Procedure

Case: Central Line Bundle: Improving Patient Safety

Read more about Case: Central Line Bundle: Improving Patient Safety

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Video case study covering the 6-point central line bundle.

Applications

Cardiology

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

Case Study Videos

Subtitles

- [Voiceover] In this Soundbytes module, we'll discuss
how we can improve patient safety through a concept
known as a central line bundle.
Now the central line bundle is a six step checklist
of initiatives that can decrease both the infectious,
and mechanical complications of central line placement.
Let's begin this module by going over some of the
potential patient benefits of central venous access.
Central venous access allows more secure
vascular access in our sickest patients,
and gives us the ability to deliver
high flow infusions in these patients.
Central venous access is also a safer administration route
of vasopressors as opposed to the peripheral route.
A central line allows for better hemodynamic monitoring
of our patients, allowing you to monitor
central venous pressure, or CVP, and also
mixed venous oxygen saturation.
However there are some serious patient risks involved
with placement of a central venous catheter.
The two main groups of complications are the mechanical,
and the infectious.
Those included under mechanical complications are
pneumothorax formation, hemothorax formation,
and inadvertent arterial puncture with hematoma formation.
The second main category are the infectious complications
and central associated bloodstream infections
are increasingly recognized cause of increased
morbidity and mortality in our sickest patients.
Because of these recognized complications of
central line placement, bedside ultrasound has stepped up
to help us lower the complication rate.
Bedside ultrasound dramatically decreases
the mechanical complications of central line placement,
allowing real time guidance of the cannulating needle
into the central vein.
Bedside ultrasound is now recommended by
governmental agencies and multiple medical societies
as an aid in placement of central lines.
And over recent years there's been increasing momentum
in initiatives to decrease
central line associated infections.
Two major initiatives were the IHI 100,000 Lives Campaign
which came out in 2005, with the aim to improve
patient safety in all USA hospitals.
Also in 2006, the Joint Commissions, JCAHO
came out with the Six National Safety Goals,
also with the aim of reducing risk of
health care associated infections.
The Institute for Health Care Improvement, or IHI
recommendations for central venous access include
five major initiatives.
The first is increasing attention to hand hygiene.
Number two, adequate skin antisepsis,
number three, maximal barrier precautions,
number four, catheter site selection,
and number five, daily review of the need
for a central line.
If one adds ultrasound guidance of line placement
to the five point IHI recommendations of hand hygiene,
skin antisepsis, maximal barrier precautions,
catheter site selection, and daily review of the need
for central line, one gets to the central line
six point bundle, the current standard
for decreasing complications of central line placement.
Before performing central venous access,
it's mandatory to perform a checklist prior to the procedure
to decrease the complication rate.
The first thing one should do is to review
the patient charts for those increased procedural risks
to our patients, such as coagulopathy,
thrombocytopenia, the presence of a DVT
within the upper extremity or lower extremity veins,
or a known latex allergy.
One should obtain informed consent from our patients,
also performing a prescan ultrasound to look for a clot
in the targeted veins.
Last but not least, it's optimal and mandatory
to perform a time out procedure together
with the nursing staff.
Going through the IHI guidelines for decreasing
the complication rate for central venous access,
the first step is to wash your hands thoroughly
prior to the procedure.
As an alternative, one can consider application of
alcohol based, waterless hand cleansers which offer
