Case: Central Venous Access - Part 2
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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<p begin="00:00:11.185" end="00:00:13.239" style="s2">- Hello, my name is Phil Perera</p>
<p begin="00:00:13.239" end="00:00:15.294" style="s2">and I'm the emergency<br />ultrasound coordinator</p>
<p begin="00:00:15.294" end="00:00:17.943" style="s2">at the New York Presbyterian<br />Hospital in New York City</p>
<p begin="00:00:17.943" end="00:00:20.610" style="s2">and welcome to Soundbytes Cases.</p>
<p begin="00:00:21.457" end="00:00:23.561" style="s2">In this Soundbytes<br />module entitled part two</p>
<p begin="00:00:23.561" end="00:00:25.861" style="s2">of Ultrasound Guided Central Venous Access</p>
<p begin="00:00:25.861" end="00:00:28.253" style="s2">we'll look further onto the<br />use of bedside ultrasound</p>
<p begin="00:00:28.253" end="00:00:30.248" style="s2">to make a more precise puncture attempt</p>
<p begin="00:00:30.248" end="00:00:31.807" style="s2">on the internal jugular vein</p>
<p begin="00:00:31.807" end="00:00:33.592" style="s2">during central venous cannulation.</p>
<p begin="00:00:33.592" end="00:00:36.332" style="s2">As we discussed in part<br />one, we first wanna map out</p>
<p begin="00:00:36.332" end="00:00:38.382" style="s2">the anatomy of the internal jugular vein</p>
<p begin="00:00:38.382" end="00:00:39.654" style="s2">by orienting the probe</p>
<p begin="00:00:39.654" end="00:00:41.679" style="s2">in both short and long axis configurations</p>
<p begin="00:00:41.679" end="00:00:45.019" style="s2">to fully investigate the<br />orientation of the vessel.</p>
<p begin="00:00:45.019" end="00:00:47.645" style="s2">We want to use the dynamic<br />technique for real time guidance</p>
<p begin="00:00:47.645" end="00:00:49.406" style="s2">of the needle into the vein lumen</p>
<p begin="00:00:49.406" end="00:00:51.412" style="s2">and for this we'll need to place the probe</p>
<p begin="00:00:51.412" end="00:00:54.680" style="s2">into a sterile sheath barrier<br />to observe sterile precautions</p>
<p begin="00:00:54.680" end="00:00:56.633" style="s2">during the puncture attempt.</p>
<p begin="00:00:56.633" end="00:00:58.463" style="s2">Here's the needle coming<br />in underneath the probe</p>
<p begin="00:00:58.463" end="00:00:59.897" style="s2">in a short axis configuration.</p>
<p begin="00:00:59.897" end="00:01:02.356" style="s2">Notice that the sheath needle is coming in</p>
<p begin="00:01:02.356" end="00:01:05.649" style="s2">underneath the probe at a 45-degree angle.</p>
<p begin="00:01:05.649" end="00:01:07.551" style="s2">And notice that we're<br />using the sheath needle</p>
<p begin="00:01:07.551" end="00:01:10.268" style="s2">to first determine the location<br />of the internal jugular vein</p>
<p begin="00:01:10.268" end="00:01:12.100" style="s2">by the ring down artifact.</p>
<p begin="00:01:12.100" end="00:01:15.319" style="s2">We would use the same approach<br />for the cannulating needle</p>
<p begin="00:01:15.319" end="00:01:18.557" style="s2">coming in underneath the<br />probe at a 45-degree angle.</p>
<p begin="00:01:18.557" end="00:01:21.115" style="s2">As we discussed prior, the<br />probe should be oriented</p>
<p begin="00:01:21.115" end="00:01:22.418" style="s2">in a side-to-side orientation</p>
<p begin="00:01:22.418" end="00:01:24.343" style="s2">with the marker down towards our left</p>
<p begin="00:01:24.343" end="00:01:26.099" style="s2">as we stand at the head of the bed</p>
<p begin="00:01:26.099" end="00:01:28.320" style="s2">so it orients directly to<br />the screen indicator dot</p>
<p begin="00:01:28.320" end="00:01:30.205" style="s2">which will be oriented towards the left</p>
<p begin="00:01:30.205" end="00:01:31.709" style="s2">of the ultrasound screen.</p>
<p begin="00:01:31.709" end="00:01:33.796" style="s2">Here we're localizing<br />the internal jugular vein</p>
<p begin="00:01:33.796" end="00:01:35.490" style="s2">using the short axis configuration.</p>
<p begin="00:01:35.490" end="00:01:38.300" style="s2">We're coming in underneath<br />the probe with a sheath needle</p>
<p begin="00:01:38.300" end="00:01:41.036" style="s2">at that 45-degree plane,<br />pushing in underneath,</p>
<p begin="00:01:41.036" end="00:01:43.780" style="s2">and notice the ring<br />down artifact coming in</p>
<p begin="00:01:43.780" end="00:01:46.253" style="s2">directly on top of that<br />internal jugular vein</p>
<p begin="00:01:46.253" end="00:01:48.732" style="s2">telling us this is the<br />correct puncture point.</p>
<p begin="00:01:48.732" end="00:01:51.229" style="s2">This video clip shows why<br />a short axis orientation</p>
<p begin="00:01:51.229" end="00:01:53.835" style="s2">is an excellent starting<br />point for cannulation</p>
<p begin="00:01:53.835" end="00:01:55.670" style="s2">of an internal jugular vein.</p>
<p begin="00:01:55.670" end="00:01:57.854" style="s2">Here we see the echogenic<br />tip of the needle coming down</p>
<p begin="00:01:57.854" end="00:02:01.453" style="s2">and permeating the<br />anterior wall of the vessel</p>
<p begin="00:02:01.453" end="00:02:04.024" style="s2">and we then note the<br />echogenic tip of the needle</p>
<p begin="00:02:04.024" end="00:02:05.955" style="s2">squarely inside the lumen of the vessel.</p>
<p begin="00:02:05.955" end="00:02:08.089" style="s2">And we can see how using<br />the short axis orientation</p>
<p begin="00:02:08.089" end="00:02:10.597" style="s2">can guide us in a side-to-side orientation</p>
<p begin="00:02:10.597" end="00:02:13.985" style="s2">on the patient's neck in terms<br />of lateral needle orientation</p>
<p begin="00:02:13.985" end="00:02:17.490" style="s2">with regard to the surface<br />down to the vessel lumen.</p>
<p begin="00:02:17.490" end="00:02:19.582" style="s2">When using the short axis orientation</p>
<p begin="00:02:19.582" end="00:02:21.997" style="s2">it's important to remember<br />the affect of probe slice</p>
<p begin="00:02:21.997" end="00:02:24.052" style="s2">on visualization of the needle tip.</p>
<p begin="00:02:24.052" end="00:02:26.435" style="s2">Here we see the probe<br />position one proximally</p>
