My emergent USGIV in the OR

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DrAmir0078

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Dear Fellows,
This is my video performing an USGIV emergently on a patient in the Ortho OR who experienced bleeding.
Just an hour ago!
Preparation time is one minute, procedure less than a minute.
I presented the idea of keeping the tip in the middle of the vein (Basilic vein)

Thanks for watching

Amir


 
Thanks for sharing! Is this how you were taught US guided IV cannulation in Iraq?

I'm inexperienced and self-taught, but my technique is somewhat similar to yours. Can someone please critique my method and offer suggestions if they see a big red flag?

1. Typically I map out the vessel and decide the entry point for the skin and vessel and then what direction it will be heading once I'm in the lumen. (The "skin entry" point is just a point in line with the vessel trajectory that will minimise distance travelled and potential collisions with nasties).
2. Line those three points up and penetrate the skin while the US is viewing the vessel where I want to penetrate it (in a transverse plane).
3. Get the tip into the vessel.
4. (Hardest bit for me when I started) slip the cannula over the needle without shredding the vessel wall/bending the cannula.
- I overcome this by doing what DrAmir does above. I.e. once I've visualised the tip in the lumen I advance 1/2mm-1mm and then shift the US probe up, advance and shift, advance and shift. This usually takes about 3-5seconds total and as I get more experienced I'm almost moving both hands simultaneously while keeping the advancing needle tip in view at all times. This way I'm sure I'm in the lumen for a good few mm and the cannula is easily advanced over the needle.

Issues I'm aware of with my approach:
- Apparently, the "proper way" to do these is with an in-plane approach, but I've never tried it before.
- Apparently, the "proper, proper way" to do these is with a complex Pythagorean equation and depth markers displayed on the US screen. You work out your triangle and you know exactly how far you need to advance the needle and to what 3-D point before you hit red gold, which makes sense and is kind of what we do without really thinking about it. However, what I don't understand is how this enables you to get the cannula in easier?
- I KNOW that I map out the vein before I prick and therefore I am comfortabe advancing US probe and needle together without looking ahead once I'm in the lumen, however... when I saw another registrar doing this it made me feel very uneasy about what vessel twist/turn/disaster was 1mm ahead of the probes vision. It making me second guess my approach having watched someone else.

Cheers.
 
Thanks for sharing! Is this how you were taught US guided IV cannulation in Iraq?

I'm inexperienced and self-taught, but my technique is somewhat similar to yours. Can someone please critique my method and offer suggestions if they see a big red flag?

1. Typically I map out the vessel and decide the entry point for the skin and vessel and then what direction it will be heading once I'm in the lumen. (The "skin entry" point is just a point in line with the vessel trajectory that will minimise distance travelled and potential collisions with nasties).
2. Line those three points up and penetrate the skin while the US is viewing the vessel where I want to penetrate it (in a transverse plane).
3. Get the tip into the vessel.
4. (Hardest bit for me when I started) slip the cannula over the needle without shredding the vessel wall/bending the cannula.
- I overcome this by doing what DrAmir does above. I.e. once I've visualised the tip in the lumen I advance 1/2mm-1mm and then shift the US probe up, advance and shift, advance and shift. This usually takes about 3-5seconds total and as I get more experienced I'm almost moving both hands simultaneously while keeping the advancing needle tip in view at all times. This way I'm sure I'm in the lumen for a good few mm and the cannula is easily advanced over the needle.

Issues I'm aware of with my approach:
- Apparently, the "proper way" to do these is with an in-plane approach, but I've never tried it before.
- Apparently, the "proper, proper way" to do these is with a complex Pythagorean equation and depth markers displayed on the US screen. You work out your triangle and you know exactly how far you need to advance the needle and to what 3-D point before you hit red gold, which makes sense and is kind of what we do without really thinking about it. However, what I don't understand is how this enables you to get the cannula in easier?
- I KNOW that I map out the vein before I prick and therefore I am comfortabe advancing US probe and needle together without looking ahead once I'm in the lumen, however... when I saw another registrar doing this it made me feel very uneasy about what vessel twist/turn/disaster was 1mm ahead of the probes vision. It making me second guess my approach having watched someone else.

Cheers.
Thanks for sharing your technique Dr. Woopedazz!
I learned this technique while I was working as a Technician at the George Washington University Hospital 2009 - 2016, probably a year or so after hiring, I entered a 3 hours course run by an Attending ER professor, then we learned how to do it.
Honestly, I was for about 2 years doing straight forward technique (once you get flush, advance the catheter, it is awesome quick unless you don't move your hand and the pressure you made by the probe on the skin, otherwise any movement especially releasing the pressure will make the tip goes back and you advance in the tissue which will lead to kincking unfortunately) then I found out Pythagoras Triangle complex is the key, then I learned from a technique (Andrew) was moving the probe proximally until the tip of the needle fade out then advance again the Cannula with the needle to revisualize the tip, as you said and I presented it took less than 10 seconds to repeat it more and more to make sure you are getting a good length of the catheter inside the vein, then take the needle out and you are good to go!
Some veins in the arm are 4 cm depth or more, so you need longer catheter like 2.25 inches and what I do, my angle is 80 to 85 degree and believe me it works!

