Hello Ki-Jinn, great video as usual. I have personally switched to long access view, amazingly easy and safe approach with a full in-plane view of the needle.
Thanks for the useful insight! What is the size of your probe? Presumably the foot print is relatively small, or do you just "ride" the distal edge of the probe up onto the clavicle to create more space for your needle entry? I also know that you are very skilled and experienced at achieving needle-beam alignment, so I'm not surprised it works well in your hands.
@@KiJinnChin Give it a try. Much easier than the short access technique. All your points are valid, a small hockey stick is nicer but a regular linear works well too. Another tip: no syringe 😂
Thanks you for sharing your videos about techniques and tips ! They are really helpful and inspiring! Is there any suggestions on neonatal IJV insertion(using the same principle?)
This is not something I have direct experience of; I only did LMG insertions during training. But I would say that (1) handling of equipment will require a lot less force, since tissues are likely to be thin and fragile (2) more control is needed with needle advancement since distances and diameters are smaller; think about how to brace your hands appropriately (3) smaller footprint probe for sure. Otherwise many of the same principles would apply. I might use warmed-up saline for contact to prevent temp loss in these little ones.
Great video. Love your series! Do you have one for femoral vein cannulation under US guidance? I find femoral like insertions to be the most difficult using the US.
I don't have one yet, but I'd be curious to know what you find difficult about the procedure. Off the top of my head, I would say that (1) in obese patients, get some help with retracting the pannus, either with broad tape, or an assistant (2) tracking the needle tip by sliding the probe is going to be tricky as you will be limited by the abdominal pannus - so consider either (3a) starting the skin puncture an equivalent distance away from the probe as depth to the target, & utilizing a 45 degree angle; or (3b) if the vein is not too deep, use a steep angle of insertion to puncture the vein as described here for the IJV, and then once punctured, flatten the needle-syringe assembly to 30 degrees so that the wire threads smoothly in.
That’s helpful. It’s definitely the obese patients with deep veins. I find in these scenarios, there is little room/area to “creep” up with the probe while trying to visualize the needle tip. The 45 degree entry (same distance away as the depth) is what I typically use in these patients but I still find the dynamic visualization of the needle with the US is still quite challenging compared to IJs.
@@ckhkim - my other piece of advice is to worry less about visualizing the tip (which may not be feasible) but pay attention instead to the tactile feel of the tip passing through the tissues and be conscious of depth of insertion - once you know you are approaching inline with the centre of the vein, intermittently look down at the needle, as we used to do in the old days, and try to sense the pop through the vein wall. Also the indirect cues of tissue movement and lifting of the transfixed tissues / vein wall as you gently bounce your needle up and down - this can be very useful in telling you where the tip is sitting in terms of depth. Which is really all that matters.
There are no specific books. This is based on my accumulated knowledge from study of multiple textbooks and written resources, and practical experience in performing and teaching the technique.
Sir i have encountered a few problems during the procedure.. The main problem is that my guide wire doesnt advance sometimes....? Sir what could be done to ensure that it doesnt happen.. Please reply
With an IJV approach, the only reasons the wire won't advance is (1) that your needle bevel is not in the centre of the vein, so the wire is abutting the vein wall. Make sure that the vein is distended well, that you have pierced the centre of the vein (not to 1 side), and that you have free flow of blood (2) that you have not flattened your needle, which means you are asking the wire to turn through a larger angle. Once you have pierced the vein, you must drop your syringe hand to flatten the angle between needle and vein (3) there is a clot or other anatomical obstruction to passage. This is unsual though.
@@srk341717 Same principles - flatten your needle, make sure that you are not pressing in and compressing the vein, and that you have good backflow on aspiration. With LMG, we usually cannot aspirate blood while advancing even after you pierce the vein because the vein gets compressed - you should always intermittently backoff / pull back slightly with your needle while advancing to see if you can aspirate, especially if you feel a pop or give, which signals that you may have entered the vein.
One of my favourite anaesthesiologists, your videos helped me a lot to overcome my academic hurdles.
Thank you sir
Tanks for the description
all your videos are great thanks!
Excellent video!
Thank you very much for your videos. They are really great for education.