<p begin="00:02:26.435" end="00:02:27.758" style="s2">along the needle shaft</p>
<p begin="00:02:27.758" end="00:02:29.918" style="s2">and note in the schematic<br />view towards the left</p>
<p begin="00:02:29.918" end="00:02:31.616" style="s2">we see the needle with the tip</p>
<p begin="00:02:31.616" end="00:02:33.123" style="s2">squarely inside the venous lumen.</p>
<p begin="00:02:33.123" end="00:02:35.718" style="s2">However, the ultrasound probe<br />is positioned more proximally</p>
<p begin="00:02:35.718" end="00:02:37.169" style="s2">along the shaft of the needle</p>
<p begin="00:02:37.169" end="00:02:39.158" style="s2">and thus on the ultrasound<br />view to the right</p>
<p begin="00:02:39.158" end="00:02:42.177" style="s2">all we visualize is the<br />needle above the vessel</p>
<p begin="00:02:42.177" end="00:02:43.754" style="s2">even though the needle tip</p>
<p begin="00:02:43.754" end="00:02:46.055" style="s2">is squarely right within the vessel lumen.</p>
<p begin="00:02:46.055" end="00:02:48.409" style="s2">So we get a false determination<br />of the tip of the needle.</p>
<p begin="00:02:48.409" end="00:02:50.981" style="s2">In order to accurately determine</p>
<p begin="00:02:50.981" end="00:02:52.345" style="s2">the location of the needle tip</p>
<p begin="00:02:52.345" end="00:02:53.810" style="s2">we need to move the probe more distally</p>
<p begin="00:02:53.810" end="00:02:56.181" style="s2">as we advance the needle<br />into the patient's neck</p>
<p begin="00:02:56.181" end="00:02:57.647" style="s2">along the course of the vessel.</p>
<p begin="00:02:57.647" end="00:02:59.811" style="s2">Here we see the probe<br />position more distally</p>
<p begin="00:02:59.811" end="00:03:01.956" style="s2">now in plane with the needle tip</p>
<p begin="00:03:01.956" end="00:03:03.954" style="s2">in the schematic view towards the left.</p>
<p begin="00:03:03.954" end="00:03:06.160" style="s2">And there we can see we can<br />get an accurate determination</p>
<p begin="00:03:06.160" end="00:03:07.675" style="s2">of the location of the needle tip</p>
<p begin="00:03:07.675" end="00:03:09.716" style="s2">with regard to the venous lumen.</p>
<p begin="00:03:09.716" end="00:03:11.619" style="s2">We see the ultrasound<br />view towards the right,</p>
<p begin="00:03:11.619" end="00:03:14.247" style="s2">and now we'll be able to see<br />the echogenic tip of the needle</p>
<p begin="00:03:14.247" end="00:03:16.834" style="s2">accurately positioned<br />within the vessel lumen.</p>
<p begin="00:03:16.834" end="00:03:18.773" style="s2">A second pitfall that must be avoided</p>
<p begin="00:03:18.773" end="00:03:20.813" style="s2">when cannulating the internal jugular vein</p>
<p begin="00:03:20.813" end="00:03:23.112" style="s2">under ultrasound guidance is to make sure</p>
<p begin="00:03:23.112" end="00:03:25.318" style="s2">that the needle tip does not<br />angle to the side of the vein</p>
<p begin="00:03:25.318" end="00:03:26.648" style="s2">during a cannulation attempt.</p>
<p begin="00:03:26.648" end="00:03:29.423" style="s2">Even though we know the<br />orientation of the vessel</p>
<p begin="00:03:29.423" end="00:03:30.703" style="s2">with regard to the skin,</p>
<p begin="00:03:30.703" end="00:03:32.468" style="s2">if we don't orient the cannulating needle</p>
<p begin="00:03:32.468" end="00:03:33.907" style="s2">along the course of the vessel</p>
<p begin="00:03:33.907" end="00:03:35.739" style="s2">it can veer to the side of the vessel</p>
<p begin="00:03:35.739" end="00:03:38.002" style="s2">as shown in trajectory's one and two here.</p>
<p begin="00:03:38.002" end="00:03:40.150" style="s2">Now if we know the course of the vessel</p>
<p begin="00:03:40.150" end="00:03:42.033" style="s2">we can accurately position the needle</p>
<p begin="00:03:42.033" end="00:03:43.872" style="s2">so that it goes along<br />the course of the vessel</p>
<p begin="00:03:43.872" end="00:03:46.228" style="s2">following trajectory three<br />into the venous lumen.</p>
<p begin="00:03:46.228" end="00:03:48.541" style="s2">The solution to avoiding this pitfall</p>
<p begin="00:03:48.541" end="00:03:50.162" style="s2">is to know the course of the vessel</p>
<p begin="00:03:50.162" end="00:03:52.066" style="s2">as it runs up and down the neck.</p>
<p begin="00:03:52.066" end="00:03:55.528" style="s2">We can do this in two<br />ways, the first of which</p>
<p begin="00:03:55.528" end="00:03:57.195" style="s2">is to mark two points on the vessel</p>
<p begin="00:03:57.195" end="00:03:58.984" style="s2">using the short axis configuration.</p>
<p begin="00:03:58.984" end="00:04:01.980" style="s2">The needle would then<br />enter at that distal mark</p>
<p begin="00:04:01.980" end="00:04:03.914" style="s2">and aim towards the proximal mark</p>
<p begin="00:04:03.914" end="00:04:06.911" style="s2">passing along the course of<br />the internal jugular vein.</p>
<p begin="00:04:06.911" end="00:04:09.115" style="s2">We can effectively do the same thing</p>
<p begin="00:04:09.115" end="00:04:12.275" style="s2">by passing the probe in<br />the long axis configuration</p>
<p begin="00:04:12.275" end="00:04:14.178" style="s2">and knowing how the needle should pass</p>
<p begin="00:04:14.178" end="00:04:17.612" style="s2">from the top of the neck<br />down towards the chest.</p>
<p begin="00:04:17.612" end="00:04:19.861" style="s2">Here we use a simulation model<br />to show the correct approach</p>
<p begin="00:04:19.861" end="00:04:23.280" style="s2">for a short axis cannulation<br />of the internal jugular vein.</p>
<p begin="00:04:23.280" end="00:04:25.329" style="s2">Notice here we have the<br />probe in a side-to-side</p>
<p begin="00:04:25.329" end="00:04:27.995" style="s2">or short axis orientation<br />and the needle coming in</p>
<p begin="00:04:27.995" end="00:04:30.294" style="s2">at a 45-degree angle underneath the probe.</p>
<p begin="00:04:30.294" end="00:04:32.500" style="s2">Now remember that we must<br />move the probe distally</p>
<p begin="00:04:32.500" end="00:04:34.565" style="s2">to stay in plane with the needle tip</p>
