Ultrasound Guided Peripheral IV Insertion

This first blog will be about inserting intravenous catheters (IVs) by ultrasound. This technique has integrated itself into the hospital setting. Currently, most IVs are inserted by visualizing and palpating a vein. However, some insertions are difficult and create quite the challenge to health care professionals, let alone more pain for the patient.

Unfortunately, patients end up getting poked numerous times before peripheral access is actually obtained. Some methods that may assist with IV insertion are the use of a flashlight with a red lens, heat, or a vein finder. When all else fails, a request is eventually made to the Vascular Access Team or the IV specialist for IV insertion who will then most likely insert the IV by ultrasound.

As I mentioned before IV ultrasound has infiltrated itself into the hospital setting mostly in the emergency department becoming a favorable procedure among patients. Ultrasound guided peripheral IV (USGPIV) has also become popular among inpatients who are requesting USGPIV over regular IV insertions. Why? Because USGPIV has proven to be more successful, requiring fewer attempts, less painful with increased patient satisfaction.

Ultrasound Guided Peripheral IV
Start by looking for veins. See if you can visualize any veins along the arm. The most prominent veins will be the Cephalic vein, Basilic vein, Median cubital vein, median antebrachial, and brachial vein.

Finding veins can sometimes be difficult, appear too easy like those pictured above.

USGPIV INDICATIONS:
• Two failed attempts
• Patients known or suspected difficult IV access
• Obese patients
• Edematous or hypovolemic patients whose veins are not visible or close to the surface of the skin
• Vein-debilitating conditions, such as sickle cell or cancer
• Those who have had multiple venipunctures
• Those who use or have used their veins to inject illicit drugs

CONTRAINDICATIONS:
• Extremities with burns
• Extremities with AV fistulas
• Extremities that have Deep Vein Thrombosis (DVT)
• Extremity with an associated history of a mastectomy
• Extremities that have had lymph nodes removed

PITFALLS OF USGPIV:
1. Using too much downward pressure when scanning with a probe, thus compressing potential vein sites.
2. Failure to compress and hold still to see if there is a pulse which would identify an artery instead of a vein.
3. Using a short catheter instead of a longer catheter, especially for deep veins which eventually lead to IV site infiltration.

ULTRASOUND MACHINE (SONOSITE) PROBE:

Begin by explaining the procedure to the patient and verifying which extremity can be utilized, if both arms available, that’s great! Make sure the patient verbally consents to the procedure. Next, make sure you have all the supplies that you will need to start the IV, including the ultrasound machine.

• Ultrasound machine (make sure it is charged, if not plug it in before making an IV attempt or the machine may go dead during the effort)
• Set ultrasound machine zoom to 2.7 or 3.3 for the best view
• Ultrasound gel
• Probe covers
• IV start kit
• Extension loop
• IV flushes
• IV catheters of all types, preferably 1.75 long

After that, prepare the arm. Expose the extremity and preferably lay it flat on the bed or some sort of solid surface so that when you push down on the arm it does not bend, because if it bends you will not be able to determine whether you are accessing a vein or an artery.

Personally, I feel the best method for finding and inserting an IV is to hold the probe straight up and down (short-axis view).

Short Axis View

Long-axis view could be used as well, but I have been more successful with the short axis view.

(Picture of the leg is only to demonstrate long-axis view, the probe is parallel to vessels.)

Apply tourniquet and ultrasound gel to the area of preference and place the probe on the surface of the arm. Then slowly scan the arm while looking for black circles on the screen similar to those below.

(Pic is of the abdomen; however, it has excellent views of what the vessels may appear like on your screen).

Once ideal vessels are located, it is crucial that the potential vessels are verified by compression. Hold the probe directly over the site and apply steady downward compression to make sure that it does compress and not pulsate, if it has a pulse it is an ARTERY, DO NOT ACCESS!!!

EXAMPLE: The picture above contains two veins and one artery, if you do not compress downward to see which one is pulsating, you may enter an artery.

The vein on the LEFT is not compressed, and the vein on the RIGHT is compressed.

Vein Cannulation:
Center IV catheter to the line or marker on the probe, then consider the depth of the vein anywhere from 0.3 cm to 1.5 cm on average (some may run deeper) and select the appropriate angle. The most common angle is 90-degree if shallow use a 45-degree angle.

Check your Success:
Good blood return is the best indicator that you have successfully accessed the vein. After the insertion slowly draw back the syringe to check for blood return. Afterward, flush the blood back into the vein with normal saline. Note: turbulence from the flush can be observed via the ultrasound by using the long axis view.

After cannulation secure IV site with appropriate dressing based on your institution’s policies.

USGPIV ACCESS

The overall concept of using an ultrasound machine is to insert an IV catheter that will decrease the number of IV attempts, lessen the pain and trauma of IV attempts, improve initiation time of IV therapy (medications and IV fluids), and most of all improve patient satisfaction when it comes to IV insertions.

Thank you for taking the time to read my blog and learn something new and or refresh your skills. Please visit NurseAvatar website next month for further information on education, until then learn as much as you can!