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- [Voiceover] Welcome back to SoundBytes Cases.
This is Phil Perera, and in this module we'll discuss
cannulation of the axillary vein using ultrasound guidance.
So why, you might ask, would I want to use
ultrasound to cannulate the axillary vein,
when in effect, the axillary vein is an alternative approach
to cannulation of the subclavian vein on the chest wall?
The axillary vein is a continuation of the brachial vein
onto the chest wall, and becomes a subclavian vein,
as it passes medially under the first rib.
The axillary vein can be well visualized
using ultrasound at this lateral position on the chest wall,
and that's in contrast to the subclavian vein,
where the presence of the bony clavical
makes imaging of the infraclavicular portion
of the subclavian vein difficult.
So in effect, this is a lateral puncture
of the subclavian vein relaying into the axillary vein,
if you're gonna use the right anatomical terminology.
Ultrasound guidance of Axillary Vein cannulation
is now well documented in the medical literature,
although many clinicians remain unaware
that ultrasound can be integrated into this approach.
Two studies document utility
of ultrasound guidance for axillary vein cannulation
with a decreased complication rate,
and the studies are shown below,
the first in 2004 and the more recent in 2012,
both from our colleagues in Great Britain.
In 2011 the CDC came out
with some guidelines for the prevention
of intravascular catheter related infections.
Their recommendations included
using a subclavian vein site, if possible,
rather than internal jugular vein or femoral vein sites,
in adult patients, to minimize the risk of infection,
with a non-tunneled catheter.
They did say to avoid the subclavian site in hemodialysis
and advanced kidney disease patients, to decrease
the risk of subclavian vein stenosis.
They also advocated the use
of ultrasound guidance, if available.
Now let's review the relevant
upper extremity venous anatomy,
that we'll need to know,
to perform successful cannulation of the axillary vein.
Here we see the axillary vein and the axillary artery,
lateral on the patient's chest wall.
Notice here the clavical and the first rib.
As these structures move medially past the first rib,
they become the subclavian vein and artery.
We can see these arteries and veins here,
more medially located on the patient's chest.
Notice also,
we see the internal jugular vein and carotid artery,
moving up and down the patient's neck,
and coming together with the subclavian vessels.
We see the brachiocephalic vein,
which is the confluence of all of these vessels,
as they move down towards the heart,
to become the superior vena cava,
and we remember that, optimally,
we want to place the tip of the catheter,
when performing central venous cannulation,
in the superior vena cava,
and not into the right atrium.
Here's another anatomical image,
showing a perspective from a more lateral orientation
on the patient's chest wall.
Here, we see the axillary vein and axillary artery,
and notice that the normal orientation
of the vein and the artery
is that the artery should be superior to the vein,
although occasionally we have seen some variation,
and it's not unusual for the vein
to be overlapped by the artery, or vice versa.
We see the continuation of the axillary vein and artery,
onto the patient's chest wall, medially,
to become the subclavian vein and artery,
as the vessels pass medial to the first rib.
We also see the internal jugular vein and carotid artery,
and the superior vena cava.
To best image the axillary vein using ultrasound
we'll place the probe on the lateral chest wall.
Here we see the probe applied,
in a longitudinal or long axis orientation
over the top of the axillary vein.
We can image the vessel, using the long axis orientation,
to get a lot of information about the vessel,
but we can look in the short axis orientation,
by turning the probe so the probe indicator
will be towards the patient's right shoulder.
This will cut the vessel in cross section,
making it appear like a circle.
Before performance of the axillary vein cannulation,
we'll want to select the right ultrasound probe for the job.
For this application,
we'll be using a higher frequency 10 MHz linear array probe,
and because we're performing this procedure in a dynamic
or real-time guidance technique,
we'll want to put a sterile sheet or barrier
over the probe, so as to maintain
sterile precautions throughout the procedure.
Note, in some of the upcoming pictures, we don't have
a sterile sheet over the probe, but if we were performing
this in real procedure, we'd want to make sure,
that we have that sterile sheet over the probe.
While someone will run through a pre-procedure checklist,
assessing for relative contraindications
to axillary vein cannulation,
as it's a relatively non-compressible vessel,
coagulopathy is a contraindication
to axillary vein cannulation.
Also, renal disease or need for dialysis
would be relative contraindications to cannulation
of the axillary vein.
We can also run through a more extensive checklist,
known as the 6 point bundle,
which is shown in the upper right,
which emphasizes the use of maximal sterile precautions
for both patient and clinician during the procedure.
Now let's specifically discuss
some of the ultrasound guided approaches
to axillary vein cannulation.
The axillary vein can be visualized
in both short and long axis orientations, using ultrasound.
Imaging of the needle during cannulation of the vein
can then be performed in either orientation,
and there are pluses and minuses of both these orientations,
for cannulation of the vessel.
I generally recommend to start
in the short axis orientation
to introduce the needle,
initially to advance the needle down to the vein.
One may successfully cannulate the vessel in short axis,
however, one thing that can be very helpful
is to flip the probe, once the needle is under the skin,
into the long axis orientation,
to be used to visualize the needle
as it approaches the vessel,
as a long axis orientation shows needle depth
better than the short axis orientation.
So, putting it altogether, here's the probe position
for cannulation of the axillary vein
in the long axis orientation.
Notice here, that the needle would be placed
in an orientation coming in
under the lateral aspect of the probe,
and moving more medially.
Thus we can image the full position of the needle
as it moves down to the axillary vein.
In the next few images,
we'll also show you the placement of the probe
for the short axis cannulation of the axillary vein,
so as to compare both long and short axis imaging.
Here's a few pictures showing the orientation of the probe,
and the placement of the probe
for cannulation of the axillary vein
in a short axis orientation.
Notice here, that we have the probe
in an up and down configuration,
with the indicator dot towards
the patient's right shoulder or superior.
Notice we're placing the needle roughly at about the
midway point underneath the probe.
Now there are some benefits
of starting with the short axis orientation,
namely that it's helpful in orienting the needle,
up or down, superior or inferior,
on the patient's chest wall,
to best aim it towards the axillary vein.
Here are some ultrasound images
of the axillary vein and artery,
taken from the short axis view.
We have the probe marker oriented
towards the patient's head,
thus to the left of the image is superior,
and to the right is inferior.
We notice the axillary artery, the smaller vessel,
superior or towards the left of the image.
We see the larger axillary vein
at about the three centimeter mark,
inferior or towards the right of the image.
Notice towards the back of the image,
we can actually see the lung
sliding up and down as the patient breathes,
at about the five centimeter mark.
Thus it's very important to cannulate the vessel carefully,
and not to pass the needle deep,
past the axillary vein or artery
to cause an inadvertent pneumothorax.
Here's another image of the axillary artery and vein,
taken from a short axis configuration.
Again, we have the probe marker indicator
towards the patient's head.
Superior to the left, inferior to the right.
Thus we see the smaller axillery artery
to the left or superior, and the larger axillery vein
inferior toward the right of the image.
Notice that as we apply probe pressure
down onto the patient's chest wall,
we can actually compress the axillary vein ,