<p begin="00:04:34.565" end="00:04:36.358" style="s2">as we advance it underneath the skin</p>
<p begin="00:04:36.358" end="00:04:38.457" style="s2">and into the internal jugular vein.</p>
<p begin="00:04:38.457" end="00:04:39.446" style="s2">And as we do that</p>
<p begin="00:04:39.446" end="00:04:41.257" style="s2">we notice that we've<br />successfully cannulated</p>
<p begin="00:04:41.257" end="00:04:44.856" style="s2">the internal jugular vein as<br />shown by the red flow of blood.</p>
<p begin="00:04:44.856" end="00:04:47.037" style="s2">And here we see a side<br />orientation of the needle</p>
<p begin="00:04:47.037" end="00:04:49.349" style="s2">with regard to the probe.</p>
<p begin="00:04:49.349" end="00:04:52.165" style="s2">Here's an actual cannulation<br />of an internal jugular vein.</p>
<p begin="00:04:52.165" end="00:04:54.025" style="s2">Notice that we see the deflection</p>
<p begin="00:04:54.025" end="00:04:55.765" style="s2">of the anterior wall of the vessel</p>
<p begin="00:04:55.765" end="00:04:57.668" style="s2">as the needle pushes down on that wall</p>
<p begin="00:04:57.668" end="00:04:58.904" style="s2">followed by the appearance</p>
<p begin="00:04:58.904" end="00:05:00.526" style="s2">of the echogenic tip of the needle</p>
<p begin="00:05:00.526" end="00:05:02.502" style="s2">within the lumen of the vessel.</p>
<p begin="00:05:02.502" end="00:05:03.990" style="s2">So let's watch that again.</p>
<p begin="00:05:03.990" end="00:05:07.095" style="s2">Notice the deflection or pushing<br />down of that anterior wall</p>
<p begin="00:05:07.095" end="00:05:09.492" style="s2">and then as the needle<br />permeates that anterior wall</p>
<p begin="00:05:09.492" end="00:05:12.093" style="s2">we see the appearance of the<br />echogenic tip of the needle</p>
<p begin="00:05:12.093" end="00:05:13.830" style="s2">within the vessel.</p>
<p begin="00:05:13.830" end="00:05:15.807" style="s2">Here's a different patient<br />receiving a central line,</p>
<p begin="00:05:15.807" end="00:05:17.975" style="s2">and notice in this clip<br />we actually can visualize</p>
<p begin="00:05:17.975" end="00:05:20.356" style="s2">the echogenic needle<br />coming from the surface</p>
<p begin="00:05:20.356" end="00:05:23.264" style="s2">and going all the way down<br />through that anterior wall</p>
<p begin="00:05:23.264" end="00:05:26.302" style="s2">of the internal jugular vein<br />to park directly into the lumen</p>
<p begin="00:05:26.302" end="00:05:27.724" style="s2">of the vessel.</p>
<p begin="00:05:27.724" end="00:05:29.952" style="s2">This video sequence shows cannulation</p>
<p begin="00:05:29.952" end="00:05:32.555" style="s2">of the internal jugular vein<br />using the long axis trajectory.</p>
<p begin="00:05:32.555" end="00:05:35.445" style="s2">Notice we swivel the probe<br />into the long axis orientation</p>
<p begin="00:05:35.445" end="00:05:37.896" style="s2">along the course of the<br />internal jugular vein</p>
<p begin="00:05:37.896" end="00:05:40.166" style="s2">as it runs up and down the patient's neck.</p>
<p begin="00:05:40.166" end="00:05:41.303" style="s2">By convention again,</p>
<p begin="00:05:41.303" end="00:05:43.695" style="s2">the probe marker should be<br />oriented towards distally</p>
<p begin="00:05:43.695" end="00:05:46.203" style="s2">or towards us as we stand<br />at the head of the bed.</p>
<p begin="00:05:46.203" end="00:05:48.020" style="s2">Notice the cannulating needle will come in</p>
<p begin="00:05:48.020" end="00:05:51.754" style="s2">at a 45-degree angle under the<br />distal aspect of the probe.</p>
<p begin="00:05:51.754" end="00:05:53.753" style="s2">Remembering that the<br />distal aspect of the probe</p>
<p begin="00:05:53.753" end="00:05:55.200" style="s2">or the marker will orient</p>
<p begin="00:05:55.200" end="00:05:56.796" style="s2">towards the left of the ultrasound screen,</p>
<p begin="00:05:56.796" end="00:05:58.798" style="s2">we can then know to look<br />towards the left of the screen</p>
<p begin="00:05:58.798" end="00:06:02.071" style="s2">for the cannulating needle<br />coming down to the vessel.</p>
<p begin="00:06:02.071" end="00:06:04.173" style="s2">Here we're performing cannulation</p>
<p begin="00:06:04.173" end="00:06:06.839" style="s2">of the internal jugular<br />vein on a simulation model.</p>
<p begin="00:06:06.839" end="00:06:08.699" style="s2">Notice here the probe is oriented</p>
<p begin="00:06:08.699" end="00:06:11.079" style="s2">along the longitudinal or long axis course</p>
<p begin="00:06:11.079" end="00:06:13.958" style="s2">of the internal jugular vein<br />with the marker dot distal</p>
<p begin="00:06:13.958" end="00:06:15.578" style="s2">or towards the patient's head.</p>
<p begin="00:06:15.578" end="00:06:18.176" style="s2">Here we see the needle coming<br />in at a 45-degree angle</p>
<p begin="00:06:18.176" end="00:06:20.592" style="s2">underneath the distal aspect of the probe.</p>
<p begin="00:06:20.592" end="00:06:23.175" style="s2">This will allow us to see the<br />entire aspect of the needle</p>
<p begin="00:06:23.175" end="00:06:25.278" style="s2">as it travels down from the surface</p>
<p begin="00:06:25.278" end="00:06:27.511" style="s2">all the way down to the venous lumen</p>
<p begin="00:06:27.511" end="00:06:30.573" style="s2">and cannulates the internal jugular vein.</p>
<p begin="00:06:30.573" end="00:06:32.247" style="s2">Here we see the long axis approach</p>
<p begin="00:06:32.247" end="00:06:33.968" style="s2">and the needle coming<br />in from left to right</p>
<p begin="00:06:33.968" end="00:06:36.120" style="s2">and we know here how the<br />long axis orientation</p>
<p begin="00:06:36.120" end="00:06:38.885" style="s2">is excellent for seeing<br />vertical needle depth.</p>
<p begin="00:06:38.885" end="00:06:41.241" style="s2">Note the needle coming<br />through the anterior wall</p>
<p begin="00:06:41.241" end="00:06:42.999" style="s2">of the vessel and now the needle tip</p>
<p begin="00:06:42.999" end="00:06:44.876" style="s2">squarely within the vessel lumen.</p>
<p begin="00:06:44.876" end="00:06:46.807" style="s2">Here we can see how the<br />long axis orientation</p>
