Your work and effort is an immense blessing because only The Best one can offer so much exceptional transparency, but I would still like to add something. Although in your example we are positioned in the Trendelenburg position, it is extremely important to adopt the practice of immediately clamping or closing the catheter due to a threatening air embolism, before the procedure of suturing the catheter. Perfect practice is inevitably the basic guarantee of any success. Thank you for all Your effort and work!
In invasive ventilated patients I am applying a some what higher PEEP (10-15) during the very Moment of punction in order to dilate and stiffen the IJV when possi le
Your videos are really helpful. Would really appreciate a video on ultrasound guided PICC line insertion. I have the NYSORA app but couldn’t find any resources on it. Please help 🙏🏼
Excellent video. Very informative. So I take it you must be using an 18 cm CVC? Also, we don’t use ether in the US. I hope chlorhexidine is good enough for cleaning skin. It’s not sticky though.
Mastisol (made by Eloquest) is an excellent tackifier for central line dressings. Cavilon from 3M and other skin prep products for dressings help also. 3M makes an excellent CVL dressing with CHG patch at the insertion site - has a perforation where the lumens exit that can be expanded for large bore introducer shears/Swans/MACs.
Thank you, your videos are super helpful (even) for anesthesiologists in training :) Would you mind doing a video for a difficult hemodialysis catheter insertion? And if possible, one for the emergency room when you have a patient in hemorrhagic shock and need to be super fast with both central venous catheter plus artery? Thanks a lot in advance!
Hey Claudia Friedrich! Thank you for the great suggestion. We will definitely put this on our list. Greetings to you and all your colleagues and make sure you subscribe to our channel so you don't miss these upcoming videos. Best Regards from NYSORA!!
@@nysoravideo thanks so much for your answer! Your teaching videos are brilliant and I keep looking at them with my peers and show them to my students. Do you maybe also plan a little regional anesthesia crash course of the most important blocks for what a fellow should be able to cover? I am actually moving to NYC for a clinical fellowship at Columbia University starting this July! Would be great to visit the NYSORA studios, if possible? How to get in touch? If you have a business email to reach out, I’ll respond soon. Greetings from good old Europe (currently Switzerland) 😁 sincerely, Claudia
Thanks for the comment, we will take that into account when shooting the following videos. Until then, you can check the content we have on this topic on NextLevel NYSORA platform: nextlevelcme.com/pediatric-atlas-of-ultrasound-and-nerve-stimulation-guided-regional-anesthesia
My issue is that once I get blood flashback...insert the guidewire... I cannot advance it further... I check for flashback once more... but no blood flow... I don't know why I kept losing the vein after flashback... maybe my introducer needle came out for some reason
Have faced this issue many times...it happens when the vein is collapsed either due to pt condition or applied pressure...try selecting a well filled vein while scanning or apply minimal pressure or use a smaller syringe like 5 ml
If your needle is not staying in the vein once you lift your ultrasound probe and go to thread your guide wire, you may not have enough needle length into the vein. You may want to try dropping the angle of the needle, advancing your probe until you no longer see the needle tip, then slowly advance the needle until the tip comes into view again then repeat one or two more times until you are confident your needle will stay in the vein when you lift the ultrasound. This is called “walking the needle in”.
Hello sir. This is Dr Rahat from Bangladesh. Sometime we have difficulties in doing Subclavian CV line, CV line SVC it goes to jugular vein. How can we Redirect this catheter to SVC. Thanks.
Very interesting! What do you think about bbraun catheters? If I use bbraun I can connect case with guide and needle. When I see the tip of the needle inside the IJV, I immediately insert the guide to avoid unnecessary steps (aspiration, syringe disconnection etc.). If I'm not mistaken it's Impossible with your set. Of course it isn't difficult to use syringe to aspirate blood. But if the guide is inside the needle, I will see it much better on the ultrasound. My ultrasound machine is not very good, so this way to improve needle visibility really helps me sometimes. Thank you!! Sorry for my english)) from Russia with great respect!
