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- 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

Case: Detection of Pleural Fluid

Read more about Case: Detection of Pleural Fluid

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This video details the use of bedside ultrasound imaging to detect pleural fluid, grade the amount of fluid in the pleural cavity, and detect loculated pleural effusions.

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Subtitles

- Hello, my name is Phil Perera
and I'm the Emergency Ultrasound Coordinator
at the New York Presbyterian Hospital in New York City.
And welcome to SoundBytes Cases.
In this SoundBytes module,
we're going to look specifically at the
use of Bedside Ultrasound to detect Pleural Fluid.
Interestingly enough, Ultrasound has been found
to detect as little as 20 ccs of fluid
within the Pleural Space.
In contrast, a Chest X-Ray will not reliably
pick up less than 100 to 150 ccs of fluid
on an AP Film.
Now this problem is only compounded
in the Supine Trauma Patient,
where a Chest X-ray may miss a significant amount of fluid
as a Hemothorax will layer out Posteriorly
and can be very difficult to detect on this film.
For these reasons,
Bedside Ultrasound may offer a more accurate way
of diagnosing Pleural Fluid.
Here's a slide reviewing how to
perform the Ultrasound examination
for detection of Pleural Effusions.
Optimally you'll have a three megahertz probe
with a small footprint that can easily sit between the ribs
as we'll be looking into the Right Upper Quadrant
and Left Upper Quadrant areas.
In position one, we'll be coming into the
standard Right Upper Quadrant Trauma FAST exam
and position the probe into that area
just above the Liver and below the Diaphragm.
We can then angle the probe upwards into the Thoracic Cavity
to look for a Dark or Anechoic Fluid Collection
signifying Thoracic Fluid.
We can repeat the exam in the left side
as shown in probe position two.
Placing the probe into that area
of the Left Upper Quadrant Trauma FAST view.
Look first into the area above the Spleen
and below the Diaphragm
and then angle the probe upwards into
the left Thoracic Cavity.
If fluid is seen with in the Thoracic Cavity,
we can then move the probe upwards
to investigate the extent of the Effusion.
Here's a video going over how to perform the examination.
Notice here, we have a probe placed
into the Right Upper Quadrant Trauma FAST area.
Notice that we're angling the probe upwards
into the Thoracic Cavity to fully investigate
for a Pleural Effusion.
Here, I'm just superimposing
about the level of the Diaphragm
as shown in the red marker.
And notice here that the probe
is positioned coming into that area
just above the Diaphragm into the Thoracic Cavity.
Traditionally, the probe should be
in a long-axis configuration
with the marker dot towards the patient's head.
Again, if a Fluid Collection is seen,
one can then move the probe upwards
to fully investigate how big the Effusion is.
To optimize your examination,
place the patient with the head slightly upwards,
so that the fluid will layer out above the Diaphragm
allowing earlier detection of smaller amounts of fluid.
Now that we know how to perform
the Ultrasound examination for Pleural Fluid,
let's take a look at a normal Right Upper Quadrant
Pleural Examination.
The probe is configured at a long-axis type orientation
with the marker towards the patient's head.
So, we see Superior to the left, Inferior to the right.
The Liver is in the middle of the image.
And let's look above the liver.
Here we see the Diaphragm, that curving, white line
which is moving up and down as the patient breathes.
And to the left or Superior to the Diaphragm
is the Thoracic Cavity.
Now, while looking at the Thoracic Cavity here,
what we see is something called Mirror Artifact.
This occurs as a result of the sound waves
coming through the Diaphragm
and reproducing what looks like a mirror image
of the Liver within the chest.
This is a normal appearance of the Thoracic Cavity
and Mirror Artifact is something that
will be seen commonly on Bedside Sonography.
Notice, however, the absence of a Dark
or Anechoic Fluid Collection within the right chest.
Now, let's take a look at a normal
Left Upper Quadrant Pleural Exam.
Again, we're in a long-axis configuration,
so Superior to the left, Inferior to the right.
We see the Spleen in the middle of the image
and we see the Diaphragm moving up and down
as the patient breathes.
Let's look above the Diaphragm into the Thoracic Cavity.
And, again, we see that Mirror Artifact.
