Ultrasound Tips and Tricks

Peripheral IV placement is the most common ED procedure performed1,2 and the use of ultrasound guidance for vascular access is associated with higher success rates, shorter insertion times and less complications than traditional approaches3. The concept of placing ultrasound IVs (USIVs) is a simple one — place US probe on patient, find vein, insert catheter. Often its not as simple to implement and it can be frustrating to figure out why or what could be done differently to be successful in getting the USIV placed. The following are some tips and tricks, to be used every time or to help your troubleshoot when you have difficulty getting an USIV.

  1. Preparation

For any procedure you perform in the ED, the first and most crucial step is preparation. Whether it’s USIV placement or an emergent trauma intubation, taking a few moments to gather all of the materials you may need will optimize your chance for success with the procedure. You do not want to be in the middle of a procedure, with your hands occupied, looking around for something you need but do not have within arms reach or that someone can hand you (so get an assistant if you need one). Similarly, placing an USIV successfully but that results in blood all over the patient’s arm or gown because you didn’t have gauze readily available is poor form and typically leads to a less than pleased patient.

Inquire about any contraindications to peripheral IV placement, including AV fistula and ipsilateral mastectomy. It is also helpful to ask the patient which upper extremity has been most successful in the past for IV placement.

When putting together my supplies, I find it easiest to remember what I need by thinking in what order I use them.  This is a list of what I routinely have at bedside for USIV placement:

  • Ultrasound with linear probe
  • Sterile ultrasound gel4
  • US probe cover or tegaderm
  • Chuck
  • Pack of chucks or box of gloves (see patient positioning below for why)
  • Tourniquet
  • Chloraprep or alcohol swab
  • 20 gauge standard-length (25mm) IV catheter
  • 20 gauge “long” (45mm) IV catheter
  • 4×4 gauze pads
  • Vacutainer and appropriate blood collection tubes (if needed)
  • IV tubing (saline flush attached, prepped)
  • IV dressing
  • Assistant if appropriate (e.g. to help patient positioning)

Regarding the use of US probe cover or adhesive barriers, like tegaderm, there is currently limited data of their efficacy in reducing risk of infection. Compared to traditionally placed peripheral IVs, USIV placement shows no increase in infection rates5. Furthermore, wiping the ultrasound transducer with an ammonia-based germicidal wipe will effectively eliminate MRSA and other clinically significant organisms6.

When selecting catheter gauge and length, you should consider vein depth, diameter and indication for the IV, such as, fluid resuscitation or CT imaging (e.g., 20 gauge for CTPE, 18 gauge for CT coronary). Although not routine practice in our emergency department, a guidewire-based catheter can be used with Seldinger technique to increase success of catheter advancement after vein cannulation7,8.

  1. Positioning

Both patient and provider comfort are important to successful USIV placement. The patient should be brought to the appropriate height so that you are not bending over or reaching up with your arms for the procedure.

Place a chuck under the patient’s arm to contain any messes and place a pack of chucks or a box of gloves (covered by chuck) under the patient’s elbow to assist upper extremity extension and patient comfort. You can also place the patient’s arm on an adjustable table next to their stretcher. If your patient has an upper extremity contracture or presents with challenges in positioning, recruit someone to help hold their arm in the position you need it in.

Lastly, the ultrasound should be on the opposite side of the stretcher as the provider with an unobstructed view8. When I’ve seen providers place the ultrasound on the same side of the stretcher that they are standing on, they often are turning their head and focus away from the working field to look at the US screen. This creates an unnecessary challenge of maintaining stability of the hand manipulating the ultrasound probe and accuracy in movement of the IV catheter.

  1. Tourniquet placement

Tourniquets improve visualization and decrease compressibility of your target vessel by obstructing the one way flow of valves9. Placing the tourniquet as close to the axilla as possible will give you better upper extremity venodilation and views of potential veins. A second tourniquet more distal to the catheter insertion site or a proximal blood pressure cuff inflated to 150mmHg can also decrease vein compressibility potentially enhancing the views of your target vein10.

  1. Vein characteristics

The vein should be evaluated for collapsibility first with gently pressure over the vessel to assess for pulsatility and then with full pressure to ensure no clot is present in the vessel8. You can also use color flow or Doppler to verify that the vessel is not an artery.  Proximal augmentation is another technique that can be used, but it has not previously been evaluated by any studies. For this technique, the provider squeezes the arm proximal to the intended vein insertion site and evaluates for backflow of blood through the vein using color flow Doppler. If flow is compromised, another vein should be selected8.

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A recent publication of the Best Practices for USIV placement recommends you measure the vein depth and diameter before attempting cannulation8. The 1cm markings on the sides of our US machines can be used to estimate these measurements. The easiest veins to cannulate with US guidance are moderate-depth vessels (0.3cm-1.5cm) and greater than 0.4cm in diameter11 12.

The basilic vein and deep brachial vein are often used for USIV’s. The basilic vein offers the advantage of being more superficial, more separated from arteries and nerves, and is associated with a higher success rate in access compared with the deep brachial vein which has been shown to have higher rates of extravasation13 14.

US short axis and long axis should be used to evaluate the vein path8. Short axis will demonstrate how straight of a course it takes and long access allows you to assess for valves15.

  1. Catheter Selection and Math

Vein depth, IV insertion angle, and insertion site relative to vein location are important factors to consider. Remember that according to the Pythagorean theorem, if you insert your IV catheter at a 45-degree angle and the vein is at a depth of 1.0cm and 1.0cm proximal to the skin insertion site, it will actually travel 1.4cm to reach the vein. See the table below for recommended catheter lengths.