By all means. THere is no ONE single best technique. The videos and techniques we post are aimed at 80% of folks, but there are always more way of doing things. Best regards
A good technique to use is to try passing the wire through the catheter before even touching the patient, to ensure that the lumens are open and that there are no factory faults in the catheter and then start the actual procedure. If after vein punction the wire doesn't pass smoothly, you need to check the needle placement again with the ultrasound to make sure you are still in the internal jugular vein and that the needle hasn't moved or that you haven't accidentally went through the opposite wall of the vein, either with the needle or the guide wire (if the angle of the needle is really steep). Also make sure that the open end of the tip of the needle is facing "up" and not against the wall of the vein so that the guide wire has a clear path to go forward.
Thank you very much for the video. I like to ask how many centimeters should the dilator be inserted over the guidewire? Does the dilator go inside the IJV? Does it only dilate the skin and deeper tissues and stay just outside the IJV? How to plan for each scenario and what are the consequences of each?
Hello sir, I am new to blocks using usg guided. Few days back I prepared whole night, read lots of books,saw ur videos for usg guided spinal anesthesia, got curvilinear prove and started scanning. I couldn't see anything. Sir if u could make one nice video of the knobs and buttons and how to take out best possible images it would be very helpful.
Do you agree that it is useful to scan both the IJV as well as the carotid artery both out of plane and in plane along the accessible parts of both vessels. I think this is needed to assure that the guide-wire is perfectly inside the IJV and did not puncture the IJV wall. This will exclude the possibility of guidewire tip position in the deep tissues or double puncture from the IJV into the carotid artery. This can avoid risky dilator injury and catheter misplacement.
Can you show a detailed video of how to hold the syringe when inserting the needle while lightly aspirating at the same time? Also how do you know when you have inserted enough guide wire?
As told in the video, you can start to see arrhytmias when the guide wire is touching the right atrium. Of couse the patient needs to be ECG monitored during the procedure because of this. When you see arrhytmias, don't go forward, instead you can pull the wire out a few millimeters.
Mansoor, that is some attention to detail! Thank you for picking this up - we will fix next go around. These videos are not scripted, so sometimes in the multitasking of presentation, the brain slips up. Very best regards and keep in touch.
Any time! Thank you for watching. Do subscribe to this channel and share with your colleagues; a lot more videos are coming up soon. Greetings from NYSORA!
Video was very well done, thank you for producing this. Very off topic question though: what brand of scrubs are you wearing with the cuffed short sleeves? I'm interested in purchasing a pair myself.
In plane technique with oblique needle insertion is much safer in challenging anatomy and hypovoluemic patient Similarly inserting a left IJV requires more US skills and practise
Gracias por abrir esta polémica sobre el caso Nadal . Es importante sacar conclusiones de cara al futuro y de sus implicaciones tanto desde el punto vista profesional como especialistas en área de dolor crónico como para los deportistas quienes podrán o no tener acceso a tratamientos analgésicos o anestesicos para futuras competencias
Thank you Sebastian. Indeed, watching the video - it looks that way. A couple of colleagues, also commented the same, but then, when re-recorded the procedure - no single recording looked any better - less bloody. If you do have one, please send along to admin@nysora.com and we will feature it. Best regards
I agree. I like to see the tip at all times with either a tilt or creep maneuver. The anatomical location of the IJ to the carotid isn’t always a slam dunk.
Thank you for your feedback. We would love for you & our subscribers to submit their own videos of better ways of doing things to info@nysora.com and we will feature them on our channel. We love the opportunity to improve upon by seeing better examples. Best regards. #1 NYSORA Team.