Very clearly u cleared all my dought, thanks a lot
Thank you
Hello Ki-Jinn, great video as usual. I have personally switched to long access view, amazingly easy and safe approach with a full in-plane view of the needle.
Thanks for the useful insight!
What is the size of your probe? Presumably the foot print is relatively small, or do you just "ride" the distal edge of the probe up onto the clavicle to create more space for your needle entry?
I also know that you are very skilled and experienced at achieving needle-beam alignment, so I'm not surprised it works well in your hands.
@@KiJinnChin Give it a try. Much easier than the short access technique. All your points are valid, a small hockey stick is nicer but a regular linear works well too. Another tip: no syringe 😂
Thanks you for sharing your videos about techniques and tips ! They are really helpful and inspiring!
Is there any suggestions on neonatal IJV insertion(using the same principle?)
This is not something I have direct experience of; I only did LMG insertions during training. But I would say that (1) handling of equipment will require a lot less force, since tissues are likely to be thin and fragile (2) more control is needed with needle advancement since distances and diameters are smaller; think about how to brace your hands appropriately (3) smaller footprint probe for sure. Otherwise many of the same principles would apply. I might use warmed-up saline for contact to prevent temp loss in these little ones.
Sir if the IJV is collapsed on Ultrasound? What should be done?
Great video. Love your series! Do you have one for femoral vein cannulation under US guidance? I find femoral like insertions to be the most difficult using the US.
I don't have one yet, but I'd be curious to know what you find difficult about the procedure.
Off the top of my head, I would say that (1) in obese patients, get some help with retracting the pannus, either with broad tape, or an assistant (2) tracking the needle tip by sliding the probe is going to be tricky as you will be limited by the abdominal pannus - so consider either (3a) starting the skin puncture an equivalent distance away from the probe as depth to the target, & utilizing a 45 degree angle; or (3b) if the vein is not too deep, use a steep angle of insertion to puncture the vein as described here for the IJV, and then once punctured, flatten the needle-syringe assembly to 30 degrees so that the wire threads smoothly in.
That’s helpful. It’s definitely the obese patients with deep veins. I find in these scenarios, there is little room/area to “creep” up with the probe while trying to visualize the needle tip. The 45 degree entry (same distance away as the depth) is what I typically use in these patients but I still find the dynamic visualization of the needle with the US is still quite challenging compared to IJs.
@@ckhkim - my other piece of advice is to worry less about visualizing the tip (which may not be feasible) but pay attention instead to the tactile feel of the tip passing through the tissues and be conscious of depth of insertion - once you know you are approaching inline with the centre of the vein, intermittently look down at the needle, as we used to do in the old days, and try to sense the pop through the vein wall. Also the indirect cues of tissue movement and lifting of the transfixed tissues / vein wall as you gently bounce your needle up and down - this can be very useful in telling you where the tip is sitting in terms of depth. Which is really all that matters.
What are the base books used for this class?
There are no specific books. This is based on my accumulated knowledge from study of multiple textbooks and written resources, and practical experience in performing and teaching the technique.
Sir i have encountered a few problems during the procedure.. The main problem is that my guide wire doesnt advance sometimes....? Sir what could be done to ensure that it doesnt happen.. Please reply
With an IJV approach, the only reasons the wire won't advance is (1) that your needle bevel is not in the centre of the vein, so the wire is abutting the vein wall. Make sure that the vein is distended well, that you have pierced the centre of the vein (not to 1 side), and that you have free flow of blood (2) that you have not flattened your needle, which means you are asking the wire to turn through a larger angle. Once you have pierced the vein, you must drop your syringe hand to flatten the angle between needle and vein (3) there is a clot or other anatomical obstruction to passage. This is unsual though.
@@KiJinnChin sir but while doing IJV cannulation without ultrsound.. HOW CAN THIS BE AVOIDED?
@@srk341717 Same principles - flatten your needle, make sure that you are not pressing in and compressing the vein, and that you have good backflow on aspiration. With LMG, we usually cannot aspirate blood while advancing even after you pierce the vein because the vein gets compressed - you should always intermittently backoff / pull back slightly with your needle while advancing to see if you can aspirate, especially if you feel a pop or give, which signals that you may have entered the vein.
Audio seems to be poor.
Thank you