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- Ultrasound can be a great adjunct
for peripheral vein access.
Normally, our nurses can get pretty good access
to the peripheral vein through standard palpations,
but sometimes the patient may have an edematous arm,
their arm may be obese,
you may not be able to feel an antecubital vein easily.
In addition, if the antecubital veins cannot be accessed,
we may want to access deeper veins of the arm,
those being the basilic and brachial veins.
Ultrasound provides great visualization
of all of those veins.
We're gonna go ahead and choose the linear array transducer.
This is going to allow high-frequency imaging
to give us really good image quality
for superficial structures.
Remember, these veins are superficial
so we're gonna to want to get as good image as possible.
I'm gonna go ahead and choose the exam type.
Once I've chosen this transducer,
I do have different exam types I can choose from.
I'm gonna use the Exam button
to choose the Venous preset,
hit Select.
I've already got some gel at the antecubital fossa.
I already have a tourniquet up.
So let me now take a look at his antecubital fossa
and see what veins we can identify.
Here we have the transducer marker here,
I'm gonna put it to the patient's right.
Again, it doesn't really matter when we do vascular access
if it's to the right or left,
as long as the target vein is in the center.
First thing I notice is
that I can probably decrease my Depth a little bit.
So I'm going to go ahead and do that.
I'm going to turn my Gain up a little bit.
And I notice here, right in the center of the screen,
is an an anechoic structure, that is easily collapsible.
And as you can see, with simple pressure with my hand,
this vessel easily collapses.
There's no pulsatile motion and it easily collapses.
It is also quite superficial.
If you look at the marks here
on the right hand of the screen,
this is a half centimeter mark,
this is a one centimeter mark.
This vein is only about four to five millimeters deep.
So it'd be very easy to access.
If I'm looking at the screen right now,
and I put the vein directly in the center,
that vein will be directly in the center
of the transducer below the skin.
If you can not find anything in the antecubital veins,
you may want to take a look at the deeper veins of the arm.
So now let's take a look at the brachial
and the basilic veins.
I'm gonna put a little gel, a little more medial
of the elbow, and a little bit more proximal.
I'm gonna scan transversely across the arm.
I see a large vein,
here in the center of the screen,
which is collapsible.
In fact, I see multiple veins.
You can put a pretty large catheter into here.
You can easily place a 14 or a 16 gauge catheter.
I will recommend you use a two inch catheter
in all of these cannulations.
If you use a standard angiocath, you will get a flashback.
But unfortunately, most likely the catheter will dislodge.
So this, this is a good vein here.
If you look around a little bit more laterally,
we can see other veins,
and we can see the artery as well.
Here in the center of the screen,
you see a pulsatile structure, which represents the artery.
If you're unsure, if it's a very small vessel,
is arterial venous, you can put the color flow on.
And we see classic color flow profile
of an arterial structure.
So we're now scanning just above the antecubital fossa,
a little bit medially.
We have a pretty good image here,
just above the antecubital fossa, a little bit medially.
And we see a few structures here I want to point out.
We can see an artery, here in the center.
Again, when I put a little compression on it,
you can see pulsatile flow.
Adjacent to that,
you can see a vessel which easily collapses.
This represents a venous structure,
which could be cannulated,
but it doesn't look like it's in a great location
because it sits right adjacent to the artery.
In addition, on the other side of it,
is a slightly hypoechoic structure.
This represents a nerve.
So if I was choosing a location for venous access,
I would not choose this vein,
given the proximity both to the artery and the nerve.

Brightcove ID

5508134285001

https://youtube.com/watch?v=Pga4SAD-J9U

Basilic Vein Trv

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Basilic Vein Color2

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Basilic Vein Color1

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Basilic Vein Color

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Basilic Vein with Valve Color

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3D How To: Peripherally Inserted Venous Catheter

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

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

Brightcove ID

5741617671001

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

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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