@@kentewing2 Thank you for the feedback. Theoretically - you are correct. Indeed, ultrasound can be used for more aspects of the central line placement - from needle puncture, to monitoring needle path, to monitoring guidewire and catheter insertion. The use of ultrasound to 1) identify the position and size (filling) of the IJ is a skill that can be acquired relatively quickly. Knowing the position of the IJ alone - will substantially decrease the # of "dry punctures, and inadvertent carotid artery punctures, even if the ultrasound is not used for needle guidance. 2) Monitoring of needle (tip) advancement during IJ cannulation is the 2nd most valuable aspect of ultrasound guidance. However, this requires a lot more skill than #1, as stated in the video at 00:55 sec. 3) Monitoring guidewire and catheter insertion real time on US requires even more skill. The reality is that level of expertise and hand-eye coordination for safety with #2 and #3 is high and often not present. As an educator who teaches trainees and colleagues on a daily basis, I witness "overshooting" with needles during peripheral nerve blocks due to the loss of needle-tip position all the time. With nerve blocks, it is usually no-harm done - the needle ends up deeper in the tissue, it is recognized by the location of the injectate and correction is easy. However, with the central line - loosing track of the needle tip while relying on ultrasound can lead to serious complications, pneumothorax etc. This is why I personally prefer for most trainees that they use only step #1 and forgo ultrasound for #2 and #3. Finally, I respectfully disagree with labeling the operator's technique "sloppy". In fact, the video shows a very high degree of skill, control, dexterity, experience, and speed. This video is minimally edited - so what you see is the reality. Admittedly, the operators' large hands and some blood in the field deduct from elegance, but the best way to put this into context of one's perception of own technique is to record oneself. Many times we think we do things much better than what is documented on a recorded video. Playback of recorded videos is also an amazing tool to improve upon. Greetings and many thanks for watching the channel and commenting.
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L
I honestly do appreciate your video tutorials, you are a blessing to many.
Glad you like them! Make sure you subscribe to the channel so that you do not miss some super educational upcoming videos!
excellent explanation.You are right that applying less pressure is the key to doing this procedure
Thank you! Can you tell us more about where you practice and what NYSORA videos are the most useful to you? Best regards
Your work and effort is an immense blessing because only The Best one can offer so much exceptional transparency, but I would still like to add something. Although in your example we are positioned in the Trendelenburg position, it is extremely important to adopt the practice of immediately clamping or closing the catheter due to a threatening air embolism, before the procedure of suturing the catheter. Perfect practice is inevitably the basic guarantee of any success. Thank you for all Your effort and work!
Excellent presentation! Thank you so much!
I’m 25 and have a Hickman and this stuff is super interesting to me!
Thank you very much sir. So far this is the best way I have ever seen..please keep posting videos..
Thank you! We are happy that you find these videos helpful!
Hello! Thank you for the great video. I want to know if you make at the end control the deep of Central Venous Katheter with EKG or X-ray?
The legendary lessons .. please accept my gratitude and appreciation.. 🙏
Hi Ali Akram! Glad to hear this! Thanks!
I love NYSORA channel ❤️
Thank you for watching! Glad you like it.
Amazing video.. Could you also upload a video teaching insertion of subclavian and femoral central line?
Thank you.
Thank you so much…..the wire you call a catheter , we call it guide wire…if I am right….beautiful and made easy as always.
Sir any cases reported losting guide wire in central circulation??
very well explained . I have done 3 ijv catheter insertion successfully. hoping to do more. thankyou
Thank you for sharing this! Greetings from NYSORA!
In invasive ventilated patients I am applying a some what higher PEEP (10-15) during the very Moment of punction in order to dilate and stiffen the IJV when possi le
Your videos are really helpful. Would really appreciate a video on ultrasound guided PICC line insertion. I have the NYSORA app but couldn’t find any resources on it. Please help 🙏🏼
Hi Leresse! Great suggestion! Greetings from NYSORA!