What it looks like is almost like
reproduction of the Spleen within the Thoracic Cavity.
So, this is a normal finding.
And one that is not to be confused with fluid.
Fluid will appear very differently
and will have the appearance of a Dark or Anechoic stripe
right above the Diaphragm.
Here's an illustration showing a positive examination
from the Right Upper Quadrant view
with a Pleural Effusion above the Diaphragm.
We're in that long-axis configuration,
so Superior to the left, Inferior to the right.
We see the Liver in the middle of the image here.
And the Diaphragm, the white line as seen
right above the Liver.
Notice in this image we have a Pleural Effusion
as represented by the Dark area of fluid,
which is immediately Superior to the Diaphragm
and tucks in there right above the Diaphragm
going up into the Thoracic Cavity.
So, this will the signature finding of a Pleural Effusion
as taken from the Trauma FAST Views,
from the Right Upper Quadrant.
And the Left Upper Quadrant will also have a similar view,
although we're just looking above the Spleen
in that orientation.
Here's a video clip showing a Small Pleural Effusion
as taken from the Left Upper Quadrant view.
Here, we see the Spleen in the middle of the image,
the Kidney Inferior to the Spleen.
And the Diaphragm, the curving white line
that's moving up and down as the patient breathes
right above the Spleen.
As we look into that area above the Diaphragm,
we actually appreciate here, the presence
of a Dark or Anechoic Fluid Collection
above the Diaphragm.
This represents a positive Pleural Effusion.
Notice that the amount of fluid is relatively small
and we can actually see the Lung moving up and down
to the left of the image here.
Here's a Moderate Plural Effusion
as taken from the Right Upper Quadrant View.
We see the Liver to the Inferior Aspect or to the right.
The curving white line making up the Diaphragm
in the middle of the image.
And fluid representing a Pleural Effusion
Superior to the Diaphragm.
Interestingly enough, we see the Lung moving around
and all the fluid compressed down
by the fluid within the chest cavity
taking on what appears to like a Liver within the chest.
And something called Hepatization of the Lung.
And this is commonly seen with a Pleural Effusion,
as it pushes in on the Lung
making it more of a solid-type organ.
Here's a Large Pleural Effusion as taken
from the Right Upper Quadrant View.
And what we see here, is the Liver Inferiorly,
the Diaphragm right above the Liver
there in the middle of the image.
And we see a large Dark or Anechoic Collection
immediately Superior to the Diaphragm.
This represents a Large Pleural Effusion.
And in the midst of the Pleural Effusion,
we can see the Lung waving around
and compressed down by all
the fluid within the Thoracic Cavity.
Again, demonstrating that Hepatization
of the Lung as it's compressed down by the Pleural Fluid.
So, this would be a Large Plural Effusion,
as there's a large amount of fluid
both Inferiorly between the Lung and the Diaphragm.
And both Anterior and Posterior to the Lung itself here.
Unfortunately, not all Plural Effusions
will be free-flowing or uncomplicated.
There are occasions where our patients
can have repeated Pleural Effusion
that can be Loculated or Complicated.
Here we see an example of a Loculated Pleural Effusion.
Notice this Lung here has an attachment
with a Fibrin area that attaches it
or glues it onto the Diaphragm Inferiorly.
Therefore, we have two Loculated areas Effusion,
both Anterior to the top of the screen and Posterior.
As the Lung is trapped within the Thoracic Cavity
by this Fibrinous Attachment to the Diaphragm,
it may be dangerous to perform an invasive procedure
like a Thoracentesis or a Chest Tube Placement.
The needle or the Chest Tube could be guided
up into the Lung causing a Pneumothorax
by the Fibrinous Attachment to the Diaphragm.
So, in conclusion, I'm glad I could share with you
this SoundBytes module going over the
Ultrasound Examination for the detection of Pleural Fluid.
As we've discussed earlier in the module,
Ultrasound may be more accurate
in detection of Pleural Fluid than a Chest X-ray.
And Ultrasound allows easy grading
of the amount of fluid within the Pleural Cavity.
It can also detect Complicated Pleural Effusions
that may be Loculated and can help determine
which patients may benefit from a Drainage Procedure
such as a Thoracentesis or a Tube Thoracostomy.
So, I hope to see you back as SoundBytes continues
and in further modules,
we'll actually look closer at
the Thoracentesis Procedure under Ultrasound guidance.

