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Disclosure Statement of Financial Interest ULTRASOUND BASICS Christian R. Falyar, CRNA, DNAP Department of Nurse Anesthesia Virginia Commonwealth University Disclosure Statement of Unapproved/Investigative Use • I, Christian Falyar, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. OBJECTIVES • 3$4-#*#6,$,),)2( I, Christian Falyar, DO/DO NOT anticipate discussing the unapproved/investigative use of a commercial product/device during this activity or presentation. • 5*&$(#)4,)2((/,,2$(-+- • ,+$-#**+()3+$)2,(-)'64$-# 2&-+,)2( • '-#,$)'*)((-,(2(/)(,)( 2&-+,)2(,6,-' • 3$4)'*&$/)(,)2&-+,)2(>,,$,- *+)2+,(,-+-"$,2,-)+2(=)+ *+3(--#' WHAT IS SOUND? WHAT IS SOUND? Rarefactions (low pressure) A Transducer λ Compressions (high pressure) PROPAGATION VELOCITY ROLE OF FREQUENCY... High frequency Low frequency • More cycles per second • Fewer cycles per second • Images are higher • Greater tissue penetration resolution • Increased attenuation • Imaging limited to shallow depths but lower resolution • Less attenuation allows for imaging of deeper structures ROLE OF FREQUENCY High frequency Low frequency BEAM PROPERTIES IMAGE CREATION +(,2+ TRANSDUCER BASICS • It’s all in the math • Depth of the echo is determined by time from when the echo was sent to when it was received • The brightness of an echo is results from differences in acoustic impedance between adjacent tissues ACOUSTIC IMPEDANCE IMAGE CREATION Transducer Incident Wave ($(- 3 Reflected Wave Incident Wave Incident Wave !- 3 Impedance Z1 Impedance Z1 Impedance Z2 Impedance Z2 Refracted Wave Attenuated Wave REFLECTION Specular REFRACTION Diffuse ($(- 3 !- 3 +- 3 RAYLEIGH SCATTERING ATTENUATION • The decreasing intensity of a sound wave as it • Rayleigh scattering occurs at interfaces involving small structures (red blood cells). • This creates a low uniform amplitude reflection in all directions. ATTENUATION COEFFICIENTS passes through tissue. • The attenuation coefficient is the relation of attenuation to distance; it is dependent on the tissues traversed and ultrasound frequency. • Higher frequencies are attenuated more than lower frequency waves. ATTENUATION Attenuation TISSUE APPEARANCE • Nerves – in cross section appear as round “honeycomb” structures NERVES Popliteal Fossa Brachial Plexus • Tendons – appear similar to nerves at the joint, but become flat and disappear when followed toward the muscle belly • Vascular Structures – anechoic circular structures in cross-section; appear tubular in longitudinal view • Fat – hypoechoic areas with streaks of irregular hyperechoic lines • Fascia – thin linear hyperechoic structures marking tissue boundaries • Muscle – feather-like in longitudinal view; “starry night in cross- section • Pleura and Air – pleura appears as thin hyperechoic lines, while lung parenchyma appears hypoechoic; reverberation artifact present • Cysts – similar vascular structures, however appear as hypoechoic circles in longitudinal view • Bone – hyperechoic linear structures with shadowing underneath NERVES AND TENDONS • Nerves and tendons can both appear as hyperechoic circles near joints • They can be differentiated by following their course into the muscle ADIPOSE TISSUE • Adipose appears as hypo- echoic areas with streaks of irregular hyperechoic lines • It is the most superficial layer imaged Adipose FLUID-FILLED STRUCTURES ARTERIES Arteries • Round in short-axis, and tube-like in long-axis view • Pulsatile in nature • Difficult to compress • Display color on Doppler • Arteries, veins, and cysts all appear as circular anechoic structures in short-axis VEINS MUSCLE Veins • Muscle appears • Ovoid in short-axis and tube-like in long-axis • Easily compressible • Valves may be visible • Display color on Doppler heterogeneous on ultrasound due to the different acoustic impedances between cell structures, the water content within the cells, and the fascia BONE PLEURA Pleura appears as a hyperechoic line with “comet tails” beneath it • Bone is a significant DOPPLER EFFECT DOPPLER EFFECT reflector, creating a hyperechoic area with significant shadowing beneath it "Über das farbige Licht der Doppelsterne und einige andere Gestirne des Himmels Versuch einer das Bradleysche Theorem als integrirenden Theil in sich schliessenden allgemeineren Theorie" Christian Andreas Doppler 1803-1853 DOPPLER EFFECT DOPPLER EFFECT • Doppler is not used to create an image • Doppler is dependent on the angle of insonation • Either the sender or receiver must be moving ARTIFACTS AIR ARTIFACT • Any phenomenon that affects the acquisition or interpretation of an ultrasound image • Artifacts occur because: • properties of sound • tissue • created by the provider • The most common artifacts are air artifact, shadow artifact, acoustic enhancement, mirror image and reverberation • Transducer does not fully contact the skin • Commonly occurs when imaging smaller structures • Add gel and apply even pressure to correct this SHADOW ARTIFACT • When ultrasound contacts tissue that is a strong reflector, the amplitude of the beam distal to structure is diminished, resulting in a hypoechoic ACOUSTIC ENHANCEMENT • When sound passes through tissue with low acoustic impedance and contacts