Is it a must to aspirate every time the needle is advanced ? Or only aspirate when the needle is ultrasonographically in the lumen ?
great video !! very good tips. Greetings from Buenos Aires
Glad it was helpful!
level of explanation is mind blowing
Thank you!
So many tricks (which are minute) you can learn from legends..which can help so much😍
Excellent video. Very informative. So I take it you must be using an 18 cm CVC? Also, we don’t use ether in the US. I hope chlorhexidine is good enough for cleaning skin. It’s not sticky though.
Mastisol (made by Eloquest) is an excellent tackifier for central line dressings. Cavilon from 3M and other skin prep products for dressings help also. 3M makes an excellent CVL dressing with CHG patch at the insertion site - has a perforation where the lumens exit that can be expanded for large bore introducer shears/Swans/MACs.
That's an amazing video Dr Hadzic, great content and a must for safety of patients. Best regards from Brazil. The surgeon made me laugh a lot.
Hi Thiago, So kind of you, and we are really glad you are enjoying our work. Greetings!
It is great to continue with other central venous cannulations like subclavian, femoral, … etc
Thank you, your videos are super helpful (even) for anesthesiologists in training :)
Would you mind doing a video for a difficult hemodialysis catheter insertion?
And if possible, one for the emergency room when you have a patient in hemorrhagic shock and need to be super fast with both central venous catheter plus artery?
Thanks a lot in advance!
Hey Claudia Friedrich! Thank you for the great suggestion. We will definitely put this on our list. Greetings to you and all your colleagues and make sure you subscribe to our channel so you don't miss these upcoming videos. Best Regards from NYSORA!!
@@nysoravideo thanks so much for your answer! Your teaching videos are brilliant and I keep looking at them with my peers and show them to my students.
Do you maybe also plan a little regional anesthesia crash course of the most important blocks for what a fellow should be able to cover?
I am actually moving to NYC for a clinical fellowship at Columbia University starting this July!
Would be great to visit the NYSORA studios, if possible?
How to get in touch? If you have a business email to reach out, I’ll respond soon.
Greetings from good old Europe (currently Switzerland) 😁 sincerely, Claudia
Excellent video Hadzic sir.
Hi Ashish Ghimire! Thank you for your comment! Stay Connected! A lot more is coming soon! Greetings!
How did he know where to point on the green screen?
Superb video. Can you do a video for pediatrics as well - say a 2 month old and another on 3-4 year old. Great job. Appreciate your efforts
Thanks for the comment, we will take that into account when shooting the following videos.
Until then, you can check the content we have on this topic on NextLevel NYSORA platform:
nextlevelcme.com/pediatric-atlas-of-ultrasound-and-nerve-stimulation-guided-regional-anesthesia
So much information so much tips love this video
Glad you liked it and thanks for watching!
Your videos are great. Much love from a cert. anesthesia tech ---> current BSN student --> hopeful CRNA student
Best of luck!
that was very helpful.
Excellent video training to all sir
Thank you very much!
Very useful sir
My issue is that once I get blood flashback...insert the guidewire... I cannot advance it further... I check for flashback once more... but no blood flow... I don't know why I kept losing the vein after flashback... maybe my introducer needle came out for some reason
Have faced this issue many times...it happens when the vein is collapsed either due to pt condition or applied pressure...try selecting a well filled vein while scanning or apply minimal pressure or use a smaller syringe like 5 ml
If your needle is not staying in the vein once you lift your ultrasound probe and go to thread your guide wire, you may not have enough needle length into the vein. You may want to try dropping the angle of the needle, advancing your probe until you no longer see the needle tip, then slowly advance the needle until the tip comes into view again then repeat one or two more times until you are confident your needle will stay in the vein when you lift the ultrasound. This is called “walking the needle in”.
Hello sir.
This is Dr Rahat from Bangladesh.
Sometime we have difficulties in doing Subclavian CV line, CV line SVC it goes to jugular vein.
How can we Redirect this catheter to SVC.
Thanks.