additional disinfection benefit over conventional washing.
The second step for decreasing the complication rate
of central venous access, is adequate attention
to skin antisepsis.
For this initiative, Chlorhexidine is going to be optimal.
Chlorhexidine offers benefits over traditional
Povidine-iodine with regard to skin antisepsis,
and it's best to scrub the Chlorhexidine sponge
vigorously across your patient's skin for 20 seconds,
applying three Chlorhexidine scrubs sequentially
to a wide field area over the patient's skin.
The third step is adequate attention to
maximal barrier precautions during the
central venous placement procedure.
The operator and all assistants should wear a cap,
mask, sterile gown and sterile gloves
throughout the procedure.
It's important to place a wide field barrier
over the patient during the procedure
to decrease the infectious risk to our patient.
The patient should be covered from head to toe
with this wide field barrier, with only a small opening
for the insertion site of the central line.
The fourth main step within the IHI guidelines,
is adequate attention to site selection
for placement of a central venous catheter.
In general, high lines are preferred.
The internal jugular vein and subclavian vein
are associated with a decreased risk of
infectious complications to our patients.
In general, low lines are less preferred,
as placement of a catheter into the femoral vein
is associated with higher risk of infection,
and also a higher risk of DVT in our patients.
Critical actions following placement of a
central venous catheter include using sterile technique
to flush all lines of the catheter, and then putting
sterile catheter caps on all lumens.
We'll then place a sterile dressing,
like the Tegaderm shown in the picture to the upper right
over the access site, and obtain a chest radiograph
after all high lines, to look for placement
of the tip of the catheter,
and also to rule out a pneumothorax.
An optimal approach to facilitate compliance
with the central line bundle, is to create a
dedicated central line bundle cart that moves
to the patient during the actual procedure.
On this dedicated central line bundle cart,
can be included all the supplies essential
to central venous access, to facilitate easy compliance
with the steps.
In the cart can be included the chlorhexidine swabs,
all the sterile barrier supplies for the operator,
such as the cap, gown and sterile gloves,
the wide field barrier for our patient,
sterile caps to go onto the central venous catheter,
and the dressing cover, the Tegaderm to cover the site
after the procedure is completed.
One should also have the ultrasound probe
sterile sheath cover, to facilitate the use of
ultrasound in a sterile manner during the procedure.
A crucial step that's more relevant for the
critical care units, is a daily review of all
central venous lines to see if the line is truly needed.
All unessential lines should be immediately removed
from the patient, if not essential for optimal patient care,
to decrease the risk of infections to our patients.
So in conclusion, the central venous access six point bundle
can potentially decrease the complication rate
for our patients undergoing this procedure.
Remember that we get to the six point bundle
by adding ultrasound guidance of line placement
to the IHI five point recommendations as shown below.
Hand hygiene, skin antisepsis, maximal barrier precautions,
catheter site selection, going for those high lines
over the low lines, and a daily review of the
need for a central line.
Through adherence to the
central venous access six point bundle,
we can potentially make the central venous access procedure
a safer one for our patients.
Remember that, number one, we can potentially
lower the rate of mechanical complications
by using ultrasound guidance throughout the procedure.
And number two, we can potentially lower the rate of
infectious complications of the procedure,
by close adherence to the IHI guidelines.
In conclusion, hopefully we can make hospitalization
a potentially safer experience for the most ill
of our patients who are receiving central venous access,
for their treatments.
So I hope to see you back in the future,
as Soundbytes continues.