and this is one way of telling vein from artery,
as normally the vein should compress,
as long as there's no thrombus inside it,
and the artery will stay open.
We can see the lung sliding
towards the deeper aspect of the image.
In this ultrasound image,
again taken from a short axis configuration,
we'll use Color Flow Doppler to further differentiate
the axillary artery from the axillary vein.
We note again, that superior is to the left,
and inferior is to the right.
We can see the smaller axillery artery,
with pulsations indicating arterial flow within the lumen.
Notice here, we also see phasic respitory flow
within the axillary vein, corresponding to
inhalation and exhalation by the patient.
Thus, another way of differentiating the axillary artery
from the axillary vein.
Here are some images showing the appropriate positioning
of the probe for long axis cannulation of the axillary vein.
Again we notice that we have a high frequency linear array
probe positioned over the lateral chest wall,
directly over the axillary vein.
We have the needle coming in,
under the long axis of the probe.
Now, I like to have the probe positioned
so that the marker on the probe is oriented lateral.
Thus, the needle will come in underneath the indicator
and progress directly underneath the probe
as it courses from the skin down to the axillery vein.
It's important to keep the needle and plane
underneath the probe at all times,
so that it can be visualized as it goes down to the vessel.
Here's a long access ultrasound image of the axillary vein
as it courses from lateral to the left of the image
to medial to the right of the image.
Notice that the axillary vein appears
as a tubular structure, at about the three centimeter mark.
Now let's take a look at the axillery artery
using B-mode or greyscale sonography.
We can see the axillary artery
arching from lateral to medial
across the patient's chest wall,
and we note the pulsations within the lumen,
indicative of an arterial structure.
We can also see the thoracoacromial trunk
coming off medially off the axillery artery.
Next, we'll use Color Flow Doppler
to further differentiate venous structures from arterial.
This will be the axillary vein and we can tell this,
as it does not have that constant arterial pulsations
within the lumen.
Notice that rather,
it has the phasic respitory variation of flow
within its lumen, as indicative of a venous structure.
We can also see the thoracoacromial trunk
coming off medially.
Let's contrast that last ultrasound clip with
this one, showing the axillary artery, using
Color Power Flow Doppler.
Color Power Flow Doppler shows amplitude of flow,
and we can see that fast flow is very yellow,
we can see the faster flow within the inner part of the
lumen of the vessel.
But notice that we have here
the characteristic arterial pulsations,
that differentiate from venous pulsations.
Now let's discuss the micropuncture technique
for central venous cannulation.
The micropuncture technique has a lot of advocates
when talking about cannulation of the axillary vein,
as it utilizes a smaller 21 gauge needle
for the initial puncture of the axillary vein.
This is in contrast to a traditional central line kit,
which uses and 18 gauge needle, a much larger needle,
for that initial vessel cannulation.
One can then use
this smaller 21 gauge needle to cannulate the vessel,
and place a guidewire into the vessel.
A larger catheter can then be inserted
over the guidewire into the vessel.
Using these smaller diameter needles
is potentially safer for deeper puncture
of vessels like the axillary vein
to avoid potential complications.
In this video clip, we'll watch cannulation
of a vessel using a short axis approach.
This is a phantom which simulates the human body
and we can see that as we place the probe
in the short axis orientation,
the vessel appears as circular end-on.
Notice here, that we can see the echogenic tip of the needle
coming down to the vessel, permeating the interior wall,
and entering into the lumen of the vessel.
So the short axis plane allows
better lateral guide of the needle path,
and is a good starting position
for cannulation of an axillary vein.
In this video clip, we'll use the long axis approach
for cannulation of a central vein.
Here we're using some new technology,
known as MBE technology,
that is on a lot of the Sonosite machines.
What we see here is the tip of the needle
is much more echogenic.
We aim the needle towards the dotted line,
which is coming from right to left on the image here.
Now let's watch the needle coming in from left to right,
and we can see that,
as the needle is in plane with the probe
in the long axis approach,
we can see the full extent of the needle
as it travels from superficial down
to permeate the anterior wall of the vessel
and enter into the vessel lumen.
Thus the long access plane allows
a much better guide to needle depth
and allows you to gauge where the tip of the needle is
at all times.
That's why I generally start with a short axis approach
and then flip to long axis.
In this video clip, we'll look at a real-time
axillary vein cannulation in a real patient.
Here we see the needle coming down from left to right,
we're using the long axis view.
Notice that the images are not quite as crisp,
because the probe is slightly off-axis to the vessel.
What we can see here is the tip of the needle
as shown by a small arrow, coming down, pushing down
on that anterior wall of the axillary vein,
and then entering into the vessel lumen.
So in this case we were able to successfully cannulate
the axillary vein, although the images are
not quite as clear as in the phantom,
and this is one pitfall from using the long axis approach,
that you must be completely in plane with the needle
throughout its entire path down to the vessel.
Here's another clip in the long axis orientation,
showing a successful cannulation of an axillary vein.
We can see here the needle pushing down
on that anterior wall, and then entering
into the vessel lumen.
Now one potential pitfall is that, occasionally,
the vessel can be pushed down, the anterior wall can tent
towards the posterior wall, as you push the needle down.
So have patience, and occasionally,
a slight pull-back with the needle
will loosen that tissue, and allow you
to free the needle tip within the vessel lumen.
But again, the teaching point here
is that the long axis view is great
for assessment of needle depth at all times.
Another use of ultrasound and the long axis technique
which I find very helpful,
is to assess that the guidewire
is safely within the position,
within the lumen of the axillary vein.
Here we note the needle coming down from left to right,
and we can see the guidewire passing
through the tip of the needle,
moving down the axillary vein,
down towards the superior vena cava.
This can be very helpful in assessing that the guidewire
is indeed safely within the axillary vein,
prior to placement of the plastic catheter.
While standard practice would dictate
that after placement of a central line,
one would obtain a chest radiograph
to look for the placement of the tip of the catheter
in the superior vena cava.
A quick and easy way of assessing
that the catheter is indeed inside the superior vena cava
is to use a saline flush.
Here we're flushing the saline into the catheter
and we can note the presence of bubbles
within the right side of the heart,
indicating that the catheter is indeed
within the vessel lumen, so a quick and easy way,
right at the bedside, prior to obtaining a chest radiograph.
In conclusion, thanks for joining me
for this SoundBytes module,
going over ultrasound guided approaches
to axillary vein cannulation.
Ultrasound guidance of axillary vein cannulation
is now well supported in the medical literature,
and in fact, the CDC guidelines from 2011
advocate placement of central lines
within the axillary and subclavian veins,
to lower the incidence of bloodstream-associated infections.
As we discussed, the micropuncture technique,
using a smaller needle
for the initial cannulation of the axillary vein,
can be very helpful for this approach.
We can then place a guidewire and larger catheters
into the vessel more safely.
So clinicians should strongly consider
this alternative approach,
using ultrasound guided approaches into the axillary vein,
when determining the location
for central venous catheter placement in their patients.
So, I hope to see you back, as SoundBytes continues.