Very interesting! What do you think about bbraun catheters? If I use bbraun I can connect case with guide and needle. When I see the tip of the needle inside the IJV, I immediately insert the guide to avoid unnecessary steps (aspiration, syringe disconnection etc.). If I'm not mistaken it's Impossible with your set.
Of course it isn't difficult to use syringe to aspirate blood. But if the guide is inside the needle, I will see it much better on the ultrasound. My ultrasound machine is not very good, so this way to improve needle visibility really helps me sometimes.
Thank you!! Sorry for my english)) from Russia with great respect!
By all means. THere is no ONE single best technique. The videos and techniques we post are aimed at 80% of folks, but there are always more way of doing things. Best regards
Thanks for the nice video...
Have you seen handheld butterfly IQ biplane needle wizard imaging. A game changer even for novices
Any specific tips on what to do if the wire doesn’t pass smoothly?
A good technique to use is to try passing the wire through the catheter before even touching the patient, to ensure that the lumens are open and that there are no factory faults in the catheter and then start the actual procedure. If after vein punction the wire doesn't pass smoothly, you need to check the needle placement again with the ultrasound to make sure you are still in the internal jugular vein and that the needle hasn't moved or that you haven't accidentally went through the opposite wall of the vein, either with the needle or the guide wire (if the angle of the needle is really steep). Also make sure that the open end of the tip of the needle is facing "up" and not against the wall of the vein so that the guide wire has a clear path to go forward.
Thank you very much for the video. I like to ask how many centimeters should the dilator be inserted over the guidewire? Does the dilator go inside the IJV? Does it only dilate the skin and deeper tissues and stay just outside the IJV? How to plan for each scenario and what are the consequences of each?
Excellent video.thanks
You are welcome!
Hello sir, I am new to blocks using usg guided. Few days back I prepared whole night, read lots of books,saw ur videos for usg guided spinal anesthesia, got curvilinear prove and started scanning. I couldn't see anything. Sir if u could make one nice video of the knobs and buttons and how to take out best possible images it would be very helpful.
U were using the wrong probe, please use the linear high frequency probe ,with depth settings 3-5 cms as mentioned in the video
thanks for sharing , kind of you to teach , good day
Hi Pravin! Thanks, you too!
Do you agree that it is useful to scan both the IJV as well as the carotid artery both out of plane and in plane along the accessible parts of both vessels. I think this is needed to assure that the guide-wire is perfectly inside the IJV and did not puncture the IJV wall. This will exclude the possibility of guidewire tip position in the deep tissues or double puncture from the IJV into the carotid artery. This can avoid risky dilator injury and catheter misplacement.
Please subtitle in Spanish, it would be very useful for many South American anesthesiologists. Thank you.
Great to have this video.Can we have usg guided lumber puncture step-by-step
Will DO just that in what of our next videos soon.
Thank you sir
Very welcome!
Can you show a detailed video of how to hold the syringe when inserting the needle while lightly aspirating at the same time? Also how do you know when you have inserted enough guide wire?
As told in the video, you can start to see arrhytmias when the guide wire is touching the right atrium. Of couse the patient needs to be ECG monitored during the procedure because of this. When you see arrhytmias, don't go forward, instead you can pull the wire out a few millimeters.
THANK YOU!!
You're welcome!
Nice display of the technique. However, at 2:40- 2:53 min, he repeatedly said "catheter" in place of the guidewire.
Mansoor, that is some attention to detail! Thank you for picking this up - we will fix next go around. These videos are not scripted, so sometimes in the multitasking of presentation, the brain slips up. Very best regards and keep in touch.
Very nice
Nice. Thanks
Very interesting!
Thanks!
Most Welcome Nelva! Make sure you subscribe to the channel so that you do not miss some super educational upcoming videos!
Thanks sir
Great info for us CRNA’s out there. Ty for the video.