Brightcove ID

5508123477001

https://youtube.com/watch?v=hUH-B7qy-fc

Case: Ultrasound Guidance for Thoracentesis

Read more about Case: Ultrasound Guidance for Thoracentesis

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This video details how bedside ultrasound imaging can be used to guide thoracentesis, detect pleural fluid levels, and analyze patient anatomy. It also discusses patient positioning during the thoracentesis and probe placement.

Media Library Type

Media Library Tag

Congested Heart Failure

Infection

Tumors

Increased Blood Pressure

Blocked Blood Vessels

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 I'd like to begin by discussing
the case of a patient who presented with worsening
shortness of breath
and had a chest X-ray which revealed this finding.
Notice here we have the presence of
an opacified left hemithorax
and notice here that the trachea is pushed away
from the left hemithorax
suggesting the presence of a very large pleural effusion
as the cause of our patient's dyspnea.
Now if in fact this was a large pleural effusion causing
our patient's shortness of breath
a therapeutic thoracentesis would be in order
to relieve her symptoms.
This leads into the topic for this SoundBytes module
which is the use of bedside ultrasound to perform the
thoracentesis procedure.
In this module I'd like to go through how sonography
can potentially make the thoracentesis procedure
a safer one for our patients
with a decrease in the inherent complications of the
procedure, such as pneumothorax or perforation
of the diaphragm.
Before a performance of a thoracentesis procedure
it's mandatory to look with sonography
to make sure that there's enough pleural fluid
amenable for a safe thoracentesis.
Notice here we have the patient positioned in
an upright position
so that the fluid will layer out above the level
of the diaphragm.
Notice here we note the diaphragm as shown by the red line
across the patient's anterior chest wall
Notice here we have the probe positioned along the lateral
aspect of the patient's chest with a marker dot towards
the patient's head.
We can angle the probe above the diaphragm
to look for a dark or anechoic collection of fluid
consistent with a pleural effusion.
This is the ultrasound image that corresponds to the
chest X-ray from the patient as we discussed in
the beginning of the module.
We have the probe positioned across the patient's left
side of the chest,
coming in with a probe marker toward the patient's head.
We can see here, superior towards the left and
inferior towards the right,
We note the spleen and the kidney,
inferior in the abdominal compartment
and we see the white line that is the diaphragm
moving up and down as the patient breathes.
We note above the diaphragm,
superior in the chest cavity,
the presence of a large, dark or anechoic
collection of fluid,
consistent with a very large pleural effusion,
and we fail to appreciate any lung within
this pleural effusion.
Just to emphasize the point that it's very important
to look with sonography, prior to performance of a
thoracentesis procedure,
we know this pleural effusion is taken from the right chest
we see the liver towards the inferior aspect of the patient
towards the right here,
and we note above the diaphragm here,
which is moving up and down as the patient breathes,
the presence of a dark or anechoic fluid collection,
but we also see here lung within the pleural effusion
and an attachment of the lung,
a fibrinous attachment,
that attaches the lung down to the diaphragm.
So this could be potentially a complicated performance
of a thoracentesis as the needle that goes into that
chest cavity could be pushed by that fibrinous attachment
up into the lung causing a pneumothorax.
This is the first traditional position of the patient
for the thoracentesis procedure.
This is the recumbent position in which we have the patient
lying down with the head of the bed elevated.
This will encourage the fluid to layer out above
the diaphragm,
and make it more amenable to a puncture attempt.
Here we see a pleural effusion within the left hemithorax,
note the effusion as denoted by the yellow liquid
around the red lung.
Here the black star indicates the appropriate position
for the needle for the puncture point for the thoracentesis.
When performing a thoracentesis procedure the needle should
be positioned above the level of the rib,
so as to avoid the neurovascular bundle,
which as shown in this illustration lies just below
to the rib.
Here I'm demonstrating the appropriate position of the probe
to investigate for the lateral approach to the thoracentesis
this time on the right chest.
Notice the positioning of the probe,
in this case the 3 MHz probe,
on the lateral chest wall,
right above the level of the diaphragm,
to look for a pleural effusion.
Here I'll indicate the orientation of the ribs
across the lateral chest wall,
and here's about the orientation of the diaphragm.
Now remember that that diaphragm will move up and down
as the patient breathes, so we want to place the probe
above the level of the diaphragm,
to look into the thoracic cavity
for a suitable collection of fluid.
Therefore here we note the position of the needle
for the appropriate positioning of the needle
for the lateral puncture approach
to the thoracentesis procedure.
And we note again that the level of the diaphragm,
on the lateral chest wall is shown by the red line,
and we note the needle above the diaphragm,
so that it can safely enter into the thoracic cavity
and not cause a complication such as puncture the diaphragm
during the thoracentesis procedure.
Here we note the second traditional positioning of
the patient for the thoracentesis procedure,
which is the standard upright position,
in which the needle would come in from a posterior approach.
And we note the patient bending forward over a stand
or a table.
Here we see a pleural effusion within the right chest
and we note here the patient has a puncture point
that would come in, into the pleural effusion,
