visible as the large hyperechoic
structure on the right of the screen.
The lateral crest of the sacrum is visible below.
The target is the void between the lateral crest
of the sacrum and the iliac crest.
This helps solidify understanding of the three-dimensional
structure of the sacroiliac joint.
- At this point the probe is removed.
I utilize the 4 x 4s to clean the area.
And a band-aid is placed over the wound.
This successfully completes the ultrasonographic
facilitation of a sacroiliac joint injection.

Brightcove ID

5734039824001

https://youtube.com/watch?v=7G56DN38mz8

Case: Ultrasound Guidance for Paracentesis

Read more about Case: Ultrasound Guidance for Paracentesis

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Using bedside ultrasound imaging when performing paracentesis, identifying ideal candidates for this procedure, mapping the internal jugular vein and ascites to determine an ideal puncture point, needle depth, and needle trajectory.

Media Library Type

Case Study Videos

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Subtitles

- Hello, my name is Phil Perera,
and I am the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City,
and welcome to Soundbytes.
In today's module we're going to focus in specifically
on the use of bedside ultrasound
for the paracentesis procedure.
Now, the use of bedside ultrasound for paracentesis
can actually lower your complication rate
and allow you to know who is a better candidate
for the actual procedure.
So, step number one, when you're deciding
if a paracentesis procedure is necessary,
is to determine if the patient actually has ascites
and if there's significant areas of fluid pockets
that are amendable to a drainage procedure.
The second step is to best mark the location
for the needle placement, using bedside ultrasound.
And the two techniques that have been used in the past
are the midline linea alba,
or the lateral gutter techniques.
And using bedside ultrasound can allow you to decide,
between the two, where is the best location
for the needle placement.
This illustration shows the preferred positions
for the paracentesis procedure.
The key concept here is, to avoid the epigastric vessels
during the puncture attempt,
note the location of the epigastric vessels,
just lateral to midline on the abdominal wall.
So we wanna use that 3 MHz probe,
and we can place the probe,
as shown in positions one and two,
in the traditional lateral gutter approaches
for the paracentesis procedure.
This would be above the anterior superior iliac crests.
And we can look for fluid within the lateral gutters
and plan for a puncture attempt
in either of these positions.
We can also place the probe in probe position three
as shown in the midline linea alba position.
We'd wanna place the probe below the umbilicus
in the midline, in a relatively avascular
midline linea alba position.
Now, we can also use the 10 MHz higher frequency probe
to get a better look at the abdominal wall
in relation to the bowel and the ascites fluid
prior to our puncture attempt.
In fact, this will give us a more detailed look
into the abdominal cavity, to better plan our approach
for the paracentesis procedure.
Here's the location of the probe to the lateral position
for the paracentesis procedure.
Note the placement of the high-frequency linear array probe
above the anterior superior iliac crests
along the lateral gutters of the patient.
Notice here, the location of the epigastric vessels
in relation to the lateral gutters,
and we want to avoid those epigastrics
during any puncture attempt.
Notice also the location of the bladder,
and we want to make sure that we decompress the bladder
prior to any puncture attempt for a paracentesis.
But we can see here that the probe
is safely lateral to most of these structures,
thus the paracentesis can be safely performed
from this position on the abdominal wall.
This video clip shows a small amount of ascites
as taken with a 3 MHz probe, and we can see here
a small amount of ascites is denoted
by that dark or anechoic fluid collection,
and we can see the intestine with anchoring mesentery
swaying back and forth within the ascites
as the patient breathes.
And this is known as gut sliding,
and it makes the intestine look almost like palm trees
swaying back and forth within the breeze.
So, from this location, it might be unsafe
to perform a paracentesis, as it could be difficult
to get a needle in between the areas of intestine
without puncturing through an area
of intestine or mesentery.
This video shows a moderate amount of ascites,
again taken with a 3 MHz probe.
And we note the intestine with anchoring mesentery
sliding back and forth as the patient breathes,
and we see a large collection of ascites,
that dark or anechoic fluid collection,
anterior to the intestine.
So this might be a good location to perform a paracentesis
as we could place the needle safely into that ascites
without going through into the intestine
or anchoring mesentery.
This video clip emphasizes the point
that using a higher-frequency 10 MHz probe
on the abdominal wall
gives a more detailed exam of the evaluation
of the ascites in relation to the intestine.
And we see the abdominal wall anteriorly,
and we can see the bowel floating within the ascites.
Here we can actually mark down and measure
the safety zone from in which a needle could safely go
through the abdominal wall, into the ascites,
without hitting bowel.
Note here, the safety zone is approximately two centimeters,
as marked out with the centimeter dots
towards the right of the image.
Another benefit of using the higher-frequency probe
prior to a paracentesis procedure
is to investigate the depth of the abdominal wall,
as a thick abdominal wall can frustrate attempts
at a paracentesis procedure.
Here we see the depth of the abdominal wall,
which measures 2.5 centimeters anteriorly,
and we can see the line,
which is the peritoneal lining there,
just deep to the abdominal wall.
Note the presence here of ascites,
the dark fluid collection,
just deep to the peritoneal lining
and we can see the gut sliding,
or bowel moving back and forth, deep within the ascites.
Note the two-centimeter safety zone