<p begin="00:06:46.807" end="00:06:49.896" style="s2">allows us to plan the optimal<br />depth for the needle tip</p>
<p begin="00:06:49.896" end="00:06:51.601" style="s2">with regard to the venous lumen</p>
<p begin="00:06:51.601" end="00:06:54.839" style="s2">to squarely secure a cannulation attempt.</p>
<p begin="00:06:54.839" end="00:06:57.274" style="s2">Now this is in difference to<br />the short axis orientation</p>
<p begin="00:06:57.274" end="00:06:59.781" style="s2">which was better for<br />lateral needle orientation</p>
<p begin="00:06:59.781" end="00:07:01.871" style="s2">with regard to the vessel lumen.</p>
<p begin="00:07:01.871" end="00:07:04.894" style="s2">So using a combination of short<br />and long axis orientations</p>
<p begin="00:07:04.894" end="00:07:06.526" style="s2">will allow you to see both lateral</p>
<p begin="00:07:06.526" end="00:07:08.903" style="s2">and vertical needle orientations</p>
<p begin="00:07:08.903" end="00:07:11.489" style="s2">with regard to the vessel lumen.</p>
<p begin="00:07:11.489" end="00:07:14.108" style="s2">Here's a video clip in the<br />long axis configuraiton</p>
<p begin="00:07:14.108" end="00:07:16.502" style="s2">emphasizing the fact<br />that the long axis view</p>
<p begin="00:07:16.502" end="00:07:19.226" style="s2">is great for determining the needle depth.</p>
<p begin="00:07:19.226" end="00:07:21.388" style="s2">And here we see a needle<br />coming in from left to right</p>
<p begin="00:07:21.388" end="00:07:23.687" style="s2">and notice how we can<br />visualize the needle tip</p>
<p begin="00:07:23.687" end="00:07:25.986" style="s2">smack within the vessel lumen.</p>
<p begin="00:07:25.986" end="00:07:27.925" style="s2">Here's another long axis clip of a patient</p>
<p begin="00:07:27.925" end="00:07:29.827" style="s2">who's receiving a central venous catheter</p>
<p begin="00:07:29.827" end="00:07:32.730" style="s2">and we see the catheter<br />coming in from left to right.</p>
<p begin="00:07:32.730" end="00:07:33.912" style="s2">Notice here the needle tip</p>
<p begin="00:07:33.912" end="00:07:36.083" style="s2">deflects the anterior wall of the vessel</p>
<p begin="00:07:36.083" end="00:07:39.117" style="s2">pushing it down so that it<br />almost meets the posterior wall.</p>
<p begin="00:07:39.117" end="00:07:40.692" style="s2">Thus the needle could easily pass</p>
<p begin="00:07:40.692" end="00:07:43.163" style="s2">through both walls of the vessel.</p>
<p begin="00:07:43.163" end="00:07:44.524" style="s2">Using the long axis technique</p>
<p begin="00:07:44.524" end="00:07:46.386" style="s2">one can best adjust the needle tip depth</p>
<p begin="00:07:46.386" end="00:07:49.983" style="s2">and avoid puncturing the<br />back wall of the vessel.</p>
<p begin="00:07:49.983" end="00:07:52.656" style="s2">Here's another great use<br />of the long axis technique.</p>
<p begin="00:07:52.656" end="00:07:55.141" style="s2">Again, we're confirming<br />that the needle tip</p>
<p begin="00:07:55.141" end="00:07:56.457" style="s2">is located within the vessel lumen</p>
<p begin="00:07:56.457" end="00:07:58.449" style="s2">and now we can watch as the guidewire</p>
<p begin="00:07:58.449" end="00:08:00.313" style="s2">passes through the tip of the needle</p>
<p begin="00:08:00.313" end="00:08:02.247" style="s2">and moves down inferiorly</p>
<p begin="00:08:02.247" end="00:08:04.454" style="s2">down the patient's internal jugular vein.</p>
<p begin="00:08:04.454" end="00:08:06.220" style="s2">This is a great way of confirming</p>
<p begin="00:08:06.220" end="00:08:08.518" style="s2">that the guidewire is safely parked</p>
<p begin="00:08:08.518" end="00:08:10.018" style="s2">within the lumen of the vessel</p>
<p begin="00:08:10.018" end="00:08:11.670" style="s2">before threading the catheter.</p>
<p begin="00:08:11.670" end="00:08:13.571" style="s2">Let's end this module<br />with a possible pitfall</p>
<p begin="00:08:13.571" end="00:08:16.061" style="s2">that can be avoided by first<br />looking with ultrasound.</p>
<p begin="00:08:16.061" end="00:08:18.725" style="s2">Here we have a patient who's<br />had a prior central line</p>
<p begin="00:08:18.725" end="00:08:21.680" style="s2">and we notice a thrombosed<br />internal jugular vein</p>
<p begin="00:08:21.680" end="00:08:24.882" style="s2">with echogenic material on<br />top of the carotid artery.</p>
<p begin="00:08:24.882" end="00:08:26.253" style="s2">When we push down with the probe</p>
<p begin="00:08:26.253" end="00:08:28.386" style="s2">the internal jugular<br />vein failed to compress.</p>
<p begin="00:08:28.386" end="00:08:30.305" style="s2">In this patient it would be best</p>
<p begin="00:08:30.305" end="00:08:32.604" style="s2">to look for an alternative<br />area for puncture</p>
<p begin="00:08:32.604" end="00:08:33.821" style="s2">of a central line.</p>
<p begin="00:08:33.821" end="00:08:36.188" style="s2">In conclusion, thanks for<br />tuning in for part two</p>
<p begin="00:08:36.188" end="00:08:38.190" style="s2">of Ultrasound Guided<br />Central Venous Access.</p>
<p begin="00:08:38.190" end="00:08:41.436" style="s2">Using ultrasound for<br />dynamic real time guidance</p>
<p begin="00:08:41.436" end="00:08:43.763" style="s2">of the needle into the<br />internal jugular vein</p>
<p begin="00:08:43.763" end="00:08:46.409" style="s2">can potentially decrease<br />the mechanical complications</p>
<p begin="00:08:46.409" end="00:08:48.170" style="s2">of the cannulation procedure</p>
<p begin="00:08:48.170" end="00:08:51.566" style="s2">making the procedure a<br />safer one for our patients.</p>
<p begin="00:08:51.566" end="00:08:53.045" style="s2">We can employ a combination</p>
<p begin="00:08:53.045" end="00:08:54.626" style="s2">of both the short and long axis views</p>
<p begin="00:08:54.626" end="00:08:57.509" style="s2">of the internal jugular<br />vein for optimal results</p>
<p begin="00:08:57.509" end="00:08:59.338" style="s2">for a cannulation attempt.</p>
<p begin="00:08:59.338" end="00:09:00.969" style="s2">So I hope you'll consider ultrasound</p>
<p begin="00:09:00.969" end="00:09:03.102" style="s2">during your next central line placement</p>