below the scapula but above the layer of the diaphragm.
In this video clip I'll outline some of the surface anatomy
important for the posterior approach to the
thoracentesis procedure.
Here's about the level of the scapula on the
posterior chest wall,
and this is about the level of the diaphragm,
so the appropriate positioning for the needle for
the thoracentesis procedure
would be about the level of my finger here.
And we'll just freeze that down,
there's the scapula,
and here's about the level of the diaphragm.
Notice my finger safely above the diaphragm,
so as not to puncture through the diaphragm
into the abdominal cavity.
As shown by the black star this would be the appropriate
positioning of the needle for the thoracentesis procedure.
Prior to the thoracentesis procedure
we'll investigate the pleural effusion using a 3 MHz probe.
Notice the 3 MHz probe is placed along the
posterior chest wall,
at first with the probe marker on the long axis trajectory
with the orientation of the marker towards
the patient's head.
We can then swivel the probe into the lateral orientation,
with the probe marker lateral to further investigate
above the diaphragm,
for a suitable collection of pleural effusion amenable
to a thoracentesis procedure.
A clinical pearl that can be very helpful in further
delineating the pleural effusion with regard to the
patient's anatomy is to look further with a
10 MHz high frequency linear array type probe
prior to the thoracentesis puncture.
Notice here we're placing the high frequency probe along the
posterior chest wall in the long axis configuration with the
probe marker swiveled toward the patient's head.
We can also orient the probe in between the patient's ribs
in the lateral orientation as well,
to further investigate the anatomy.
This illustration shows what the anatomy of a pleural
effusion will look like using a high frequency 10 MHz probe.
In this illustration the probe is configured in the
long axis orientation.
So we have superior to the left and inferior to the right.
We see anteriorly the chest wall and we see the
superior rib to the left and the inferior rib to the right.
We know that the parietal pleura,
that white line just deep to the ribs,
and below the parietal pleura we can see the darker
anechoic pleural effusion.
In this illustration we're actually showing here
the visceral pleura, that coats the outside of the lung,
and we can actually see the distance between the pleura
layers, the parietal pleura and the visceral pleura,
which would be the full extent of the pleural effusion.
This would be your safety zone,
or the area in which it would be safe to place a needle.
It would be not safe to place a needle any deeper
than that safety zone,
as a needle could puncture through the visceral pleura
and into the lung, causing a pneumothorax.
Here's an ultrasound image showing a very large pleural
effusion as taken with a high frequency 10 MHz probe.
Superior towards the left, inferior towards the right.
We can see the hyperechoic, or bright bone tables of the rib
both superior and inferior,
which will show us the areas of the rib to avoid
during the thoracentesis procedure.
We'd actually want to come in over the top of the inferior
rib to avoid the neurovascular bundle.
We can see here the white line making up the parietal pleura
and deep to the parietal pleura we note a large amount of
pleural effusion.
We note here the absence of a lung in the pleural effusion
so we can place the needle pretty deeply here
without causing a pneumothorax.
This ultrasound image is again taken with a high frequency
10 MHz probe,
but in this orientation the probe is configured between
the ribs in the lateral orientation.
So, all we see is the chest wall, anteriorly,
we see the parietal pleura, that white line deep to the
chest wall,
and just deep to the parietal pleura we can see the
pleural effusion as made up by the darker anechoic
collection of fluid.
Now, note here that we also see the lungs sliding
back and forth as the patient breathes,
and we can see the full extent of the pleural effusion,
or the safety zone for performance of
the thoracentesis procedure.
In this ultrasound image,
again taken with a 10 MHz high frequency probe,
we can see the diaphragm moving back and forth as
the patient breathes,
defining the lower aspect of the thoracic cavity.
Thus, it would probably be unsafe to perform a
thoracentesis at this level of the chest wall,
because we might go through the diaphragm and into
the spleen with a needle.
So, it's important to look first to ascertain
the level of the diaphragm,
and make sure that the thoracentesis needle is going
safely above the diaphragm so as not to puncture
into the abdominal compartment.
In this video clip we'll first place the
high frequency 10 MHz probe along the posterior
aspect of the chest wall to define the proper
orientation for the puncture for the posterior approach
to thoracentesis procedure.
The needle can then come in directly underneath the probe
as shown here.
Now, I'll show a wide angle shot here and note this is
the proper position for the thoracentesis needle,
as definied by sonography from the posterior approach
to thoracentesis.
In conclusion, thanks for tuning in for this SoundBytes
module going over ultrasound guidance for the
thoracentesis procedure.
Sonography can potentially make the procedure a safer one
for our patients with a decrease in the complication rate,
such as pneumothorax or perforation of the diaphragm.
We'll want to use both the 3 MHz and higher frequency 10 MHz
probes to fully evaluate the effusion in relation to
the patient's anatomy, prior to a puncture attempt.
We can either use the static technique where we position
the patient appropriately and then mark off the
puncture spot with sonography,
prior to the thoracentesis procedure.
Or, we can use a dynamic technique,
where we place the probe in a sterile sheet
and watch the needle in real-time go into the chest cavity.
So, I hope to see you back in the future
as SoundBytes continues.

