<p begin="00:00:13.967" end="00:00:15.927" style="s2">- Ultrasound can be a great adjunct</p>
<p begin="00:00:15.927" end="00:00:17.673" style="s2">for peripheral vein access.</p>
<p begin="00:00:17.673" end="00:00:20.002" style="s2">Normally, our nurses can<br />get pretty good access</p>
<p begin="00:00:20.002" end="00:00:22.303" style="s2">to the peripheral vein<br />through standard palpations,</p>
<p begin="00:00:22.303" end="00:00:25.191" style="s2">but sometimes the patient<br />may have an edematous arm,</p>
<p begin="00:00:25.191" end="00:00:26.276" style="s2">their arm may be obese,</p>
<p begin="00:00:26.276" end="00:00:29.121" style="s2">you may not be able to feel<br />an antecubital vein easily.</p>
<p begin="00:00:29.121" end="00:00:32.451" style="s2">In addition, if the antecubital<br />veins cannot be accessed,</p>
<p begin="00:00:32.451" end="00:00:35.354" style="s2">we may want to access<br />deeper veins of the arm,</p>
<p begin="00:00:35.354" end="00:00:37.564" style="s2">those being the basilic<br />and brachial veins.</p>
<p begin="00:00:37.564" end="00:00:40.056" style="s2">Ultrasound provides great visualization</p>
<p begin="00:00:40.056" end="00:00:41.549" style="s2">of all of those veins.</p>
<p begin="00:00:41.549" end="00:00:43.741" style="s2">We're gonna go ahead and choose<br />the linear array transducer.</p>
<p begin="00:00:43.741" end="00:00:45.881" style="s2">This is going to allow<br />high-frequency imaging</p>
<p begin="00:00:45.881" end="00:00:48.073" style="s2">to give us really good image quality</p>
<p begin="00:00:48.073" end="00:00:49.893" style="s2">for superficial structures.</p>
<p begin="00:00:49.893" end="00:00:51.943" style="s2">Remember, these veins are superficial</p>
<p begin="00:00:51.943" end="00:00:55.245" style="s2">so we're gonna to want to get<br />as good image as possible.</p>
<p begin="00:00:55.245" end="00:00:57.085" style="s2">I'm gonna go ahead and<br />choose the exam type.</p>
<p begin="00:00:57.085" end="00:00:58.546" style="s2">Once I've chosen this transducer,</p>
<p begin="00:00:58.546" end="00:01:01.158" style="s2">I do have different exam<br />types I can choose from.</p>
<p begin="00:01:01.158" end="00:01:04.075" style="s2">I'm gonna use the Exam button</p>
<p begin="00:01:04.075" end="00:01:06.408" style="s2">to choose the Venous preset,</p>
<p begin="00:01:07.971" end="00:01:09.375" style="s2">hit Select.</p>
<p begin="00:01:09.375" end="00:01:11.857" style="s2">I've already got some gel<br />at the antecubital fossa.</p>
<p begin="00:01:11.857" end="00:01:13.255" style="s2">I already have a tourniquet up.</p>
<p begin="00:01:13.255" end="00:01:15.420" style="s2">So let me now take a look<br />at his antecubital fossa</p>
<p begin="00:01:15.420" end="00:01:18.017" style="s2">and see what veins we can identify.</p>
<p begin="00:01:18.017" end="00:01:19.703" style="s2">Here we have the transducer marker here,</p>
<p begin="00:01:19.703" end="00:01:21.371" style="s2">I'm gonna put it to the patient's right.</p>
<p begin="00:01:21.371" end="00:01:24.183" style="s2">Again, it doesn't really matter<br />when we do vascular access</p>
<p begin="00:01:24.183" end="00:01:25.550" style="s2">if it's to the right or left,</p>
<p begin="00:01:25.550" end="00:01:29.217" style="s2">as long as the target<br />vein is in the center.</p>