Any time! Thank you for watching. Do subscribe to this channel and share with your colleagues; a lot more videos are coming up soon. Greetings from NYSORA!
subclavian aswell or only jugular?
Video was very well done, thank you for producing this. Very off topic question though: what brand of scrubs are you wearing with the cuffed short sleeves? I'm interested in purchasing a pair myself.
In plane technique with oblique needle insertion is much safer in challenging anatomy and hypovoluemic patient
Similarly inserting a left IJV requires more US skills and practise
I totally agree!
Can you please describe in more details what do you mean by “in plane with oblique needle technique” ?
Gracias por abrir esta polémica sobre el caso Nadal . Es importante sacar conclusiones de cara al futuro y de sus implicaciones tanto desde el punto vista profesional como especialistas en área de dolor crónico como para los deportistas quienes podrán o no tener acceso a tratamientos analgésicos o anestesicos para futuras competencias
Cewnik przechodzi przez zyle szyjna zewnetrzna, mozna bylo ja ominąć
👍👍
Good explanation but too much blood
Thank you Sebastian. Indeed, watching the video - it looks that way. A couple of colleagues, also commented the same, but then, when re-recorded the procedure - no single recording looked any better - less bloody. If you do have one, please send along to admin@nysora.com and we will feature it. Best regards
You keep saying catheter when you are meaning to say wire...
so no one is going to call out them casually not holding the wire for extended periods of time... cool
No
Unfortunatelly the use of US is not properly done here.
Hi Enrique! Would you care to share your experience? We're always happy to hear from our viewers. Kind regards from NYSORA's team.
That was pretty sloppy technique, both the out of plane puncture and the cannulation process itself, I expected better from NYSORA.
I agree. I like to see the tip at all times with either a tilt or creep maneuver. The anatomical location of the IJ to the carotid isn’t always a slam dunk.
Thank you for your feedback. We would love for you & our subscribers to submit their own videos of better ways of doing things to info@nysora.com and we will feature them on our channel. We love the opportunity to improve upon by seeing better examples. Best regards. #1 NYSORA Team.
@@kentewing2 Thank you for the feedback. Theoretically - you are correct. Indeed, ultrasound can be used for more aspects of the central line placement - from needle puncture, to monitoring needle path, to monitoring guidewire and catheter insertion. The use of ultrasound to 1) identify the position and size (filling) of the IJ is a skill that can be acquired relatively quickly. Knowing the position of the IJ alone - will substantially decrease the # of "dry punctures, and inadvertent carotid artery punctures, even if the ultrasound is not used for needle guidance. 2) Monitoring of needle (tip) advancement during IJ cannulation is the 2nd most valuable aspect of ultrasound guidance. However, this requires a lot more skill than #1, as stated in the video at 00:55 sec. 3) Monitoring guidewire and catheter insertion real time on US requires even more skill. The reality is that level of expertise and hand-eye coordination for safety with #2 and #3 is high and often not present. As an educator who teaches trainees and colleagues on a daily basis, I witness "overshooting" with needles during peripheral nerve blocks due to the loss of needle-tip position all the time. With nerve blocks, it is usually no-harm done - the needle ends up deeper in the tissue, it is recognized by the location of the injectate and correction is easy. However, with the central line - loosing track of the needle tip while relying on ultrasound can lead to serious complications, pneumothorax etc. This is why I personally prefer for most trainees that they use only step #1 and forgo ultrasound for #2 and #3. Finally, I respectfully disagree with labeling the operator's technique "sloppy". In fact, the video shows a very high degree of skill, control, dexterity, experience, and speed. This video is minimally edited - so what you see is the reality. Admittedly, the operators' large hands and some blood in the field deduct from elegance, but the best way to put this into context of one's perception of own technique is to record oneself. Many times we think we do things much better than what is documented on a recorded video. Playback of recorded videos is also an amazing tool to improve upon. Greetings and many thanks for watching the channel and commenting.