Brightcove ID

5508139234001

https://youtube.com/watch?v=zxmkrrq1P3M

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3D How To: Peripherally Inserted Venous Catheter

Read more about 3D How To: Peripherally Inserted Venous Catheter

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3D animation demonstrating an ultrasound guided Peripheral Inserted Venous Catheter (upper extremity).

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- [Voiceover] A liner array transducer with
a venous exam type is used to preform
an ultrasound guided insertion
of a peripherally inserted central catheter
via a transverse approach.
The patient is in a supine position
with the arm extended 90 degrees at the patient's side
and externally rotated.
The transducer is placed transversely just proximal
to the medial condyle in the bicipital groove
with the orientation marker directed to the patient's right.
The basilic vein is seen as a dark anechoic circular,
compressible structure in the mid-portion of
the ultrasound image, between the biceps and triceps muscle.
Deeper, and slightly to the right of the screen,
the bright hyper-echoic humerus can be seen.
Adjust the transducer so it is
centered over the basilic vein.
Follow the needle entry by slowly sliding
the transducer in the direction of needle advancement.
The needle will appear as a small bright dot.
When the needle tip appears,
the transducer should be advanced a short distance
to follow the tip of the needle trajectory
and stay in advance of the needle entry.
The needle is slowly advanced under
direct ultrasound visualization until the tip
is seen to indent and then puncture the basilic vein.
The transducer should be moved slightly proximally
and distally to confirm that the needle tip
lies in the mid portion of the basilic vein.
This technique can also be used
with the deep brachial or cephalic vein.

Brightcove ID

5741617671001

https://youtube.com/watch?v=rWxN4JFBEJc

3D How To: Interscalene Nerve Block

Read more about 3D How To: Interscalene Nerve Block

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3D animation demonstrating an ultrasound guided interscalene nerve block.

