Ultrasound guided approach to Internal Jugular venous cannulation. Explanation of Ultrasound physics and in plane and out of plane approach.

1. Ultasound guided central
Venous Cannulation
By
Sherry Nabil Elia
February 2011

2. Anatomy Of the Internal Jugular vein
• The internal jugular vein begins just medial to the
mastoid process at the base of the skull.
• The inferior petrosal sinus and the Sigmoid Sinus
join to form each internal jugular vein, and begins in
the posterior compartment of the Jugular Foramen.
• At its origin, it is somewhat dilated, and this
dilatation is called the Superior bulb.

3. Anatomy Of the Internal Jugular vein

4. Anatomy Of the Internal Jugular vein
• It runs down the side of the neck in a vertical
direction, lying first posteriorly to the Internal
Carotid artery before moving laterally and then
anterolaterally, to the Common Carotid A.
• At the root of the neck, the Rt. IJV is a little distance
from the Common Carotid A., and crosses the first
part of the Subclavian A., while the Lt. IJV usually
overlaps the common carotid artery.
• At the root of the neck, it unites with the Subclavian
V. behind the sterno-clavicular joint to form the
Brachiocephalic V.
• The carotid artery, internal jugular vein, and the
vagus nerve are all contained in the same carotid

5. Anatomy Of the Internal Jugular vein
Common Carotid A.
Internal Jugular V.
Internal jugular V.
Clavicle1st
Rib
Aorta
Brachiocephalic V.
Subclavian A.
Sternocleidomastoid

6. Anatomy Of the Internal Jugular
vein
• A little above its termination is a second dilatation,
the Inferior bulb.
• vein is superficial in the upper part of the neck and
then descends deep to the sternocleidomastoid
muscle. The structures through which a cannulating
needle passes are skin and subcutaneous tissue, the
platysma muscle, sternocleidomastoid(in the lower
neck) and the loose fascia of the carotid sheath.

7. Anatomy Of the Internal Jugular vein

8. Anatomy Of the Internal Jugular vein
• The left vein is generally smaller than the right, and
each contains a pair of valves, which are placed
about 2.5 cm above the termination of the vessel.
• The two internal jugular veins collect the blood
from the brain, the superficial parts of the face, and
the neck.

9. Anatomy Of the Internal Jugular vein

10. Physics of Ultrasound
• In most humans the audible frequency range is
approximately 20 Hertz ( Hz) – 20,000 Hz
• US may be defined as sound energy of frequency
higher than 20Kilohertz ( kHz).
• The propagation of US energy requires a material
medium ; it can’t take place in empty space. A
source of US in contact with a medium transfers the
mechanical disturbance to the medium , initiating
vibrations in the particles of the medium.

11. Physics of Ultrasound
• The mechanical movements of a source of
US
• In the forward direction, the US
compresses the medium particles in front
of it , increasing their concentration per
unit volume , hence creating increased
pressure.
• When the Us moves in the reverse
direction, the medium particles are
decompressed, giving rise to a low
pressure phase known as rarefaction

12. Physics of Ultrasound

13. Generation and Detection of US Waves
• The prefix “ Piezo-“ means pressure. When
crystals of piezoelectric materials are compressed
or stretched , electrical charge will appear on their
surfaces. Mechanical energy will have been
transformed into electrical energy

14. Generation and Detection of US Waves
•Production of US waves relies on the phenomenon of
the reverse piezoelectric effect,while detection is
based on the piezoelectric effect.

15. US Transducers
• Devices which convert one form of energy into
another are called transducers.
• The piezoelectric properties of an artificial crystal
can be destroyed if the crystal is heated to high
temperatures. For this reason the sterilization of US
transducers should not be done by autoclaving.

16. US Transducers

17. Interaction of US with Matter
• Reflection of US:
When a beam of US strikes an acoustic boundary,
part of the beam energy is transmitted across the
boundary, while some is redirected backwards or
reflected.
The most useful specular reflection takes place
when the US beam strikes a reflector at 90 degree to
the surface of the boundary.

18. Interaction of US with Matter

19. Interaction of US with Matter
• Refraction of US
In case of normal incidence, part of the beam
energy is reflected directly backwards, and the
remaining energy is transmitted into the second
medium without directional change. At any other
angle of incidence, the transmitted beam is deviated
from the original direction of the incident beam ,
either towards or away from the normal, depending
on the relative velocities of US in the two media.