<p begin="00:09:03.102" end="00:09:07.269" style="s2">and I hope to see you back<br />as Soundbytes continues.</p>
<p begin="00:00:13.239" end="00:00:15.294" style="s2">and I'm the emergency<br />ultrasound coordinator</p>
<p begin="00:00:15.294" end="00:00:17.943" style="s2">at the New York Presbyterian<br />Hospital in New York City</p>
<p begin="00:00:17.943" end="00:00:20.610" style="s2">and welcome to Soundbytes Cases.</p>
<p begin="00:00:21.457" end="00:00:23.561" style="s2">In this Soundbytes<br />module entitled part two</p>
<p begin="00:00:23.561" end="00:00:25.861" style="s2">of Ultrasound Guided Central Venous Access</p>
<p begin="00:00:25.861" end="00:00:28.253" style="s2">we'll look further onto the<br />use of bedside ultrasound</p>
<p begin="00:00:28.253" end="00:00:30.248" style="s2">to make a more precise puncture attempt</p>
<p begin="00:00:30.248" end="00:00:31.807" style="s2">on the internal jugular vein</p>
<p begin="00:00:31.807" end="00:00:33.592" style="s2">during central venous cannulation.</p>
<p begin="00:00:33.592" end="00:00:36.332" style="s2">As we discussed in part<br />one, we first wanna map out</p>
<p begin="00:00:36.332" end="00:00:38.382" style="s2">the anatomy of the internal jugular vein</p>
<p begin="00:00:38.382" end="00:00:39.654" style="s2">by orienting the probe</p>
<p begin="00:00:39.654" end="00:00:41.679" style="s2">in both short and long axis configurations</p>
<p begin="00:00:41.679" end="00:00:45.019" style="s2">to fully investigate the<br />orientation of the vessel.</p>
<p begin="00:00:45.019" end="00:00:47.645" style="s2">We want to use the dynamic<br />technique for real time guidance</p>
<p begin="00:00:47.645" end="00:00:49.406" style="s2">of the needle into the vein lumen</p>
<p begin="00:00:49.406" end="00:00:51.412" style="s2">and for this we'll need to place the probe</p>
<p begin="00:00:51.412" end="00:00:54.680" style="s2">into a sterile sheath barrier<br />to observe sterile precautions</p>
<p begin="00:00:54.680" end="00:00:56.633" style="s2">during the puncture attempt.</p>
<p begin="00:00:56.633" end="00:00:58.463" style="s2">Here's the needle coming<br />in underneath the probe</p>
<p begin="00:00:58.463" end="00:00:59.897" style="s2">in a short axis configuration.</p>
<p begin="00:00:59.897" end="00:01:02.356" style="s2">Notice that the sheath needle is coming in</p>
<p begin="00:01:02.356" end="00:01:05.649" style="s2">underneath the probe at a 45-degree angle.</p>
<p begin="00:01:05.649" end="00:01:07.551" style="s2">And notice that we're<br />using the sheath needle</p>
<p begin="00:01:07.551" end="00:01:10.268" style="s2">to first determine the location<br />of the internal jugular vein</p>
<p begin="00:01:10.268" end="00:01:12.100" style="s2">by the ring down artifact.</p>
<p begin="00:01:12.100" end="00:01:15.319" style="s2">We would use the same approach<br />for the cannulating needle</p>
<p begin="00:01:15.319" end="00:01:18.557" style="s2">coming in underneath the<br />probe at a 45-degree angle.</p>
<p begin="00:01:18.557" end="00:01:21.115" style="s2">As we discussed prior, the<br />probe should be oriented</p>
<p begin="00:01:21.115" end="00:01:22.418" style="s2">in a side-to-side orientation</p>
<p begin="00:01:22.418" end="00:01:24.343" style="s2">with the marker down towards our left</p>
<p begin="00:01:24.343" end="00:01:26.099" style="s2">as we stand at the head of the bed</p>
<p begin="00:01:26.099" end="00:01:28.320" style="s2">so it orients directly to<br />the screen indicator dot</p>
<p begin="00:01:28.320" end="00:01:30.205" style="s2">which will be oriented towards the left</p>
<p begin="00:01:30.205" end="00:01:31.709" style="s2">of the ultrasound screen.</p>
<p begin="00:01:31.709" end="00:01:33.796" style="s2">Here we're localizing<br />the internal jugular vein</p>
<p begin="00:01:33.796" end="00:01:35.490" style="s2">using the short axis configuration.</p>
<p begin="00:01:35.490" end="00:01:38.300" style="s2">We're coming in underneath<br />the probe with a sheath needle</p>
<p begin="00:01:38.300" end="00:01:41.036" style="s2">at that 45-degree plane,<br />pushing in underneath,</p>
<p begin="00:01:41.036" end="00:01:43.780" style="s2">and notice the ring<br />down artifact coming in</p>
<p begin="00:01:43.780" end="00:01:46.253" style="s2">directly on top of that<br />internal jugular vein</p>
<p begin="00:01:46.253" end="00:01:48.732" style="s2">telling us this is the<br />correct puncture point.</p>
<p begin="00:01:48.732" end="00:01:51.229" style="s2">This video clip shows why<br />a short axis orientation</p>
<p begin="00:01:51.229" end="00:01:53.835" style="s2">is an excellent starting<br />point for cannulation</p>
<p begin="00:01:53.835" end="00:01:55.670" style="s2">of an internal jugular vein.</p>
<p begin="00:01:55.670" end="00:01:57.854" style="s2">Here we see the echogenic<br />tip of the needle coming down</p>
<p begin="00:01:57.854" end="00:02:01.453" style="s2">and permeating the<br />anterior wall of the vessel</p>
<p begin="00:02:01.453" end="00:02:04.024" style="s2">and we then note the<br />echogenic tip of the needle</p>
<p begin="00:02:04.024" end="00:02:05.955" style="s2">squarely inside the lumen of the vessel.</p>
<p begin="00:02:05.955" end="00:02:08.089" style="s2">And we can see how using<br />the short axis orientation</p>
<p begin="00:02:08.089" end="00:02:10.597" style="s2">can guide us in a side-to-side orientation</p>
<p begin="00:02:10.597" end="00:02:13.985" style="s2">on the patient's neck in terms<br />of lateral needle orientation</p>
<p begin="00:02:13.985" end="00:02:17.490" style="s2">with regard to the surface<br />down to the vessel lumen.</p>
<p begin="00:02:17.490" end="00:02:19.582" style="s2">When using the short axis orientation</p>
<p begin="00:02:19.582" end="00:02:21.997" style="s2">it's important to remember<br />the affect of probe slice</p>
<p begin="00:02:21.997" end="00:02:24.052" style="s2">on visualization of the needle tip.</p>
<p begin="00:02:24.052" end="00:02:26.435" style="s2">Here we see the probe<br />position one proximally</p>
<p begin="00:02:26.435" end="00:02:27.758" style="s2">along the needle shaft</p>