<p begin="00:01:30.742" end="00:01:32.190" style="s2">First thing I notice is</p>
<p begin="00:01:32.190" end="00:01:35.900" style="s2">that I can probably decrease<br />my Depth a little bit.</p>
<p begin="00:01:35.900" end="00:01:38.538" style="s2">So I'm going to go ahead and do that.</p>
<p begin="00:01:38.538" end="00:01:41.771" style="s2">I'm going to turn my Gain up a little bit.</p>
<p begin="00:01:41.771" end="00:01:45.438" style="s2">And I notice here, right in<br />the center of the screen,</p>
<p begin="00:01:45.438" end="00:01:49.183" style="s2">is an an anechoic structure,<br />that is easily collapsible.</p>
<p begin="00:01:49.183" end="00:01:53.520" style="s2">And as you can see, with<br />simple pressure with my hand,</p>
<p begin="00:01:53.520" end="00:01:56.592" style="s2">this vessel easily collapses.</p>
<p begin="00:01:56.592" end="00:02:00.528" style="s2">There's no pulsatile motion<br />and it easily collapses.</p>
<p begin="00:02:00.528" end="00:02:02.397" style="s2">It is also quite superficial.</p>
<p begin="00:02:02.397" end="00:02:03.490" style="s2">If you look at the marks here</p>
<p begin="00:02:03.490" end="00:02:05.529" style="s2">on the right hand of the screen,</p>
<p begin="00:02:05.529" end="00:02:06.854" style="s2">this is a half centimeter mark,</p>
<p begin="00:02:06.854" end="00:02:08.412" style="s2">this is a one centimeter mark.</p>
<p begin="00:02:08.412" end="00:02:12.579" style="s2">This vein is only about four<br />to five millimeters deep.</p>
<p begin="00:02:13.840" end="00:02:16.378" style="s2">So it'd be very easy to access.</p>
<p begin="00:02:16.378" end="00:02:18.513" style="s2">If I'm looking at the screen right now,</p>
<p begin="00:02:18.513" end="00:02:20.634" style="s2">and I put the vein directly in the center,</p>
<p begin="00:02:20.634" end="00:02:22.691" style="s2">that vein will be directly in the center</p>
<p begin="00:02:22.691" end="00:02:25.441" style="s2">of the transducer below the skin.</p>
<p begin="00:02:27.253" end="00:02:29.917" style="s2">If you can not find anything<br />in the antecubital veins,</p>
<p begin="00:02:29.917" end="00:02:32.415" style="s2">you may want to take a look at<br />the deeper veins of the arm.</p>
<p begin="00:02:32.415" end="00:02:34.320" style="s2">So now let's take a look at the brachial</p>
<p begin="00:02:34.320" end="00:02:36.748" style="s2">and the basilic veins.</p>
<p begin="00:02:36.748" end="00:02:40.748" style="s2">I'm gonna put a little<br />gel, a little more medial</p>
<p begin="00:02:42.784" end="00:02:46.879" style="s2">of the elbow, and a<br />little bit more proximal.</p>
<p begin="00:02:46.879" end="00:02:50.388" style="s2">I'm gonna scan transversely<br />across the arm.</p>
<p begin="00:02:50.388" end="00:02:51.971" style="s2">I see a large vein,</p>
<p begin="00:02:53.529" end="00:02:56.279" style="s2">here in the center of the screen,</p>
<p begin="00:02:58.694" end="00:03:00.086" style="s2">which is collapsible.</p>
<p begin="00:03:00.086" end="00:03:02.586" style="s2">In fact, I see multiple veins.</p>
<p begin="00:03:07.630" end="00:03:09.504" style="s2">You can put a pretty<br />large catheter into here.</p>
<p begin="00:03:09.504" end="00:03:12.792" style="s2">You can easily place a 14<br />or a 16 gauge catheter.</p>
<p begin="00:03:12.792" end="00:03:15.179" style="s2">I will recommend you<br />use a two inch catheter</p>