20. Interaction of US with Matter

21. Interaction of US with Matter
• Absorption of US
It is the process by which energy in the US beam is
transferred to the propagating medium, where it is
transformed into a different form of energy , mostly
heat

22. Generation and Display of the US Image

23. Generation and Display of the US Image
1.Electronic Processing of Signals
A- Compensation :
It is for attenuation of differences. Time gain
compensation ( TGC) is a process of applying
differential amplification to signals received from
different tissue depths , with echoes originating
from longer distances being amplified to a greater
extent than those from shorter distances in such a
way that similar tissue boundaries give equal
sized signals regardless of their depth in tissue

24. Generation and Display of the US Image
B-Compression:
As the dynamic range of signal sizes may be very
wide, the range is compressed by using logarithmic
amplifier
C-Rejection:
Signal sizes which are extremely small can be
electronically rejected. Rejection eliminates all
signals whose magnitude are below a certain
threshold level, the rejection level.

25. Generation and Display of the US Image
2.Display Modes:
A-The Amplitude Mode ( A-mode):
In the amplitude mode, the signals from the
returning echoes are displayed in the form of
spikes , traced along a time base.

26. Generation and Display of the US Image
A-The Amplitude Mode ( A-mode):

27. Generation and Display of the US Image
B- The Brightness mode ( B-mode):
In the brightness mode, signals from
returning echoes are displayed as dots of
varying intensities. The intensity of a dot ,
brightness, is a relative measure of echo size

28. Generation and Display of the US Image
B- The Brightness mode ( B-mode):

29. Generation and Display of the US Image
• Real-Time Mode:
It is a rapid B-mode scanning to generate images
of a selected cross section within the subject
repetitively at a rate high enough to create the
motion picture impression.

30. Generation and Display of the US Image
C- The Motion Mode ( M-mode):
Returning echoes are displayed in the form of
dots of varying intensity along a time base as in
B-mode. Dots for stationary reflectors will remain
in the same positions along the time base, but
dots for reflectors which move in the direction of
the scan lie will change their positions along the
time base.

31. Generation and Display of the US Image
C- The Motion Mode ( M-mode):

32. Generation and Display of the US Image
D- The Doppler Mode:
An approaching sound is perceived to be
emitting sound at higher frequency than it
actually is, while a receding source appears to
emit at lower frequency.

33. Generation and Display of the US Image
D- The Doppler Mode:

34. Generation and Display of the US Image
3-Basic Controls of the US Keyboard:
• Trackball:
• Freeze:
• Zoom:
• Caliper:
• Printer

35. Artifacts in the Clinical US
1-Reverberations
It is caused by the sound bouncing back and forth
between tissue boundaries and then returning to the
receiver.

36. Artifacts in the Clinical US
2- Mirror Image

37. Artifacts in the Clinical US
3- Enhancement:
Enhancement is seen as an abnormally high
brightness. This occurs when sound travels
through a medium with an attenuation rate lower
than surrounding tissue.
4- Attenuation:
Tissue deeper than strongly attenuating objects,
such as calcification, appear darker because the
intensity of the transmitted beam is lower.

38. 1- Type of Transducer
High frequency linear probes 10–15 MHz are
ideal for maximal resolution, particularly in the
neck where the Jugular vein is superficial.
Application Technique and
Sonoanatomy

39. Application Technique andSonoanatomy
2- Patient Position

40. Application Technique andSonoanatomy
3- Scanning:
• Is best scanned in the transverse plane, this is
called short-axis view. This provides a cross
section image of the vein and surrounding
structures.
• Occasionally a long-axis (longitudinal) view is
helpful, although sometimes more challenging,
because the operator looses the ability to
readily recognize lateral and medial sides of the
nerve on the 2-dimensional image obtained.

41. Application Technique and Sonoanatomy
• Examination begins with the carotid view, which
is obtained by placing the probe transversely over
the paratracheal groove in the anterior triangle
between the cricoid cartilage and the
sternocleidomastoid muscle.
4- Sonoanatomy:
• Arteries and veins are anechoic or empty and
are seen as black on ultrasound. Muscles are
both hyperechoic and hypoechoic, fat is
hypoechoic and bone is very hyperechoic.

42. Application Technique and Sonoanatomy

43. Application Technique and Sonoanatomy
nerves running in the neural bundle resulting in an
honeycomb appearance

44. Application Technique and Sonoanatomy
5-Needle Insertion