<p begin="00:02:27.758" end="00:02:29.918" style="s2">and note in the schematic<br />view towards the left</p>
<p begin="00:02:29.918" end="00:02:31.616" style="s2">we see the needle with the tip</p>
<p begin="00:02:31.616" end="00:02:33.123" style="s2">squarely inside the venous lumen.</p>
<p begin="00:02:33.123" end="00:02:35.718" style="s2">However, the ultrasound probe<br />is positioned more proximally</p>
<p begin="00:02:35.718" end="00:02:37.169" style="s2">along the shaft of the needle</p>
<p begin="00:02:37.169" end="00:02:39.158" style="s2">and thus on the ultrasound<br />view to the right</p>
<p begin="00:02:39.158" end="00:02:42.177" style="s2">all we visualize is the<br />needle above the vessel</p>
<p begin="00:02:42.177" end="00:02:43.754" style="s2">even though the needle tip</p>
<p begin="00:02:43.754" end="00:02:46.055" style="s2">is squarely right within the vessel lumen.</p>
<p begin="00:02:46.055" end="00:02:48.409" style="s2">So we get a false determination<br />of the tip of the needle.</p>
<p begin="00:02:48.409" end="00:02:50.981" style="s2">In order to accurately determine</p>
<p begin="00:02:50.981" end="00:02:52.345" style="s2">the location of the needle tip</p>
<p begin="00:02:52.345" end="00:02:53.810" style="s2">we need to move the probe more distally</p>
<p begin="00:02:53.810" end="00:02:56.181" style="s2">as we advance the needle<br />into the patient's neck</p>
<p begin="00:02:56.181" end="00:02:57.647" style="s2">along the course of the vessel.</p>
<p begin="00:02:57.647" end="00:02:59.811" style="s2">Here we see the probe<br />position more distally</p>
<p begin="00:02:59.811" end="00:03:01.956" style="s2">now in plane with the needle tip</p>
<p begin="00:03:01.956" end="00:03:03.954" style="s2">in the schematic view towards the left.</p>
<p begin="00:03:03.954" end="00:03:06.160" style="s2">And there we can see we can<br />get an accurate determination</p>
<p begin="00:03:06.160" end="00:03:07.675" style="s2">of the location of the needle tip</p>
<p begin="00:03:07.675" end="00:03:09.716" style="s2">with regard to the venous lumen.</p>
<p begin="00:03:09.716" end="00:03:11.619" style="s2">We see the ultrasound<br />view towards the right,</p>
<p begin="00:03:11.619" end="00:03:14.247" style="s2">and now we'll be able to see<br />the echogenic tip of the needle</p>
<p begin="00:03:14.247" end="00:03:16.834" style="s2">accurately positioned<br />within the vessel lumen.</p>
<p begin="00:03:16.834" end="00:03:18.773" style="s2">A second pitfall that must be avoided</p>
<p begin="00:03:18.773" end="00:03:20.813" style="s2">when cannulating the internal jugular vein</p>
<p begin="00:03:20.813" end="00:03:23.112" style="s2">under ultrasound guidance is to make sure</p>
<p begin="00:03:23.112" end="00:03:25.318" style="s2">that the needle tip does not<br />angle to the side of the vein</p>
<p begin="00:03:25.318" end="00:03:26.648" style="s2">during a cannulation attempt.</p>
<p begin="00:03:26.648" end="00:03:29.423" style="s2">Even though we know the<br />orientation of the vessel</p>
<p begin="00:03:29.423" end="00:03:30.703" style="s2">with regard to the skin,</p>
<p begin="00:03:30.703" end="00:03:32.468" style="s2">if we don't orient the cannulating needle</p>
<p begin="00:03:32.468" end="00:03:33.907" style="s2">along the course of the vessel</p>
<p begin="00:03:33.907" end="00:03:35.739" style="s2">it can veer to the side of the vessel</p>
<p begin="00:03:35.739" end="00:03:38.002" style="s2">as shown in trajectory's one and two here.</p>
<p begin="00:03:38.002" end="00:03:40.150" style="s2">Now if we know the course of the vessel</p>
<p begin="00:03:40.150" end="00:03:42.033" style="s2">we can accurately position the needle</p>
<p begin="00:03:42.033" end="00:03:43.872" style="s2">so that it goes along<br />the course of the vessel</p>
<p begin="00:03:43.872" end="00:03:46.228" style="s2">following trajectory three<br />into the venous lumen.</p>
<p begin="00:03:46.228" end="00:03:48.541" style="s2">The solution to avoiding this pitfall</p>
<p begin="00:03:48.541" end="00:03:50.162" style="s2">is to know the course of the vessel</p>
<p begin="00:03:50.162" end="00:03:52.066" style="s2">as it runs up and down the neck.</p>
<p begin="00:03:52.066" end="00:03:55.528" style="s2">We can do this in two<br />ways, the first of which</p>
<p begin="00:03:55.528" end="00:03:57.195" style="s2">is to mark two points on the vessel</p>
<p begin="00:03:57.195" end="00:03:58.984" style="s2">using the short axis configuration.</p>
<p begin="00:03:58.984" end="00:04:01.980" style="s2">The needle would then<br />enter at that distal mark</p>
<p begin="00:04:01.980" end="00:04:03.914" style="s2">and aim towards the proximal mark</p>
<p begin="00:04:03.914" end="00:04:06.911" style="s2">passing along the course of<br />the internal jugular vein.</p>
<p begin="00:04:06.911" end="00:04:09.115" style="s2">We can effectively do the same thing</p>
<p begin="00:04:09.115" end="00:04:12.275" style="s2">by passing the probe in<br />the long axis configuration</p>
<p begin="00:04:12.275" end="00:04:14.178" style="s2">and knowing how the needle should pass</p>
<p begin="00:04:14.178" end="00:04:17.612" style="s2">from the top of the neck<br />down towards the chest.</p>
<p begin="00:04:17.612" end="00:04:19.861" style="s2">Here we use a simulation model<br />to show the correct approach</p>
<p begin="00:04:19.861" end="00:04:23.280" style="s2">for a short axis cannulation<br />of the internal jugular vein.</p>
<p begin="00:04:23.280" end="00:04:25.329" style="s2">Notice here we have the<br />probe in a side-to-side</p>
<p begin="00:04:25.329" end="00:04:27.995" style="s2">or short axis orientation<br />and the needle coming in</p>
<p begin="00:04:27.995" end="00:04:30.294" style="s2">at a 45-degree angle underneath the probe.</p>
<p begin="00:04:30.294" end="00:04:32.500" style="s2">Now remember that we must<br />move the probe distally</p>
<p begin="00:04:32.500" end="00:04:34.565" style="s2">to stay in plane with the needle tip</p>
<p begin="00:04:34.565" end="00:04:36.358" style="s2">as we advance it underneath the skin</p>
<p begin="00:04:36.358" end="00:04:38.457" style="s2">and into the internal jugular vein.</p>