Brightcove ID

5729244712001

https://youtube.com/watch?v=X1E7OgOLzw0

Case: Central Venous Access - Part 2

Read more about Case: Central Venous Access - Part 2

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This video (part 2 of 2) details how to use bedside ultrasound imaging to map the anatomy and orientation of the internal jugular vein, as well as determine puncture point, needle depth, and needle trajectory during central venous cannulation.

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Subtitles

- Hello, my name is Phil Perera
and I'm the emergency ultrasound coordinator
at the New York Presbyterian Hospital in New York City
and welcome to Soundbytes Cases.
In this Soundbytes module entitled part two
of Ultrasound Guided Central Venous Access
we'll look further onto the use of bedside ultrasound
to make a more precise puncture attempt
on the internal jugular vein
during central venous cannulation.
As we discussed in part one, we first wanna map out
the anatomy of the internal jugular vein
by orienting the probe
in both short and long axis configurations
to fully investigate the orientation of the vessel.
We want to use the dynamic technique for real time guidance
of the needle into the vein lumen
and for this we'll need to place the probe
into a sterile sheath barrier to observe sterile precautions
during the puncture attempt.
Here's the needle coming in underneath the probe
in a short axis configuration.
Notice that the sheath needle is coming in
underneath the probe at a 45-degree angle.
And notice that we're using the sheath needle
to first determine the location of the internal jugular vein
by the ring down artifact.
We would use the same approach for the cannulating needle
coming in underneath the probe at a 45-degree angle.
As we discussed prior, the probe should be oriented
in a side-to-side orientation
with the marker down towards our left
as we stand at the head of the bed
so it orients directly to the screen indicator dot
which will be oriented towards the left
of the ultrasound screen.
Here we're localizing the internal jugular vein
using the short axis configuration.
We're coming in underneath the probe with a sheath needle
at that 45-degree plane, pushing in underneath,
and notice the ring down artifact coming in
directly on top of that internal jugular vein
telling us this is the correct puncture point.
This video clip shows why a short axis orientation
is an excellent starting point for cannulation
of an internal jugular vein.
Here we see the echogenic tip of the needle coming down
and permeating the anterior wall of the vessel
and we then note the echogenic tip of the needle
squarely inside the lumen of the vessel.
And we can see how using the short axis orientation
can guide us in a side-to-side orientation
on the patient's neck in terms of lateral needle orientation
with regard to the surface down to the vessel lumen.
When using the short axis orientation
it's important to remember the affect of probe slice
on visualization of the needle tip.
Here we see the probe position one proximally
along the needle shaft
and note in the schematic view towards the left
we see the needle with the tip
squarely inside the venous lumen.
However, the ultrasound probe is positioned more proximally
along the shaft of the needle
and thus on the ultrasound view to the right
all we visualize is the needle above the vessel
even though the needle tip
is squarely right within the vessel lumen.
So we get a false determination of the tip of the needle.
In order to accurately determine
the location of the needle tip
we need to move the probe more distally
as we advance the needle into the patient's neck
along the course of the vessel.
Here we see the probe position more distally
now in plane with the needle tip
in the schematic view towards the left.
And there we can see we can get an accurate determination
of the location of the needle tip
with regard to the venous lumen.
We see the ultrasound view towards the right,
and now we'll be able to see the echogenic tip of the needle
accurately positioned within the vessel lumen.
A second pitfall that must be avoided
when cannulating the internal jugular vein
under ultrasound guidance is to make sure
that the needle tip does not angle to the side of the vein
during a cannulation attempt.
Even though we know the orientation of the vessel
with regard to the skin,
if we don't orient the cannulating needle
along the course of the vessel
it can veer to the side of the vessel
as shown in trajectory's one and two here.
Now if we know the course of the vessel
we can accurately position the needle
so that it goes along the course of the vessel
following trajectory three into the venous lumen.
The solution to avoiding this pitfall
is to know the course of the vessel
as it runs up and down the neck.
We can do this in two ways, the first of which
is to mark two points on the vessel
using the short axis configuration.
The needle would then enter at that distal mark
and aim towards the proximal mark
passing along the course of the internal jugular vein.
We can effectively do the same thing
by passing the probe in the long axis configuration
and knowing how the needle should pass
from the top of the neck down towards the chest.
Here we use a simulation model to show the correct approach
for a short axis cannulation of the internal jugular vein.
Notice here we have the probe in a side-to-side
or short axis orientation and the needle coming in
at a 45-degree angle underneath the probe.
Now remember that we must move the probe distally
to stay in plane with the needle tip
as we advance it underneath the skin
and into the internal jugular vein.
And as we do that
we notice that we've successfully cannulated
the internal jugular vein as shown by the red flow of blood.
