Peripheral IV

Ultrasound guided IV catheter placement

Intravenous catheter placement is one of the most common procedures performed in both the pre and intra hospital setting. Placement of peripheral intravenous (IV) catheters is a fundamental skill that all providers should possess. Difficult venous access presents a unique challenge to nurses and physicians alike. Ultrasound guidance can facilitate placement of IVs in difficult vascular access patients resulting in fewer needle sticks, quicker time to vessel cannulation, and less patient discomfort.

Indication

Ultrasound guided IVs traditionally are utilized when visualization and palpation based techniques fail. Anticipated difficult vascular access patients can often be spared repetitive needle sticks if ultrasound guidance if utilized from the start. Common conditions resulting in anticipated difficulty in venous access include ESRD, cardiovascular disease, contractures, smoking history, obesity, edema, drug abuse, and hypovolemia/hypotension. Conversely, it is not wrong to attempt ultrasound guidance on patients with easily palpable veins, however the additional time and equipment setup in this instance may be unnecessary.

Contraindications include infection over the vascular access site, AV fistula in that extremity, and patient refusal.

Patient evaluation

Venous anatomy should be identified if possible with classical visualization and palpation techniques prior to U/S guidance. Contraindications including infection, etc, should be noted and avoided.

Anatomy

The common U/S guided targets of the upper extremity venous system include the cephalic, antebrachial, median cubital, and basilic veins. With the palm facing upwards (thumb lateral), the cephalic vein runs along the lateral aspect of the arm while the basilic veins runs medially. Both the forearm and upper arm can be scanned for potential target.

Technique

1. Collect and position supplies necessary for procedure
   1. Clean ultrasound machine with high frequency linear transducer and ultrasound gel
   2. IV supplies within easy reach: tourniquet, alcohol, catheters, flushed extension tubing, tegederm/securement device, tape, gauze. Consider SQ lidocaine for patients with low pain tolerance.
2. Position patient
   1. Bed height comfortable for sitting or standing IV placement
   2. Arm positioned for easy vascular scanning
3. Place tourniquet
4. Scan arm for IV targets
   1. The probe should be held in the non dominant hand with a “C” grip on the probe. The first three digits form the C on the probe and the pinky and ring finger are used to stabilize/anchor the probe on the patient  
   2. The transverse/out of plane/short axis technique is generally utilized although the longitudinal/in plane approach while more advanced also has utility.
      1. Out of plane allows identification of the vessels and needle in cross section as well as better medial/lateral localization
      2. In plane allows for the needle to be seen entering the vein and provides better guidance into the lumen of the vessel.
   3. Target choice
      1. Fluid filled vessels should appear black (anechoic)
      2. Veins should easily collapse under gentile downwards pressure
      3. Arteries will be visible pulsatile (Color doppler can assist) and resist collapse
      4. Target vessels should not be immediately surrounded by arteries or nervous tissue
      5. Depth must be reasonable and in reach of IV catheter length
      6. Aline midline of the probe with the middle of the vessel on the screen
      7. Be patient, scan the entire arm, and attempt to identify the single most likely to be successful site before needle insertion
5. Place IV catheter
   1. Clean skin at area of insertion
   2. Ensure tourniquet is in place
   3. Consider SQ lidocaine
   4. Insert needle bevel up into the skin, 1 cm distal to the probe, at approximately 45 degree angle, and in line with the midline indication on the probe
   5. Focus eyes on screen and identify needle tip.
      1. Keep the needle still and scan distal/proximal until you identify the hyperechoic needle tip
      2. Advance the needle with small bites forward towards the target vessel, adjusting medially/laterally as needed
      3. Peirce through the vessel wall and position the needle tip in the center of the vessel
      4. Flatten needle angle and confirm needle tip
      5. Move probe proximally until the needle tip is lost, with the flattened angle, advance the needle into the vessel until tip is again visualized.
      6. Repeat above step slowly "walking" the needle and catheter into the vessel
      7. Once needle and catheter are definitively in the vessel, drop the probe, and advance catheter until fully inserted at skin
   6. Remove tourniquet
   7. Ensure blood return and flush IV
   8. Clean and apply dressing

Troubleshooting

• Make your first attempt your best attempt! Prepping materials/equipment, patient positioning, and target choice are critical to first pass success.
• If your initial needle insertion if significantly far off the probe's midline, it may be best to remove and attempt again more midline
• The deeper the vessel, the steeper your initial angle needs to be
• Once the needle is through the skin, focus entirely on the ultrasound screen. Resist the temptation to stare at your needle hand.
• Remember the short axis (out of plane) approach will only show you a slice in cross section of your needle. This could be the tip or anywhere along the shaft of the needle. Therefore, to avoid being too deep, it is critical to identify the very tip of the needle.

Summary

In summary, the ultrasound guided IV technique is relatively easy to learn for those already accustomed to traditional IV placement techniques and can result if faster cannulation in challenging vascular access patients. Practice and patience are critical to develop this important vascular access tool.