for placement of the needle into the ascites fluid,
but note here we'd need to use a longer needle,
a needle longer than 2.5 centimeters,
just to get through the abdominal wall
to get fluid from the abdominal cavity.
In this video clip, we've moved the probe slightly lateral
from the last position in the same patient.
Again, we note the deep abdominal wall,
at 2.5 centimeters, denoting that a longer needle
will be needed to get the ascites fluid.
But here we see a large collection of ascites,
and note here the absence of gut sliding,
denoting a larger pocket of ascites
and a more favorable position
for the paracentesis procedure.
So this is actually the position
in which we perform the paracentesis,
using a longer lumbar puncture needle
and we're safely able to get a paracentesis done
and get the ascites fluid out for evaluation in the lab.
In this video clip, we'll reemphasize the surface anatomy
for the lateral abdominal position for paracentesis.
Note we're coming with a cap needle
underneath the 10 MHz probe, at the lateral puncture point.
This would be the preferred position
for the lateral approach for paracentesis,
as shown by the black star.
Now, some of the surface anatomy that we can palpate
includes the iliac crest, and note here
we're about four to five centimeters
above the iliac crest there.
We also want to avoid
those all-important epigastric vessels,
which we can see medial to the puncture point
from the lateral paracentesis approach.
Using ultrasound guidance, we can map out
the best position on the abdominal wall
for the paracentesis approach,
and go either right or left-side
depending on the maximal pocket of ascites present.
We also want to ascertain the relative locations
of the liver and spleen, so as to avoid
iatrogenic injury to a solid organ.
And as we emphasized earlier in the video clips,
you want to look for that intestine
with anchoring mesentery,
so as to avoid intestinal puncture during the procedure.
While the lateral gutter approach to paracentesis
is commonly emphasized during medical training,
the midline linea alba position
can be a great location for a paracentesis procedure.
Note here the probe is placed along the midline linea alba
with a marker dot towards the patient's head.
And we see it placed along the midline,
just inferior to the umbilicus.
Here we'll further investigate
the midline linea alba position
for the paracentesis procedure.
Note the high-frequency probe,
placed along the midline linea alba,
and we're coming with a cap needle
at a 45-degree angle underneath the probe
looking for the ring down artifact
onto a suitable pocket of ascites.
Here's a different view point
from the same midline linea alba position.
Again, we're placing that probe along the midline.
And this would be about the appropriate position
for the paracentesis procedure.
And here we just place the needle right there,
directly inferior to the umbilicus.
And I'll indicate that with a black star.
Note here, we'd be coming through
the relatively avascular midline linea alba.
But recall that it's very, very important
from this position to not puncture
through the bladder, and we can see
the relative location of the bladder
in relation to the puncture point.
So we must have the patient void
or place a Foley catheter, prior to attempting
a paracentesis from the midline linea alba position.
Here's a video clip from the midline linea alba,
taken with a 3 MHz probe.
I have the probe oriented towards the patient's head
so the superior aspect is towards the left
and inferior's towards the right.
Note here, we see the bowels superiorly,
moving up and down within the ascites fluid,
which we see in the middle of the image here,
and note the bladder, relatively large,
towards the inferior aspect of the image here.
Now, we can see that this would be a pocket
amendable to paracentesis, but recall again,
to increase the safety of the procedure
from the midline linea alba approach,
we'd want to drain the bladder prior to a puncture attempt.
Here's a video clip taken from the same patient
after having him completely void.
And note now, we have the decompressed bladder,
making the ascites pocket much larger
and more amenable to a paracentesis puncture
from that midline linea alba technique.
And we can see here now, the pocket of ascites
as denoted by the dark or anechoic fluid collection,
between the bowel superior
and the decompressed bladder inferiorly.
In this video clip, we can see
how using the higher-frequency 10 MHz probe
can allow real-time guidance of the needle
down into the ascites pocket,
and we see the detection of the needle
coming in from left to right through the abdominal wall,
with the tip of the needle safely parked
within the ascites fluid.
Notice here that the bowel is distant
to the tip of the needle,
thereby we can minimize any puncture
through the bowel during the paracentesis procedure.
We need to put a sterile sheet over the probe
during this procedure.
So, in conclusion, thanks for tuning in
for ultrasound guidance of paracentesis.
Ultrasound guidance for this procedure
can potentially make the paracentesis procedure
a safer one for our patients, and using a combination
of both the three and 10 MHz probes
can fully evaluate the ascites prior to a procedure.
We can use either one of two techniques.
Either the static technique, we position the patient
and then mark off the puncture spot with ultrasound
prior to a procedure,
or we can actually use a dynamic technique
where we place the probe in a sterile sheet
and watch the needle in real-time
go through the abdominal wall into the ascites fluid.
Either of these techniques
can potentially decrease your complication rate,
so I hope in the future you'll consider
ultrasound guidance for paracentesis
during your next paracentesis procedure.

Brightcove ID

5508114740001

https://youtube.com/watch?v=bWxv_a9CkBs

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3D How To: Ultrasound Guided Paracentesis

3D How To: Ultrasound Guided Paracentesis

How To: Sacroiliac Injection

How To: Sacroiliac Injection

Case: Ultrasound Guidance for Paracentesis

Case: Ultrasound Guidance for Paracentesis

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