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- [Voiceover] A linear array transducer
with a nerve exam type is used to perform
an ultrasound-guided, interscalene nerve block.
The target depth is approximately one to three centimeters
in an 80-kilogram adult.
The patient is positioned in a 45-degree reclining position
with a pillow under their head
and the head turned toward the contralateral side.
The examination begins by finding
the supraclavicular region of the brachial plexus
as a landmark technique.
The transducer is placed posterior
to the midpoint of the clavicle
with the orientation marker
directed to the patient's right at a three-o'clock position.
The subclavian artery is seen
as a round, pulsatile structure
superior to the bright reflection of the first rib.
The pleura is seen as a bright, hyperechoic reflection
deep to or at the same depth as the first rib.
The nerves of the brachial plexus are posterior or superior
to the subclavian artery.
The nerves appear as hypoechoic dark circles
within the bright hyperechoic fascia
surrounding the brachial plexus.
To identify the interscalene region of the brachial plexus,
slowly slide the transducer up the neck.
The interscalene muscles will frame the nerves
within the interscalene groove.
The nerves will change in shape
from a grape-like cluster in the supraclavicular region
to a chain-link appearance in the interscalene groove.
The C5 and C6 nerve roots appear as three circles.
The hypoechoic pulsatile carotid artery
will appear medial to the anterior scalene muscle.
The needle can be advanced
using an in-plane or out-of-plane technique.
For an in-plane technique,
the needle is positioned one to two centimeters
lateral to the transducer and advanced under the transducer
until the tip is just posterior to or between
the C5 and C6 nerve roots.
The local anesthetic is injected incrementally
close to the nerve roots.
The needle can be redirected
if the spread of local anesthetic is not deemed adequate.
It is not necessary to have local anesthetic
anterior and posterior to the nerve roots.
Posterior spread only of local anesthetic is effective.

Brightcove ID

5508123555001

https://youtube.com/watch?v=wAABZF1aSO8

3D How To: Infraclavicular Nerve Block

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3D animation demonstrating an ultrasound guided infraclavicular nerve block.

Clinical Specialties

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- [Voiceover] A linear array transducer
with a nerve exam type is used to perform
an ultrasound-guided, infraclavicular regional nerve block.
The target depth is approximately three to four centmeters
in an 80 kilogram adult.
The patient is positioned supine
with the arm abducted 90 degrees
and the elbow bent 90 degrees
to move the clavicle posterior,
and permit a shallow angle of needle insertion.
The patient's head should be rotated
toward the contralateral side.
The transducer is placed on the chest in a paramedian plane,
inferior to the midpoint of the clavicle
with the orientation marker directed to the patient's head.
The axillary artery is seen as
a dark, round pulsatile structure with a hyperechoic wall
inferior to the pectoralis major and minor muscles.
The axillary vein lies beside the axillary artery
and collapses with compression.
The nerve cords appear as hyperechoic circles
with a honeycomb appearance
within the bright hyperechoic fascia of the brachial plexus.
The transducer is slowly moved in a lateral direction,
following the course of the axillary artery.
The nerves will split into a lateral,
medial, and posterior cord.
The optimum position of the transducer
for the infraclavicular nerve block
is as lateral as possible.
The needle is positioned two centimeters cephalad
to the transducer and advanced using an in-plane technique.
The needle path is directed over the clavicle
and through the pectoral muscles.
The initial endpoint for the needle is
immediately posterior to the midpoint of the artery.
The spread of local anesthetic should be observed.
Supplemental injections can be made anterior to the artery
to deposit local anesthetic
around the lateral and medial cords if required.

Brightcove ID

5745561363001

https://youtube.com/watch?v=8xRDVLKb5BY

3D How To: Axillary Nerve Block

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3D animation demonstrating an ultrasound guided axillary nerve block.

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- [Voiceover] A linear array transducer with a nerve
exam type, is used to perform an ultra sound
guided axillary regional nerve block.
The target depth is approximately one to two
centimeters in an 80 kilogram adult.
The patient is positioned supine with the arm
abducted 90 degrees, and the elbow bent 90 degrees.
The transducer is placed high as possible in the axilla,
with the orientation marker directed to the patient's head.
Slowly slide the transducer in a lateral to medial
direction to identify the axillary artery.
The axillary artery is a dark, round, pulsitile structure
with a hyperechoic wall.
The axilalry veins lie around the periphery of the artery
and are easily compressed.
Slide the transducer up the arm to a proximal
position, so the terrace major muscle,
which helps control the distribution of local
anesthetic during injection, is postero-medial
to the artery and nerves.
The biceps and coracobrachialis muscles, will appear
lateral to the artery.
The median, ulner, and radial nerves appear as
hyperechoic circles, with a honey comb appearance
surrounding the artery.
The nerve positions will vary around the artery.
The transducer is slowly moved laterally over
the biceps and corocobrachealis muscles.
The musculocutaneous nerve can be seen between
these muscles as a small, bright, hyperechoic circle
or triangle.
The needle is positioned one to two centimeters
lateral to the transducer, and advanced using
an in plane technique.
The needle path is directed through the biceps muscle,
toward the musculocutaneous nerve.
The initial end point for the needle is immediately
beside the musculocutaneous nerve, where three
to five CCs of anesthetic should be injected.
The needle is then advanced to a position immediately
post-terior to the artery.
As local anesthetic is injected, the terrace muscle
is pushed down, and the local anesthetic should
spread medial and lateral underneath the artery.
The needle can be advanced through hydrodisection
to facilitate appropriate spread of local anesthetic.
Finally, the needle is withdrawn and redirected anterior
to the artery.
Local anesthetic should be injected over the artery
to finish with a circumferential spread of local anesthetic
around the artery.