tissue with a much higher impedance, making it appear more echogenic than it actually is REVERBERATION MIRROR IMAGE • When sound reflects off Sound trapped between two highly reflective surfaces two strong specular reflectors separated by a thin layer of air or fluid an illusion of “multiple” structures are displayed below the actual one SCANNING BASICS TRANSDUCERS • Successful procedures begin with choosing the • The transducers used for USRA are either linear correct transducer and holding it properly • Several basic functions will improve outcomes as well. These include: or curved linear array transducers • Transducers are the link between the ultrasound system and the tissue. They play a significant role in determining the resolution and accuracy of an image • Transducer selection is determined by the depth of the structures to be imaged • Depth • Contrast adjustment (gain) • Color-flow Doppler LINEAR ARRAY CURVED ARRAY HANDLING HANDLING • Notch to the anesthetist’s left or the patient’s head • Hold the transducer flat against the skin for maximal contact • Hold the transducer like a pencil • Support the scanning arm; rest it on a firm surface • Apply firm, but gentle pressure HANDLING Transducer Perpendicular Correct Hand Position Improper Hand Position B-MODE IMAGING Transducer Angled Cross-Section/Short-Axis Longitudinal/Long-Axis DEPTH DEPTH – MEDIAN NERVE Proper depth • Depth determines how far into tissues echoes are interpreted • Increasing the depth, decreases resolution • The structure of interest is kept in the center of the screen GAIN GAIN – JUST RIGHT • Gain compensates for attenuation • It amplifies RETURNING echoes • Gain can be adjusted either in the near field, far field, or overall image • Gain is adjusted so that the image is uniform Too deep GAIN COLOR-FLOW DOPPLER • Color-flow allows you to confirm the presence or absence of vascular structures • Doppler is super-imposed over the B-mode image COLOR-FLOW DOPPLER COLOR-FLOW DOPPLER MOVEMENTS SLIDING • In 1999, the American Institute for Ultrasound Medicine (AIUM) established terminology to describe transducer movements. • These terms do not include specification of direction (i.e. proximal, distal, clockwise) • In general, a transducer can be manipulated in five ways: sliding, tilting, rocking, rotating and compressing. ROCKING • Rocking can be used to correct air artifact and increase contact of the transducer • Sliding allows the provider to find the appropriate level to perform the block TILTING • Tilting improves nerve image by accounting the effect of anistropy ANISTROPY Transducer Tilted ROTATING Transducer perpendicular • Rotating allows the provider to optimize all structures in the image on the same plane COMPRESSING ORIENTATION • Proper placement of the transducer in relation to • Compressing can be used to decrease space from the skin to the desired structure the patient is key to obtaining a correct image • The transducer should be oriented to the anesthetist’s left in cross-section or toward the patient’s head in longitudinal view • When the transducer is not properly oriented, a “mirror-image” will result ORIENTATION PROPER ORIENTATION IMPROPER ORIENTATION ERGONOMICS • Appropriate bed height • Ultrasound in line with the provider and patient • Scanning arm supported • Assistant (if available) • Proper transducer handling ERGONOMICS Poor Ergonomics WHAT NOW? Good Ergonomics OPTIMIZE THE IMAGE • Use PLENTY of gel. Gel acts as a coupler between the transducer and the skin, and improves the image quality • Ensure your transducer is initially perpendicular and flat against the skin • Optimize your depth so the structures you wish to image are in the center of the screen • Adjust your gain to make picture look uniform • You have the right patient, discussed the proposed anesthetic technique, obtained consent, verified the site, and gathered your supplies • Select the appropriate frequency transducer • Imagine how the image should appear on the monitor • Use good ergonomics • Apply sufficient gel to the transducer • Jump in! NEEDLE VISUALIZATION In-Plane NEEDLE VISUALIZATION Out-of-Plane SAFETY STRATEGIES • Ultrasound itself is non-invasive • Ultrasound-guided procedures introduce a needle and/or local anesthetic into the patient increasing the potential for complications • Needle insertion should first be practiced using a phantom numerous times, with emphasis placed viewing the entire needle as it passes through the tissue • Strategies such as wiggling, or hydro-location can be used to verify the location of the needle tip ANATOMY • Know it. Most nerves blocked using regional anesthesia are in close proximity to arteries, veins, or other vital organs (i.e. the lungs) • Anticipate what you will be seeing before you start scanning. • Proper orientation of the picture make your picture appear correctly QUESTIONS? REFERENCES • • • • • •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• • • • • 6&)+9)&&(<)**&+2,<*+-$<,$*+$($*&,9$(,-+2'(-/)(9( *$.&&,< !<EMMD:EKH?F@;FMK>GDK< +6< % ##$&&*#$9< 2(+,9&,3$+:FDED;HI>JK< )&&+9#(< ! % "$ <)+)(-)<($3+,$-6))+)(-)+,, (<: FDDM;FG>FL< $"&$,(99+2"#9)6+$9-&< % #&/')+9<$**$()1$&&$',A$&%$(,: FDED;FJ>GG< ),,)<,$*#6,$,($'"$("#+-+$,/,)2&-+,)2(< < FDDD:FH;EGH>EHF<