Subclavian Artery

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

Brightcove ID

5745561363001

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

3D How To: Subclavian Vein Catheter Insertion

Read more about 3D How To: Subclavian Vein Catheter Insertion

/sites/default/files/CentralVenous_SubclavianVein_edu00473_thumbnail.jpg

3D animation demonstrating an ultrasound guided insertion of a Subclavian Vein Catheter.

Applications

Cardiology

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Subtitles

- [Voiceover] A linear array transducer
with a venous exam type, is used to perform
an ultrasound guided insertion of a subclavian
vein catheter via an transverse approach.
The patient is in a supine position
with the head neutral.
The operator should stand to the patient's right side.
The transducer is placed transversely
just inferior to the mid portion of the clavicle,
with the orientation marker directed
to the patient's head at a 12 o'clock position.
The hyperechoic clavicle can be seen
in the superior portion of the ultrasound image.
The vein is dark, and anechoic,
just inferior and deep to the clavicle.
The transducer should be slowly moved one to two inches
toward the shoulder, with the face of the transducer
staying below the clavicle to obtain the best view
of the subclavian or axillary vein.
It is important to note that the lung lies directly
posterior to the vessel.
So, posterior wall puncture of the axillary vein
should be avoided.
Adjust the transducer so it is centered over the vein.
Follow the needle entry by slowly sliding the transducer
in the direction of needle advancement.
The needle will appear as a small, bright, hyperechoic dot.
When the needle tip appears, the transducer
should be advanced a short distance distally
to follow the tip of the needle trajectory,
and stay in advance of the needle entry.
The needle is slowly advanced
under direct ultrasound visualization
until the tip is seen to puncture the subclavian vein.
The probe should be moved slightly proximally and distally
to confirm that the needle tip lies
in the mid portion of the vein.

Brightcove ID

5508120188001

https://youtube.com/watch?v=IBmbc1ak5fY

3D How To: Supraclavicular Nerve Block

Read more about 3D How To: Supraclavicular Nerve Block

/sites/default/files/Supraclavicular_edu00495_thumbnail_.jpg

3D animation demonstrating an ultrasound guided Supraclavicular nerve block.

Clinical Specialties

Anesthesiology (Regional)

Media Library Type

How To Videos

Media Library Tag

Subtitles

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

Brightcove ID

5750031878001

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

Body

3D animation demonstrating an ultrasound guided Supraclavicular nerve block.

How to: Infraclavicular Brachial Plexus Nerve Block

Read more about How to: Infraclavicular Brachial Plexus Nerve Block

/sites/default/files/ST_BPB_Infraclavicular_EDU00163.jpg

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 .

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