Brightcove ID

5765653161001

https://youtube.com/watch?v=3MBmUFMoH7w

3D How To: Supraclavicular Nerve Block

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3D animation demonstrating an ultrasound guided Supraclavicular nerve block.

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- [Voiceover] A linear array transducer with
a nerve exam type is used to perform an ultrasound guided
supraclavicular regional nerve block.
The target depth is approximately one to three centimeters
in an 80 kilogram adult.
The patient is positioned in a 45 degree
reclining position with a pillow under their head
and the neck exposed on the operative side.
The patient's head is rotated toward the contralateral side.
The examination begins by finding the supraclavicular region
of the brachial plexus as a landmark technique.
The transducer is placed posterior
to the midpoint of the clavicle at an acute angle
with the orientation marker directed
to the patient's right at a ten o'clock position
with the transducer aimed into the thorax.
The subclavian artery is seen as a round pulsal tile
structure superior to the bright reflection
of the first rib.
The plura is seen as a bright hyperechoic reflection
deep two, or at the same depth as the first rib.
The nerves of the brachial plexus are posterior
or superior to the subclavian artery.
The nerve trunks appear as hypoechoic dark circles
within the bright hyperechoic fascia of the brachial plexus.
Colored doppler imaging may be used
to identify smaller arterial branches
running through the brachial plexus
or lying in the path of needle advancement.
The needle is positioned one to two centimeters
lateral to the transducer, and advanced
using an in plane technique.
The initial end point of the needle
is just posterior to the artery
immediately above the first rib.
It is important to distinguish the plura
from the first rib to avoid a pneumothorax.
The local anesthetic is injected
incrementally close to the nerves.
The needle can be redirected towards
the upper trunks of the brachial plexus
if the spread of local anesthetic is not deemed adequate.

Brightcove ID

5750031878001

https://youtube.com/watch?v=9vW1uo7mKDc

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3D animation demonstrating an ultrasound guided Supraclavicular nerve block.

Case: Peripheral Venous Access - Part 2

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Use ultrasound imaging to identify anatomy prior to intravenous catheter needle punctures, verify needle depth, and use dynamic techniques for attaining optimal needle guidance during deep vein cannulation & IV placement.