Brightcove ID

5733895862001

https://youtube.com/watch?v=6ThpUpgjSiM

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.

Applications

Media Library Type

Media Library Tag

Congested Heart Failure

Infection

Tumors

Increased Blood Pressure

Blocked Blood Vessels

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.

Applications

Cardiology

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

Case Study Videos

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.

Applications

Cardiology

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

Case Study Videos

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.
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

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.

Media Library Type

How To Videos

Subtitles

- 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 .

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

- The infraclavicular block is used for surgery
below the mid-humerus.
Any surgery of the elbow, forearm, wrist or hand
can be performed under a properly executed
infraclavicular block.
Many people use curvilinear, low-frequency
or mid-frequency probe to do the infraclavicular block.
With proper positioning
you can do a infraclavicular block
with a basic linear probe.
I'm gonna demonstrate the infraclavicular block
with a basic linear probe
because most people have a linear probe
in their ultrasound repertoire.
Proper positioning for
the infraclavicular block is important.
We usually keep the patient supine
for infraclavicular block.
We also move the patient completely to the other side
of the bed of the site to be blocked.
Abduction of the arm moves the clavicle down
and out of the way of your needle.
If the arm is down by the side
our needle approach is gonna bump into the clavicle.
Usual depth settings
for infraclavicular block in a normal patient
usually range between four to six centimeters total depth.
Ultrasound probe positioning in the infraclavicular region
is done in the parasagittal plane below the clavicle.
I will orient the probe
so the left side of the screen is caudal
and the right side of the screen is cranial.
This makes sense because if I bring
the needle from the cranial side on the screen
it will also come from the right side.
The first thing we see here
is the pectoralis major
and we also will see a pectoralis minor
if I move slightly lateral.
Here we now have identified both the axillary vein
and the axillary artery.
The vein is found more caudal than the artery.
The artery is found cranial.
Around the artery we now identify our nerves.
The nerves at this level
are the cords of the brachial plexus.
Traditionally the medial cord is described as being
approximately seven to ten o'clock
on the artery in this picture.
The posterior cord is described around
six o'clock on the artery
and the lateral cord is described between three
and six o'clock on this picture.
It's difficult to see individual nerves
because this is a deep block.
So the important thing is to surround the artery
with local anesthetic.
Now if we move more medially
we see some lung on the bottom left side of the screen here.
Lateral approaches to the infraclavicular block are safer
because the more lateral you are
the less likely you are to enter the lung with your needle.
Typically we use about 20 to 30 milliliters
of local anesthetic for infraclavicular block.
Our first injection of the artery
will be below the artery.
Some studies have described a single injection
resulting in a complete brachial plexus block
by depositing our entire local anesthetic below the artery.
Usually I do my first injection below the artery
and look at the spread.
If the spread is adequate I'll stop there.
If I need to position the needle in other places
I'll go either to the lateral cord
or approximately three o'clock
and then lastly at the medial cord
which would be about ten o'clock on the artery.
Complete spread of local anesthetic around the artery
will result in a good brachial plexus block.
In this image of the infraclavicular block
we see the local anesthetic being injected
cranial to the axillary artery.
Superficial we see the pectoralis major.
The pectoralis minor's not very visible on this picture.
Deep to the artery we see the subscapularis.
The needle has now injected on the cranial side
and is being advanced deep to the artery.
And you can see the injection there below the artery
getting local anesthetic around the posterior cord.
We continued to advance the needle
so it injects around the medial cord
on the more caudal side of the artery.