<p begin="00:03:15.179" end="00:03:17.008" style="s2">in all of these cannulations.</p>
<p begin="00:03:17.008" end="00:03:20.069" style="s2">If you use a standard angiocath,<br />you will get a flashback.</p>
<p begin="00:03:20.069" end="00:03:24.236" style="s2">But unfortunately, most likely<br />the catheter will dislodge.</p>
<p begin="00:03:25.734" end="00:03:27.629" style="s2">So this, this is a good vein here.</p>
<p begin="00:03:27.629" end="00:03:31.546" style="s2">If you look around a<br />little bit more laterally,</p>
<p begin="00:03:33.041" end="00:03:35.144" style="s2">we can see other veins,</p>
<p begin="00:03:35.144" end="00:03:38.079" style="s2">and we can see the artery as well.</p>
<p begin="00:03:38.079" end="00:03:39.859" style="s2">Here in the center of the screen,</p>
<p begin="00:03:39.859" end="00:03:43.954" style="s2">you see a pulsatile structure,<br />which represents the artery.</p>
<p begin="00:03:43.954" end="00:03:46.975" style="s2">If you're unsure, if<br />it's a very small vessel,</p>
<p begin="00:03:46.975" end="00:03:51.142" style="s2">is arterial venous, you<br />can put the color flow on.</p>
<p begin="00:03:52.021" end="00:03:55.104" style="s2">And we see classic color flow profile</p>
<p begin="00:03:56.440" end="00:03:58.523" style="s2">of an arterial structure.</p>
<p begin="00:03:59.685" end="00:04:03.321" style="s2">So we're now scanning just<br />above the antecubital fossa,</p>
<p begin="00:04:03.321" end="00:04:04.854" style="s2">a little bit medially.</p>
<p begin="00:04:04.854" end="00:04:06.704" style="s2">We have a pretty good image here,</p>
<p begin="00:04:06.704" end="00:04:10.272" style="s2">just above the antecubital<br />fossa, a little bit medially.</p>
<p begin="00:04:10.272" end="00:04:13.884" style="s2">And we see a few structures<br />here I want to point out.</p>
<p begin="00:04:13.884" end="00:04:17.008" style="s2">We can see an artery, here in the center.</p>
<p begin="00:04:17.008" end="00:04:19.530" style="s2">Again, when I put a<br />little compression on it,</p>
<p begin="00:04:19.530" end="00:04:21.780" style="s2">you can see pulsatile flow.</p>
<p begin="00:04:22.927" end="00:04:24.917" style="s2">Adjacent to that,</p>
<p begin="00:04:24.917" end="00:04:28.477" style="s2">you can see a vessel<br />which easily collapses.</p>
<p begin="00:04:28.477" end="00:04:31.143" style="s2">This represents a venous structure,</p>
<p begin="00:04:31.143" end="00:04:32.538" style="s2">which could be cannulated,</p>
<p begin="00:04:32.538" end="00:04:35.108" style="s2">but it doesn't look like<br />it's in a great location</p>
<p begin="00:04:35.108" end="00:04:38.475" style="s2">because it sits right<br />adjacent to the artery.</p>
<p begin="00:04:38.475" end="00:04:41.061" style="s2">In addition, on the other side of it,</p>
<p begin="00:04:41.061" end="00:04:44.680" style="s2">is a slightly hypoechoic structure.</p>
<p begin="00:04:44.680" end="00:04:46.458" style="s2">This represents a nerve.</p>
<p begin="00:04:46.458" end="00:04:50.148" style="s2">So if I was choosing a<br />location for venous access,</p>
<p begin="00:04:50.148" end="00:04:51.776" style="s2">I would not choose this vein,</p>
<p begin="00:04:51.776" end="00:04:55.943" style="s2">given the proximity both to<br />the artery and the nerve.</p>