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- Hello, my name is Phil Perera
and I'm the emergency ultra sound coordinator
at the New York Presbyterian hospital in New York City
and welcome to SoundBytes Cases.
In this SoundBytes module, entitled Ultrasound Guided
Cannulation of Arm Veins Part 2,
we'll look further into the techniques needed
to use ultrasonography to guide a IV into
one of the deep arm veins.
As we discussed in part one of this module,
we first want to map out the vein using both short
and long axis views and we'll employ a dynamic technique
for optimal guidance for the catheter down to the vein.
Want to use a longer angiocath for the procedure,
preferably 1.88 inch or longer
as we need a good amount of plastic catheter in the vein
to avoid extravasation of fluids or meds
during resuscitation of the patient.
This recent published study showed that it's crucial
to select the correct target vessel when deciding
to cannulate a deep arm IV.
169 patients were enrolled in the study
and it was determined that the size of the vessel
directly correlated with the success rate
of the cannulation procedure.
A vessel with a diameter less than three millimeters
correlated to a success rate of only 56%.
While a diameter greater than 6 millimeters correlated
to success rate of 92%.
That's showing that the diameter was directly correlating
to the success rate of placement of a deep arm IV.
Also the depth of the vessel was very important
as no vessel that was deeper than 1.6 centimeters
was successful cannulated.
A very nice study by Dr. Panebianco et al.
A academic emergency medicine, 2009.
Armed with the knowledge of the last study,
here we're going to measure the diameter of a brachial vein
prior to a puncture attempt.
Notice here, we've selected a brachial vain
and we're measure the diameter at 3.7 millimeters
by 4.3 millimeters.
Thus, this would correlate with a low likelihood
of success rate during a cannulation attempt.
Notice also we're measuring the depth of the vessel
and while the depth of the vessel is six millimeters
less than the 1.6 centimeters that correlated
to no successful outcomes of peripheral IV cannulation,
the diameter of the vessel would be very difficult
to cannulate.
Now let's take a look at a better target.
This is a basilic vessel and we can see here
that the diameter is much larger than the last
brachial vein and we measure it at 6.5 millimeters
by 6.7 millimeters.
Thus, this would have a very high success rate
in terms of cannulation with a ultrasound guided IV.
We can also see that the vessel depth is relatively
superficial, again making it more amenable
to a cannulation attempt.
Once we have selected a favorable target vessel
for cannulation, we can place the probe in a short axis
of side to side orientation.
Here we're using a q-tip coming in underneath the probe
at 45 degree angle to look for the ring down artificat
for guidance for placement of the IV in a side to side
or lateral orientation on the patients arm.
We can look for a finding know as the ring down artifact
on the ultrasound screen as shown here.
Notice we have a nice plump basilic vein in the middle
of the field here and we can see a dark mark
emanating from the surface directly down.
Which is the ring down artifact caused by pressure
from the q-tip.
Thus this would be the appropriate poke point
on the side to side orientation on the patients arm
for placement of the IV.
We can also localize a vessel using the long axis technique.
Notice here we have the probe oriented
in an up and down configuration on the patients arm
and are placing the q-tip underneath the distal aspect
again at a 45 degree angle
to look for that ring down artifact onto the vessel.
To increase the accuracy of an ultrasound guided IV,
it's important to know the course of the vessel
as it runs up and down the arm.
Here we see in the picture to the left
that we're localizing the vessel at one point
on the patients arm but it's not enough
to know only one point.
We need to know the course of the vessel
as it runs up and down the arm as show in the picture
here to the right.
Notice we're marking two points on the vessel.
We have the distal poke point as noted by the blue x
towards the outer part of the patients arm
and then we're moving the probe more up the arm
more proximally to mark a second point on the vessel.
A line drawn between these marks would identify
the trajectory that the IV should follow
once it comes in at the the distal poke point
to successfully cannulate the vessel.
This longer angiocath at 1.88 inches would be more
optimal for cannulation of a deep arm vein
using ultrasound guidance.
This schematic shows the reason
that we need a longer angiocath when cannulating
a deeper arm vein.
While the vein my only be one centimeter deep to the skin.
Notice that the needle is not going directly down,
it comes in at about a 45 degree angle
to cannulate the vessel.
So we need a longer aspect of the needle just
to make it down to the target vein.
Plus we also need an ample amount of catheter
to be within the vessel lumen
to avoid extravasation of fluids or medications.
For this reason, 1.88 inch or longer is essential
for cannulation of a deep arm vein.
Now we're ready to cannulate a vessel
using ultrasound guidance.
We'll begin using the short axis or side to side orientation
of the probe with the probe maker
orientated towards the left
as we stand in front of the patient.
This will correlate with the ultrasound screen indicator
dot which is towards the left of the screen.
Generally I want to go and place the IV at a 45 degree angle
underneath the patients skin and then I'll place
the probe over the area of the IV to guide the IV
directly into the vein.
This phantom shows why using the short axis technique
can be an excellent starting point for guiding
the IV directly down to the vein under ultrasound guidance.
Here we can see a target vessel and note we see
the echogenic tip of the needle going
through the anterior wall of the vessel
and permeating into the vessel lumen.
So the short axis technique is optimal
for viewing lateral needle orientation
across the patients arm and guiding the IV directly
down into the venous lumen.
When using the short axis technique,
one must keep in mind the effect of probe slice
on visualization of the needle.
Note here, the probe is position more proximally
along the course of the needle and even though the needle
tip is securely within the vessel lumen,
we're only visualizing the needle to be above the vessel.
Notice the schematic view here towards the left
and we can see the probe is more proximal along
the course of the needle and the ultrasound view
towards the right and even thought the tip of the needle
is securely within the lumen of the vessel,
we're only visualizing the needle above the vein
and may get a false determination of where the tip
of the needle is.
Therefore, when using the short axis technique
when cannulating a deep arm vessel,
it's important to move the probe along the course
of the vessel to stay in plane with the tip
of the needle as you advance the needle under the skin
and into the vessel lumen.
Here we see we've moved the probe more distally along
the course of the vessel and now we're more
in plane with the tip of the needle.
We see the schematic view to left
and the ultrasound view towards the right
showing successful cannulation of the vessel
and the tip of the needle right within the vein lumen.
This video clip shows successful cannulation
of a brachial vein using the short axis technique.
Notice here we see the vessel and notice
we see the echogenic tip of the needle coming down
from the surface and permeating the anterior wall
of the vessel
and there we can see the echogenic tip of the needle
right within the vessel lumen.
We can also use the long axis configuration
for cannulation of a deep arm IV.
Optimally, you want to place the probe in the configuration
of the vessel as it runs up and down the patients arm.
By tradition, we want to have the probe marker oriented
distal so that the distal aspect of the probe
will line up to the left of the ultrasound screen,
as shown here.
So distal on the screen will be to the left
and proximal to the right.
The IV would then enter underneath the probe
at that 45 degree angle.
While the short axis configuration gives
a lot of information about side to side
or lateral orientation of the needle,
the long axis configuration gives a lot of information
with regard to vertical needle depth.
Here we see a needle coming from the left
and permeating into the vein lumen.
Notice here we can get an accurate determination
of the optimal depth of the needle
in relation to the venous lumen for cannulation
of the vessel.
Here's a real cannulation of a brachial vein
in a long axis configuration.
We see the vein stretching out in a long axis configuration
as a tubular structure running from left to right
along the screen and we see the needle coming
in from the left to the right moving up and down
and cannulating within the venous lumen.
So at this point, we're ready to thread the catheter.
This video clip captures a long axis cannualtion
of a deep arm vein and we can see the needle coming
in from left to right and we can see the needle tip
permeating through the vessel lumen.
Now we can see the actual threading of the plastic catheter.
So again we'll look at the needle coming in from left
to right and now we'll go ahead and freeze it
so we can see the actual plastic catheter
securely within the lumen of the vessel
and it's nice to visualize the catheter
within the vessel lumen to ensure
that there's enough catheter there to give a good amount
of medications and fluids with extravasation
of either of these liquids into the patients arm.
In conclusion, thanks for tuning in to this SoundBytes
module going over part 2 of ultrasound guided
cannulation of arm veins.
Ultrasound guidance for peripheral IV insertion
is an extremely helpful technique
and optimally you want to choose a target vessel
greater than six millimeter in diameter
and at a depth of less than 1.6 centimeters
to optimize our cannulation success.
We want also pick a longer catheter so we have
enough needle and plastic catheter to get into
these deep arm vessels.
We use a combination of short and long axis views
to dynamically guide the angiocath into the vein
and just bear with it because there is a steep learning
curve for these ultrasound guided IVs.
So you'll get it with time so don't give up
and practice practice practice.
So I hope to see you back in the future
as we SoundBytes continues.