<p begin="00:04:38.457" end="00:04:39.446" style="s2">And as we do that</p>
<p begin="00:04:39.446" end="00:04:41.257" style="s2">we notice that we've<br />successfully cannulated</p>
<p begin="00:04:41.257" end="00:04:44.856" style="s2">the internal jugular vein as<br />shown by the red flow of blood.</p>
<p begin="00:04:44.856" end="00:04:47.037" style="s2">And here we see a side<br />orientation of the needle</p>
<p begin="00:04:47.037" end="00:04:49.349" style="s2">with regard to the probe.</p>
<p begin="00:04:49.349" end="00:04:52.165" style="s2">Here's an actual cannulation<br />of an internal jugular vein.</p>
<p begin="00:04:52.165" end="00:04:54.025" style="s2">Notice that we see the deflection</p>
<p begin="00:04:54.025" end="00:04:55.765" style="s2">of the anterior wall of the vessel</p>
<p begin="00:04:55.765" end="00:04:57.668" style="s2">as the needle pushes down on that wall</p>
<p begin="00:04:57.668" end="00:04:58.904" style="s2">followed by the appearance</p>
<p begin="00:04:58.904" end="00:05:00.526" style="s2">of the echogenic tip of the needle</p>
<p begin="00:05:00.526" end="00:05:02.502" style="s2">within the lumen of the vessel.</p>
<p begin="00:05:02.502" end="00:05:03.990" style="s2">So let's watch that again.</p>
<p begin="00:05:03.990" end="00:05:07.095" style="s2">Notice the deflection or pushing<br />down of that anterior wall</p>
<p begin="00:05:07.095" end="00:05:09.492" style="s2">and then as the needle<br />permeates that anterior wall</p>
<p begin="00:05:09.492" end="00:05:12.093" style="s2">we see the appearance of the<br />echogenic tip of the needle</p>
<p begin="00:05:12.093" end="00:05:13.830" style="s2">within the vessel.</p>
<p begin="00:05:13.830" end="00:05:15.807" style="s2">Here's a different patient<br />receiving a central line,</p>
<p begin="00:05:15.807" end="00:05:17.975" style="s2">and notice in this clip<br />we actually can visualize</p>
<p begin="00:05:17.975" end="00:05:20.356" style="s2">the echogenic needle<br />coming from the surface</p>
<p begin="00:05:20.356" end="00:05:23.264" style="s2">and going all the way down<br />through that anterior wall</p>
<p begin="00:05:23.264" end="00:05:26.302" style="s2">of the internal jugular vein<br />to park directly into the lumen</p>
<p begin="00:05:26.302" end="00:05:27.724" style="s2">of the vessel.</p>
<p begin="00:05:27.724" end="00:05:29.952" style="s2">This video sequence shows cannulation</p>
<p begin="00:05:29.952" end="00:05:32.555" style="s2">of the internal jugular vein<br />using the long axis trajectory.</p>
<p begin="00:05:32.555" end="00:05:35.445" style="s2">Notice we swivel the probe<br />into the long axis orientation</p>
<p begin="00:05:35.445" end="00:05:37.896" style="s2">along the course of the<br />internal jugular vein</p>
<p begin="00:05:37.896" end="00:05:40.166" style="s2">as it runs up and down the patient's neck.</p>
<p begin="00:05:40.166" end="00:05:41.303" style="s2">By convention again,</p>
<p begin="00:05:41.303" end="00:05:43.695" style="s2">the probe marker should be<br />oriented towards distally</p>
<p begin="00:05:43.695" end="00:05:46.203" style="s2">or towards us as we stand<br />at the head of the bed.</p>
<p begin="00:05:46.203" end="00:05:48.020" style="s2">Notice the cannulating needle will come in</p>
<p begin="00:05:48.020" end="00:05:51.754" style="s2">at a 45-degree angle under the<br />distal aspect of the probe.</p>
<p begin="00:05:51.754" end="00:05:53.753" style="s2">Remembering that the<br />distal aspect of the probe</p>
<p begin="00:05:53.753" end="00:05:55.200" style="s2">or the marker will orient</p>
<p begin="00:05:55.200" end="00:05:56.796" style="s2">towards the left of the ultrasound screen,</p>
<p begin="00:05:56.796" end="00:05:58.798" style="s2">we can then know to look<br />towards the left of the screen</p>
<p begin="00:05:58.798" end="00:06:02.071" style="s2">for the cannulating needle<br />coming down to the vessel.</p>
<p begin="00:06:02.071" end="00:06:04.173" style="s2">Here we're performing cannulation</p>
<p begin="00:06:04.173" end="00:06:06.839" style="s2">of the internal jugular<br />vein on a simulation model.</p>
<p begin="00:06:06.839" end="00:06:08.699" style="s2">Notice here the probe is oriented</p>
<p begin="00:06:08.699" end="00:06:11.079" style="s2">along the longitudinal or long axis course</p>
<p begin="00:06:11.079" end="00:06:13.958" style="s2">of the internal jugular vein<br />with the marker dot distal</p>
<p begin="00:06:13.958" end="00:06:15.578" style="s2">or towards the patient's head.</p>
<p begin="00:06:15.578" end="00:06:18.176" style="s2">Here we see the needle coming<br />in at a 45-degree angle</p>
<p begin="00:06:18.176" end="00:06:20.592" style="s2">underneath the distal aspect of the probe.</p>
<p begin="00:06:20.592" end="00:06:23.175" style="s2">This will allow us to see the<br />entire aspect of the needle</p>
<p begin="00:06:23.175" end="00:06:25.278" style="s2">as it travels down from the surface</p>
<p begin="00:06:25.278" end="00:06:27.511" style="s2">all the way down to the venous lumen</p>
<p begin="00:06:27.511" end="00:06:30.573" style="s2">and cannulates the internal jugular vein.</p>
<p begin="00:06:30.573" end="00:06:32.247" style="s2">Here we see the long axis approach</p>
<p begin="00:06:32.247" end="00:06:33.968" style="s2">and the needle coming<br />in from left to right</p>
<p begin="00:06:33.968" end="00:06:36.120" style="s2">and we know here how the<br />long axis orientation</p>
<p begin="00:06:36.120" end="00:06:38.885" style="s2">is excellent for seeing<br />vertical needle depth.</p>
<p begin="00:06:38.885" end="00:06:41.241" style="s2">Note the needle coming<br />through the anterior wall</p>
<p begin="00:06:41.241" end="00:06:42.999" style="s2">of the vessel and now the needle tip</p>
<p begin="00:06:42.999" end="00:06:44.876" style="s2">squarely within the vessel lumen.</p>
<p begin="00:06:44.876" end="00:06:46.807" style="s2">Here we can see how the<br />long axis orientation</p>
<p begin="00:06:46.807" end="00:06:49.896" style="s2">allows us to plan the optimal<br />depth for the needle tip</p>
<p begin="00:06:49.896" end="00:06:51.601" style="s2">with regard to the venous lumen</p>