And here we see a side orientation of the needle
with regard to the probe.
Here's an actual cannulation of an internal jugular vein.
Notice that we see the deflection
of the anterior wall of the vessel
as the needle pushes down on that wall
followed by the appearance
of the echogenic tip of the needle
within the lumen of the vessel.
So let's watch that again.
Notice the deflection or pushing down of that anterior wall
and then as the needle permeates that anterior wall
we see the appearance of the echogenic tip of the needle
within the vessel.
Here's a different patient receiving a central line,
and notice in this clip we actually can visualize
the echogenic needle coming from the surface
and going all the way down through that anterior wall
of the internal jugular vein to park directly into the lumen
of the vessel.
This video sequence shows cannulation
of the internal jugular vein using the long axis trajectory.
Notice we swivel the probe into the long axis orientation
along the course of the internal jugular vein
as it runs up and down the patient's neck.
By convention again,
the probe marker should be oriented towards distally
or towards us as we stand at the head of the bed.
Notice the cannulating needle will come in
at a 45-degree angle under the distal aspect of the probe.
Remembering that the distal aspect of the probe
or the marker will orient
towards the left of the ultrasound screen,
we can then know to look towards the left of the screen
for the cannulating needle coming down to the vessel.
Here we're performing cannulation
of the internal jugular vein on a simulation model.
Notice here the probe is oriented
along the longitudinal or long axis course
of the internal jugular vein with the marker dot distal
or towards the patient's head.
Here we see the needle coming in at a 45-degree angle
underneath the distal aspect of the probe.
This will allow us to see the entire aspect of the needle
as it travels down from the surface
all the way down to the venous lumen
and cannulates the internal jugular vein.
Here we see the long axis approach
and the needle coming in from left to right
and we know here how the long axis orientation
is excellent for seeing vertical needle depth.
Note the needle coming through the anterior wall
of the vessel and now the needle tip
squarely within the vessel lumen.
Here we can see how the long axis orientation
allows us to plan the optimal depth for the needle tip
with regard to the venous lumen
to squarely secure a cannulation attempt.
Now this is in difference to the short axis orientation
which was better for lateral needle orientation
with regard to the vessel lumen.
So using a combination of short and long axis orientations
will allow you to see both lateral
and vertical needle orientations
with regard to the vessel lumen.
Here's a video clip in the long axis configuraiton
emphasizing the fact that the long axis view
is great for determining the needle depth.
And here we see a needle coming in from left to right
and notice how we can visualize the needle tip
smack within the vessel lumen.
Here's another long axis clip of a patient
who's receiving a central venous catheter
and we see the catheter coming in from left to right.
Notice here the needle tip
deflects the anterior wall of the vessel
pushing it down so that it almost meets the posterior wall.
Thus the needle could easily pass
through both walls of the vessel.
Using the long axis technique
one can best adjust the needle tip depth
and avoid puncturing the back wall of the vessel.
Here's another great use of the long axis technique.
Again, we're confirming that the needle tip
is located within the vessel lumen
and now we can watch as the guidewire
passes through the tip of the needle
and moves down inferiorly
down the patient's internal jugular vein.
This is a great way of confirming
that the guidewire is safely parked
within the lumen of the vessel
before threading the catheter.
Let's end this module with a possible pitfall
that can be avoided by first looking with ultrasound.
Here we have a patient who's had a prior central line
and we notice a thrombosed internal jugular vein
with echogenic material on top of the carotid artery.
When we push down with the probe
the internal jugular vein failed to compress.
In this patient it would be best
to look for an alternative area for puncture
of a central line.
In conclusion, thanks for tuning in for part two
of Ultrasound Guided Central Venous Access.
Using ultrasound for dynamic real time guidance
of the needle into the internal jugular vein
can potentially decrease the mechanical complications
of the cannulation procedure
making the procedure a safer one for our patients.
We can employ a combination
of both the short and long axis views
of the internal jugular vein for optimal results
for a cannulation attempt.
So I hope you'll consider ultrasound
during your next central line placement
and I hope to see you back as Soundbytes continues.

Brightcove ID

5743138573001

https://youtube.com/watch?v=zV3hw_QbgK4

Case: Central Venous Access - Part 1

Read more about Case: Central Venous Access - Part 1

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This video (part 1 of 2) details how the use of bedside ultrasound for placing central venous catheters can reduce the number of puncture attempts, increase patient safety, and increase procedural efficiency.

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

Brightcove ID

5743132351001

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

Case: Peripheral Venous Access - Part 2

Read more about 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

Read more about 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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