Brightcove ID

5508134289001

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

Case: Peripheral Venous Access - Part 1

Read more about Case: Peripheral Venous Access - Part 1

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Use ultrasound imaging to help identify deep and nonpalpable veins that can accommodate the placement of an IV catheter. Doppler color flow is used to differentiate the brachial artery from other anatomical structures.

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- [Voiceover] 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.
It's today's module, we'll look at the use
of bedside ultrasound to help us place peripheral IVs.
Specifically, we'll look at ultrasound guidance
for cannulation of deep arm veins.
Ultrasound can allow us to cannulate nonpalpable
arm veins, which have traditionally been off-limits
using traditional palpation techniques.
Thus we can avoid central venous access in those
with poor traditional access in whom we can get
a peripheral IV using ultrasound.
Ultrasound allows precise determination
of vascular anatomy prior to a puncture attempt,
and there's been a number of research studies
that have shown a decrease in number of attempts
and time to successful cannulation using ultrasound.
Here's an illustration showing the anatomy
of the arm veins: a long axis view to the right,
and a short axis view to the left.
Note here on the long axis view,
the brachial artery running down the arm,
and adjacent to the brachial artery,
we can see here the brachial vein.
Notice that the brachial vein is composed of
two major veins: the basilic vein, which is the
larger vein located more superficially and medially,
and the deep brachial veins found
adjacent to the brachial artery,
in a deeper and more lateral position on the arm.
Let's look at the short axis view,
and here we can see well the brachial complex:
the brachial artery surrounded by
two deep brachial veins here, and the more superficial
and medial basilic vein, which is really
the preferred target for a deep ultrasound guided IV.
Note the median nerve lying on top of
the deep brachial vein, which must be avoided
during a puncture attempt on this structure.
Here's a picture showing the surface anatomy
of the veins of the upper arm.
Notice here the basilic vein in a more medial position
on the patient's arm, and the brachial vein complex,
which would be located more laterally
on the patient's arm.
And these are the positions over which
we should place the probe in order to
inspect the veins of the upper arm.
Here are the orientations in which we can
place the probe to inspect the vein
for vascular line placement.
We see the short axis view to the left.
And notice that we're placing the probe
perpendicular to the vein, and note that
the resulting ultrasound image of the vein
will appear as a circle, as the vascular structure,
the vein here, will be cut end on.
Note the long axis view to the right
in which the probe is placed in a longitudinal manner
along the course of the vein, and note
the resulting image of the vein,
which appears as a tubular structure
on the ultrasound screen.
Here's the high-frequency, linear type of ray probe
that we'll be using for vascular access.
And that line on the side is the indicator marker
on the probe.
Here's the high-frequency, linear type of ray probe
placed on the patient's upper arm.
Notice here that it's placed in a short axis,
or side-to-side configuration.
Here we have the probe positioned over
the more medial, basilic vein.
Notice also that the probe marker here
is towards our left as we stand in front of the patient,
and the reason for that is note on the screen
that the indicator dot is also located here to the left.
Therefore left on the probe lines up
with left on the screen.
So now that we know the proper configuration
of the probe in the short axis view,
let's take a look at a typical appearance
of vascular structures cut end on.
Here we have the probe positioned over
the brachial complex, and we see here
the central brachial artery, surrounded by
two deep brachial veins.
So let's put that into video play here,
and notice with compression that
both of the veins compress completely,
helping us differentiate venus structures
from the artery in the center.
And notice that the artery has less distensible walls,
and stays open, even as we compress down with the probe.
We can further differentiate vascular structures
by applying color doppler flow.
Notice here as we apply doppler,
that we see arterial pulsations
in the central brachial artery.
However notice the absence here of any flow
within the deep brachial veins,
and that's because of the slightest flow
within those two vascular structures
as compared to the brisk arterial flow
in the central brachial artery.
So putting it all together, using doppler flow
and applying compression, notice here again
that the brachial artery in the center stays open
and has brisk arterial pulsations.
And notice that the two flanking
deep brachial veins compress completely
and have a lack of vascular flow with doppler interrogation.
Now let's look at a video clip that shows
all of the veins of the upper arm
in relation to one another.
Medial is to the right, and lateral is to the left.
Here we see the larger and more superficial basilic vein,
more medial and superficial to the brachial complex,
which is located here to the left.
And note the central brachial artery,
and two flanking deep brachial veins.
In this patient, the basilic vein would be
the preferred target for placement of a deep arm IV.
Here's a different patient.
Again, we're looking at the relation
of the basilic vein to the brachial complex.
Medial is to the left, and lateral is to the right.
We see here the superficial basilic vein,
and the deeper brachial complex.
Notice we apply pressure, that all of the venus structures-
the basilic vein, and the deep brachial veins,
all compress completely, helping us differentiate
venus from arterial vascular structures.
Here we're applying doppler flow,
and again we can differentiate the brachial artery
by its pulsations consistent with arterial flow.
And note the lack of significant flow
within the venus structures.
Specifically, the basilic vein.
Here's the high-frequency, linear type of ray probe
in a longitudinal, or long access orientation
over the patient's upper arm.
Here it's located over the more medial, basilic vein.
In this orientation, we have the probe marker
going distally, and this helps us line up the probe
with regard to the screen.
Notice the screen indicator dot here
is located towards the left, therefore,
distal on the screen would be over towards the left,
and the proximal on the screen
would be located over towards the right.
Here's a typical appearance of a venus structure
cut in a longitudinal, or long axis orientation.
Notice here that the vein has more of a tubular
appearance on the screen, and that the flow of blood here
is from the left, which is distal on the vein,
towards the right, which is proximal on the vein.
Looking in long axis gives complementary information
about the vein.
So thanks for tuning in to part one of
ultrasound guided peripheral IV insertion.
As we mentioned, ultrasound can be very helpful
in identifying deeper and nonpalpable veins
that can still allow placement of intravenous catheter.
We'll be looking at the vein in both short
and long axis views to determine the anatomy
prior to a puncture attempt.
And now that we have a good sense in terms
of how to look at a vein in both short and long axis,
we're ready to move directly to learning
how to cannulate the vein using ultrasound.
So I look forward to seeing you in part two
of peripheral venous access.