Screen Shot 2018-10-18 at 9.02.15 AM

(Originally published in: Gottlieb M, Sundaram T, Holladay D, and Nakitende D. Ultrasound-guided peripheral intravenous lines placement: a narrative review of evidence-based best practices. W Jour Emerg Med. 2017;18(6):1047-1054.)

For our purposes remember to consider these factors when selecting an IV catheter and that a longer catheter may be better. Longer catheters do have lower rates of failure16. This is thought to be because longer catheters allow more of the catheter to be within the vessel lumen, making it more difficult to dislodge than shorter catheters.

  1. Technique

Short axis (transverse) US views are the most common approach for USIV placement, although the long axis (sagittal) approach is recommended due to lower risk of injury to the posterior vessel wall8. The long axis approach can be challenging because it requires both the needle and vessel stay in the same plane. If using the long axis approach, be aware that veins may appear similar to arteries and you should first confirm the vessel is a vein using short axis8.

Regardless of which technique you choose, when the catheter enters the vein, lower the angle of the needle and continue to advance while keeping the needle tip in the center of the vessel on ultrasound until the IV catheter is “hubbed” to the skin8. This makes sure the maximal length of the catheter is in the vessel and can reduce posterior wall injury.

Grasp the US probe so that your thumb is facing you and the rest of your hand is behind the probe resting on the patient’s arm for stability. Apply pressure to the vessel proximally with your palm or fifth finger of the hand holding the US probe to avoid vessel compression during IV placement8.

  1. Confirmation

The last step in USIV placement is confirming you did the procedure successfully. You should confirm placement by visualization of the catheter within the vein on US and or by flushing 5-10 mL of normal saline and visualizing bubbles within the vein on US8. Successful blood withdrawal is also an indicator of catheter placement within a vessel but may not always be present even with successful catheter placement.

Lastly, respect the US machines. We all rely on clean, fully-functioning US machines in their designates spaces on every single shift.

References

  1. Fields J, Piela N, Au A, et al. Risk factors associated with difficult venous access in adult ED patients. Am J Emerg Med. 2014;32(10):1179-82.
  2. Alexandrou E. The One Million Global Catheters PIVC worldwide prevalence study. Br J Nurs. 2014;23(8):S16-7.
  3. Leung J, Duffy M, Finckh A. Real-Time ultrasonographically-guided Internal jugular vein catheterization in the emergency department increases success rates and reduces complications: a randomized, prospective study. Ann Emerg Med. 2006;48(5):540-7.
  4. Oleszkowicz S, Chittick P, Russo V, et al. Infections associated with use of ultrasound transmission gel: proposed guidelines to minimize risk. Infect Control Hosp Epidemiol. 2012;33(12):1235-7.
  5. Adhikari S, Blaivas M, Morrison D, et al. Comparison of infection rates among ultrasound-guided versus traditionally placed peripheral intravenous lines. J Ultrasound Med. 2010;29(5):741-7.
  6. Frazee BW, Fahimi J, Lambert L, et al. Emergency department ultrasonographic probe contamination and experimental model of probe disinfection. Ann Emerg Med. 2011;58(1):56-63.
  7. Meyer P, Cronier P, Rousseau H, et al. Difficult peripheral venous access: clinical evaluation of a catheter inserted with the Seldinger method under ultrasound guidance. J Crit Care. 2014;29(5):823-7.
  8. Gottlieb M, Sundaram T, Holladay D, and Nakitende D. Ultrasound-guided peripheral intravenous lines placement: a narrative review of evidence-based best practices. W Jour Emerg Med. 2017;18(6):1047-1054.
  9. McNamee J, Jeong J, & Patel, N. (2014, December 17). 10 tips for ultrasound-guided peripheral venous access [Web log post]. Retrieved September 14, 2018 from https://www.acepnow.com.
  10. Kule A, Hang B, Bahl A. Preventing the collapse of a peripheral vein during cannulation: an evaluation of various tourniquet techniques on vein compressibility. J Emerg Med. 2014:46:659-66.
  11. Panebianco NL, Fredette JM, Szyld D, et al. What you see (sonographically) is what you get: vein and patient characteristics associated with successful ultrasound-guided peripheral intravenous placement in patients with difficult access. Acad Emerg Med.
  12. Witting M, Schenkel S, Lawner B, et al. Effects of vein width and depth 
on ultrasound-guided peripheral intravenous success rates. J Emerg 
Med. 2010;39(1):70-5.
  13. Chinnock B, Thornton S, Hendey GW. Predictors of success in nurse-performed ultrasound-guided cannulation. J Emerg Med. 
2007;33(4):401-5.
  14. Hardie AD, Kereshi B. Incidence of intravenous contrast extravasation: 
increased risk for patients with deep brachial catheter placement from 
the emergency department. Emerg Radiol. 2014;21(3):235-8.
  15. Duran-Gehring P, Bryant L, Reynolds JA, et al. Ultrasound-guided peripheral intravenous catheter training results in physician-level success for emergency department technicians. J Ultrasound Med.2016;35(11):2343-52.
  16. Elia F, Ferrari G, Molino P, et al. Standard-length catheters vs long 
catheters in ultrasound-guided peripheral vein cannulation. Am J Emerg 
 2012;30(5):712–16.

Author

Kavita Jackson, MD PGY4

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