Your steps as long it is good and successful, go for it brother!

I commented yesterday about this technique in another post who was complaining of infiltration!

Cheers
 
That's how I learned to do USG IVs in peds fellowship. My chairman used to stress the "bullseye" method like the video shows. Get the best picture of the vessel and get it in the middle of the probe. Then look at the depth of the vessel and then using fuzzy math poke and go at an angle that will get the tip into the middle of the vessel. I can't stress this to residents enough... whether it's for IV access or blocks. They seem to just get the image but then have no idea about the dimensions they are looking at... I say "wait... how far away is the vessel/nerve? It's 2cm deep and 2cm in the middle, so why are you aiming too deep or shallow or why is your needle so far away from the probe?" Amazed at how often they are hubbed on a 2" needle and they are still not reaching their target which is only 1cm deep...

Anywho... once I get the needle tip in middle of the vessel (bullseye), I scan up a little and push in a little. Then scan up a little and push in a little. Do this for a few millimeters and thread the catheter. If I'm training someone I'll have them hub the catheter and just remove the needle to get them better at it. But usually only need to go in a few millimeters.
 
That's how I learned to do USG IVs in peds fellowship. My chairman used to stress the "bullseye" method like the video shows. Get the best picture of the vessel and get it in the middle of the probe. Then look at the depth of the vessel and then using fuzzy math poke and go at an angle that will get the tip into the middle of the vessel. I can't stress this to residents enough... whether it's for IV access or blocks. They seem to just get the image but then have no idea about the dimensions they are looking at... I say "wait... how far away is the vessel/nerve? It's 2cm deep and 2cm in the middle, so why are you aiming too deep or shallow or why is your needle so far away from the probe?" Amazed at how often they are hubbed on a 2" needle and they are still not reaching their target which is only 1cm deep...

Anywho... once I get the needle tip in middle of the vessel (bullseye), I scan up a little and push in a little. Then scan up a little and push in a little. Do this for a few millimeters and thread the catheter. If I'm training someone I'll have them hub the catheter and just remove the needle to get them better at it. But usually only need to go in a few millimeters.
Loved the way you explained it Dr. Sigrhoillusion

no matter how deep the vein is and where is located next to an artery or nerve (just not behind a bone), as long as I have the enough length of the catheter, this vien is under my custody !

This vein in the video was poked by 17 guage catheter!
 
Sounds like some other things were going on in the patient. Based on the alarm sounds...... good iv
It was an exploration of GSW in the lower limb, lots of bleeding came out and we all get freaked out, but I remembered I was talking about USGIV the other day, and told the Anesthesia Tech to video me and to post it here !
Thanks Dr. Narcusprince !
 
Very cool. Also interesting how you guys talk in english during this
I meant to talk in English so I can posted here after I uploaded it to YouTube (unlisted) specifically for this forum and my Facebook group.
Thanks Dr. Psai
 
Well done. I must say that seems like a very nice ultrasound! aren't you in a resource poor area lol!

And in terms of IV placement i think as long as it works its fine. some people do it in plane, some out of plane, most ive seen have been out of plane. what you did is how it's usually taught.
 
Well done. I must say that seems like a very nice ultrasound! aren't you in a resource poor area lol!

And in terms of IV placement i think as long as it works its fine. some people do it in plane, some out of plane, most ive seen have been out of plane. what you did is how it's usually taught.

Dr. Anbuitachi,
Thanks a lot for reviewing my video !
Yes, we are in a resource poor area; this machine was just before the government austerity campaign starts in 2014, as I heard whatever medicine you ask, they will provided to you, but after the government entered in a shortage due to politics and corruption, they set the priorities.
As I heard this machine was provided by a biomed supply company after the tender approved to them, they sent our Anesthesiologists for a week training in Jordan about how to use this UltraSound machine, I mean how to operate it.
Once I came back from the US, I was truly amazed that we have a used second hand US machine in the ER (I started as SHO in General surgery prior to switch to Anesthesia 7 months later in mid of the last year) and I used it for my trauma patients and then in the OR, I noticed this one, and it didn't take few minutes to learn how to operate it and although the picture is really bad compared to Sonosite Machine the one I used to work with at GWUH.

It is true, as long as you are comfortable, do it !
 
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