Brightcove ID

5769198966001

https://youtube.com/watch?v=lREUPXCpK8Y

How To Perform An Interscalene Nerve Block

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Dr. David Auyong reviews scanning techniques and sonographic landmarks for an interscalene brachial plexus nerve block.

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- The interscalene block is used
for shoulder surgery and clavicle surgery.
So, to start the interscalene block,
proper positioning is very important.
The best way to get to the interscalene block
is to have the patient sitting up
about 30 or 45 degrees.
Next, we turn the patients head away
from the shoulder to the opposite side.
This gives us a lot of room to put the probe
and have our hands come from the posterior side.
The proper approach to the interscalene block
is to have the needle approach from the posterior side.
This avoids the phrenic nerve and allows us
to not injure the phrenic nerve with our needle approach.
So, for the interscalene block,
we usually use a high frequency linear probe.
The high frequency linear probe is best
for structures that are superficial.
Usually, in the interscalene groove,
the interscalene nerves or the roots
of the brachial plexus lie very shallow.
Usually, two centimeters or less
even in large patients.
So, to start, I usually set my ultrasound depth
to approximately three centimeters
in an average sized patient.
I also set the frequency to general setting
or resolution setting, in skinnier patients.
To get to the interscalene groove
the best place to start is in the supraclavicular region.
The reason we start in the supraclavicular region
is that it allows us to use
a vascular structure to find the nerves.
So, when I start, I put the probe on
just posterior to the clavicle
aiming straight down the body.
In this area we will see a pulsating artery
sitting on the first rib,
as well as some pleura, possibly.
Posterior to the pulsating subclavian artery
are your nerves.
Your nerves in this setting are hyperechoic, or bright,
and have many fascicles, or dark circles, within 'em.
These are the nerves that are gonna become
the roots of the brachial plexus
as we trace backwards up the neck.
Now, to find the interscalene groove
we take our pulsating artery,
look for the nerves posterior,
and we're gonna slide the probe back up the neck.
The probe slides up the neck as well as tilts
as we move the probe up the neck.
Here, we are moving up the neck
following the upper trunk, this most superior nerve,
as we go up the neck those nerves will become
more dark and larger fascicles, or dark circles.
Now, we are up at the interscalene groove.
The interscalene groove is found by identifying
the anterior scalene muscle,
anterior here is to the left of the screen
and the middle scalene muscle
posterior to the right of the screen.
The nerves are hypoechoic, or dark, surrounded by
hyperechoic, or bright, fascial covering.
Here, we are looking at the C5 and C6 nerve roots
in the interscalene groove.
If I slide the probe anterior,
we get a carotid artery
with a internal jugular vein on top of it.
The sternocleidomastoid is above these structures.
As I slide posterior, we have out anterior scalene,
our interscalene groove,
and posterior is our middle scalene.
Here is a very good picture
of the nerve roots here and they are
sandwiched between the anterior scalene on the left
and the middle scalene on the right.
So, now, we are looking specifically
at the C5 and C6 nerve roots.
Our needle approach comes from posterior.
Usually, I start the needle
approximately one centimeter away from the probe.
In this image we see the interscalene groove
with the C5, C6 nerve roots.
The needle is passing through the middle scalene muscle.
You'll see an injection on the posterior side
of the brachial plexus.
The needle will be then moved
underneath the C6 nerve root.
An injection will be given now.
You can see the local anesthetic spreading
on the anterior side of the brachial plexus,
between the brachial plexus and the anterior scalene muscle.
And the needle is positioned below the C6 nerve roots.
I usually deposit about
20 to 30 milliliters of local anesthetic.
Some people use less to avoid
paralysis of the phrenic nerve, temporarily,
from the local anesthetic.

Brightcove ID

5508105692001

https://youtube.com/watch?v=0Cboqf1Qnhc

Body

Dr. David Auyong reviews scanning techniques and sonographic landmarks for an interscalene brachial plexus nerve block.

How to: Infraclavicular Brachial Plexus Nerve Block

Read more about How to: Infraclavicular Brachial Plexus Nerve Block

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Dr. David Auyong reviews scanning techniques and sonographic landmarks for an ultrasound guided nerve block .

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