Brightcove ID

5508104662001

https://youtube.com/watch?v=1xTsXuiUNiw

Body

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

How to: Axillary Nerve Block

Read more about How to: Axillary Nerve Block

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

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

- Axillary nerve blocks are used for surgery,
usually below the elbow.
If properly executed, axillary nerve block
can be performed by identifying individual nerves
or just in depositing local anesthetic
below the artery and above the axillary artery.
Axillary nerve blocks under ultrasound
can improve safety because you can view
many of the small arteries and veins in the axilla,
and avoid intravascular injection.
To properly position for the axillary nerve block,
we have moved our patient to the opposite side of the bed,
and we will now abduct the arm 90 degrees.
For the axillary nerve block,
we usually use a linear probe.
Usually axillary nerve blocks are very shallow,
so I've put my initial depth setting
to about two and a half to three centimeters.
Usually, I also set the frequency settings
to general or resolution for the axillary nerve block.
To do a properly executed axillary nerve block,
identification of the artery and vein is important.
If you find the artery,
injection below and above the axillary artery
usually results in a good nerve block.
We initially place the probe in the axilla,
and identify a pulsating artery in the axilla.
This is your axillary artery.
Now, as you can see, the pulsating artery,
there is no vein in my initial picture.
This is because the vein is collapsed
with light pressure of the probe.
It is very important to identify the axillary vein,
so you do not inject into the axillary vein.
As I let up some pressure,
you can now see the axillary vein
superficial to my pulsating artery.
Other structures visualized in this shot
include the biceps and coracobrachialis
on the right side of the screen,
and either the latissimus dorsi,
or the triceps, on the left side of the screen,
depending on what level I am at.
Our needle approach to the axillary block
is always cranial to caudal in this direction.
The reason we come cranial to caudal
is for two reasons:
the axillary vein, as you see on the picture,
usually lies caudal,
and we do not wanna puncture the axillary vein
with a needle approach from the caudal side.
Also, it's much cleaner to go through the deltoid
or the biceps, rather than the axilla.
My initial needle insertion point
will direct the needle below the artery.
If you inject below the artery,
local anesthetic can spread backwards
along the latissimus dorsi, or triceps muscle,
to get to the radial and ulnar nerves.
Here, we can see the needle,
advancing through the biceps muscle.
Our first injection is gonna be below the artery,
and you can see the needle advancing to that area.
You can see the axillary artery, and the axillary vein.
The radial nerve is located deep to the axillary artery.
The ulnar nerve is located between the artery and vein,
and the median nerve is located at nine o'clock
on the axillary artery.
Now we see the needle being advanced above the artery.
You can see the local anesthetic has already been injected
deep to the artery,
and now the median nerve is sitting on top of the artery,
at twelve o'clock.
The needle is now pushing the artery down
and injecting local anesthetic all around the artery
and the median nerve.
We then advance the needle towards the ulnar nerve,
which is now directly in front of the needle.
Our goal is to get local anesthetic
around the ulnar nerve here.
Total volume injected appears to be large,
but it is only 20 milliliters so far.
Now the ulnar nerve is visible,
floating in the local anesthetic,
in the median on top of the artery.
Next, I would like to identify the musculocutaneous nerve.
The musculocutaneous nerve is the fourth nerve
of a properly executed axillary block.
I find the musculocutaneous nerve by moving slightly distal
along the arm.
I also wanna increase the depth,
and look for a hyperechoic nerve
within the biceps or coracobrachialis muscle.
Traditionally, the musculocutaneous nerve
can be oval or triangular.
The musculocutaneous nerve is one of the brightest,
or most hyperechoic nerves in the body,
and it's easily blocked with local anesthetic
in the realm of three to five milliliters.
Here we see a hyperechoic musculocutaneous nerve
surrounded by a hyperechoic fascia.
Our needle is being advanced to the lateral portion.
The local anesthetic is now being injected
below the musculocutaneous nerve,
and now above the musculocutaneous nerve,
to give complete surrounding of that nerve.
The needle is being advanced to the biceps muscle.
You can see the pulsatile axillary artery medial as well.

Brightcove ID

5765651694001

https://youtube.com/watch?v=rG7PXuXrqbU

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

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