<p begin="00:06:51.601" end="00:06:54.839" style="s2">to squarely secure a cannulation attempt.</p>
<p begin="00:06:54.839" end="00:06:57.274" style="s2">Now this is in difference to<br />the short axis orientation</p>
<p begin="00:06:57.274" end="00:06:59.781" style="s2">which was better for<br />lateral needle orientation</p>
<p begin="00:06:59.781" end="00:07:01.871" style="s2">with regard to the vessel lumen.</p>
<p begin="00:07:01.871" end="00:07:04.894" style="s2">So using a combination of short<br />and long axis orientations</p>
<p begin="00:07:04.894" end="00:07:06.526" style="s2">will allow you to see both lateral</p>
<p begin="00:07:06.526" end="00:07:08.903" style="s2">and vertical needle orientations</p>
<p begin="00:07:08.903" end="00:07:11.489" style="s2">with regard to the vessel lumen.</p>
<p begin="00:07:11.489" end="00:07:14.108" style="s2">Here's a video clip in the<br />long axis configuraiton</p>
<p begin="00:07:14.108" end="00:07:16.502" style="s2">emphasizing the fact<br />that the long axis view</p>
<p begin="00:07:16.502" end="00:07:19.226" style="s2">is great for determining the needle depth.</p>
<p begin="00:07:19.226" end="00:07:21.388" style="s2">And here we see a needle<br />coming in from left to right</p>
<p begin="00:07:21.388" end="00:07:23.687" style="s2">and notice how we can<br />visualize the needle tip</p>
<p begin="00:07:23.687" end="00:07:25.986" style="s2">smack within the vessel lumen.</p>
<p begin="00:07:25.986" end="00:07:27.925" style="s2">Here's another long axis clip of a patient</p>
<p begin="00:07:27.925" end="00:07:29.827" style="s2">who's receiving a central venous catheter</p>
<p begin="00:07:29.827" end="00:07:32.730" style="s2">and we see the catheter<br />coming in from left to right.</p>
<p begin="00:07:32.730" end="00:07:33.912" style="s2">Notice here the needle tip</p>
<p begin="00:07:33.912" end="00:07:36.083" style="s2">deflects the anterior wall of the vessel</p>
<p begin="00:07:36.083" end="00:07:39.117" style="s2">pushing it down so that it<br />almost meets the posterior wall.</p>
<p begin="00:07:39.117" end="00:07:40.692" style="s2">Thus the needle could easily pass</p>
<p begin="00:07:40.692" end="00:07:43.163" style="s2">through both walls of the vessel.</p>
<p begin="00:07:43.163" end="00:07:44.524" style="s2">Using the long axis technique</p>
<p begin="00:07:44.524" end="00:07:46.386" style="s2">one can best adjust the needle tip depth</p>
<p begin="00:07:46.386" end="00:07:49.983" style="s2">and avoid puncturing the<br />back wall of the vessel.</p>
<p begin="00:07:49.983" end="00:07:52.656" style="s2">Here's another great use<br />of the long axis technique.</p>
<p begin="00:07:52.656" end="00:07:55.141" style="s2">Again, we're confirming<br />that the needle tip</p>
<p begin="00:07:55.141" end="00:07:56.457" style="s2">is located within the vessel lumen</p>
<p begin="00:07:56.457" end="00:07:58.449" style="s2">and now we can watch as the guidewire</p>
<p begin="00:07:58.449" end="00:08:00.313" style="s2">passes through the tip of the needle</p>
<p begin="00:08:00.313" end="00:08:02.247" style="s2">and moves down inferiorly</p>
<p begin="00:08:02.247" end="00:08:04.454" style="s2">down the patient's internal jugular vein.</p>
<p begin="00:08:04.454" end="00:08:06.220" style="s2">This is a great way of confirming</p>
<p begin="00:08:06.220" end="00:08:08.518" style="s2">that the guidewire is safely parked</p>
<p begin="00:08:08.518" end="00:08:10.018" style="s2">within the lumen of the vessel</p>
<p begin="00:08:10.018" end="00:08:11.670" style="s2">before threading the catheter.</p>
<p begin="00:08:11.670" end="00:08:13.571" style="s2">Let's end this module<br />with a possible pitfall</p>
<p begin="00:08:13.571" end="00:08:16.061" style="s2">that can be avoided by first<br />looking with ultrasound.</p>
<p begin="00:08:16.061" end="00:08:18.725" style="s2">Here we have a patient who's<br />had a prior central line</p>
<p begin="00:08:18.725" end="00:08:21.680" style="s2">and we notice a thrombosed<br />internal jugular vein</p>
<p begin="00:08:21.680" end="00:08:24.882" style="s2">with echogenic material on<br />top of the carotid artery.</p>
<p begin="00:08:24.882" end="00:08:26.253" style="s2">When we push down with the probe</p>
<p begin="00:08:26.253" end="00:08:28.386" style="s2">the internal jugular<br />vein failed to compress.</p>
<p begin="00:08:28.386" end="00:08:30.305" style="s2">In this patient it would be best</p>
<p begin="00:08:30.305" end="00:08:32.604" style="s2">to look for an alternative<br />area for puncture</p>
<p begin="00:08:32.604" end="00:08:33.821" style="s2">of a central line.</p>
<p begin="00:08:33.821" end="00:08:36.188" style="s2">In conclusion, thanks for<br />tuning in for part two</p>
<p begin="00:08:36.188" end="00:08:38.190" style="s2">of Ultrasound Guided<br />Central Venous Access.</p>
<p begin="00:08:38.190" end="00:08:41.436" style="s2">Using ultrasound for<br />dynamic real time guidance</p>
<p begin="00:08:41.436" end="00:08:43.763" style="s2">of the needle into the<br />internal jugular vein</p>
<p begin="00:08:43.763" end="00:08:46.409" style="s2">can potentially decrease<br />the mechanical complications</p>
<p begin="00:08:46.409" end="00:08:48.170" style="s2">of the cannulation procedure</p>
<p begin="00:08:48.170" end="00:08:51.566" style="s2">making the procedure a<br />safer one for our patients.</p>
<p begin="00:08:51.566" end="00:08:53.045" style="s2">We can employ a combination</p>
<p begin="00:08:53.045" end="00:08:54.626" style="s2">of both the short and long axis views</p>
<p begin="00:08:54.626" end="00:08:57.509" style="s2">of the internal jugular<br />vein for optimal results</p>
<p begin="00:08:57.509" end="00:08:59.338" style="s2">for a cannulation attempt.</p>
<p begin="00:08:59.338" end="00:09:00.969" style="s2">So I hope you'll consider ultrasound</p>
<p begin="00:09:00.969" end="00:09:03.102" style="s2">during your next central line placement</p>
<p begin="00:09:03.102" end="00:09:07.269" style="s2">and I hope to see you back<br />as Soundbytes continues.</p>
Brightcove ID
5743138573001
https://youtube.com/watch?v=zV3hw_QbgK4