Ultrasound-Guided Peripheral Intravenous Access

Indications

• o  Failure of peripheral IV-line placement by traditional methods (anatomy, palpation)

• o   Multiple failed attempts

• o   Atypical anatomy

• o   Anticipation of difficulty based on chronic illness (renal failure, chemotherapy, sickle cell disease, etc.)

Contraindications

• o   Thrombus of selected location visualized on ultrasound
• o   Known history of site lymphedema
• o   Limb ischemia
• o   Injury to proximal IV insertion site
• o   Signs or symptoms of compartment syndrome

Materials

• o   Ultrasound machine
• o   High-frequency (13–16 MHz) linear probe.
• o   Needle of minimum 1 inch length (1.5+ inch preferred)
• o   Single-use ultrasound gel (or single-use lube) packets
• o   Probe cover or similar protective barrier (ideally with <30 nm pore size)
• o   IV setup kit

Procedure

1. Selection: Scan the selected area(s) to identify a good target vessel for PIV cannulation.

• o   The basilic vein (Fig. 2.2), which runs on the medial side of the upper arm, and the cephalic vein, which runs on the lateral side of the upper arm, are good superficial veins that are generally not seen without ultrasound.
• o   The brachial vein is also an option, but extra caution is required, as it runs with the brachial artery and is usually adjacent to a nerve, so there is greater risk of discomfort and possible complications (Fig. 2.3).
• o   The median vein of the forearm and the median cubital vein are additional alternatives when the basilic or brachial veins cannot be accessed.

2. Preparation: The selected site for IV insertion should be located for use when access is obtained. Needles that are too short will not reach deeper vessels.

 

3. Scanning:

• o   The ultrasound probe should be placed in the transverse plane to best visualize surrounding structures and the vein. Alternatively, the probe can be placed longitudinally for better visualization of needle depth and slope.
• o   It is important to note that in the longitudinal approach, considerable stability is necessary to maintain the desired plane of approach.
• o   Arteries travel close to the veins and can easily be mistaken without proper training.

 

4. Technique:

• o   The recommendation for all procedures is to place the probe marker to the left of the person performing the procedure, in order to align the image on the screen to the anatomical appearance on the patient. Probe and needle management are thus simplified: To move the needle to the left, you go left, and vice versa.
• o   The needle tip should always be observed while scanning. The concept of the Pythagorean theorem is used for accuracy: The needle should be inserted at a 45° angle to the skin, with the distance back from the probe approximately equal to the vertical depth of the vessel. The depth is given on the screen in centimeters, usually at the right side.
• o   As soon as the needle has penetrated the skin, the needle tip should be located by fanning the probe toward the needle until it is identified. The needle should then be advanced slowly, always keeping the needle tip in view. Once directly on top of the vein, it should tent with pressure, and then the needle should be inserted into the vein.
• o   It is recommended then to drop from the initial angle to a shallower one while keeping a view of the needle tip in the center of the vein. To make sure that the catheter is securely in the vein and does not infiltrate, the needle is advanced several centimeters while keeping the tip of the needle in the center of the vein.

Complications and Tips

• o   Inadvertent puncture of an artery: Veins should be thin walled and compressible and have no pulsations.
• o   Inability to pass catheter: Many times, this is due to a premature attempt. Ideally, the needle should be advanced slowly into the vein before attempting to thread the catheter.
• o   The medial side of the arm usually contains the best venous targets for ultrasound guidance. The basilic vein is a globally preferred site.
• o   Ideally, the ultrasound probe should maintain the same axis as the vein selected. This is achieved by keeping the vein in the middle of the screen as you move proximally or distally in the arm.

Pearls and Pitfalls

• o   The midshaft of the needle can be mistaken for the needle tip. If this occurs, the needle tip is actually deeper than expected. The ultrasound machine will plot a hyperechoic “dot” on the screen for the needle tip, as long as it crosses the ultrasound beam at any point. This same “dot” will appear whether the tip is directly centered under the beam or any segment of the needle shaft is intersecting the beam. This can be visually deceiving and makes this procedure difficult to grasp.
• o   Very slow movements of the needle and the probe are important for keeping the needle tip in view. Once the needle tip is identified, the probe should be fanned forward (away from the operator) just slightly and then the needle advanced until the needle tip comes into view again. This procedure is repeated until the needle is securely moved further into the vein.

Probe Cleaning and Disinfection

• o   Special care should be taken to protect the probe as much as possible from blood or similar contaminating environments. Ultrasound-guided peripheral IVs are not required to be sterile, but adequate protection should be used to prevent cross-contamination between patients.
• o    Low-level disinfection (soap and water, ammonia sprays, wipes) will destroy most bacteria, some viruses, and fungi.
• o   High-level disinfection will remove all organisms except bacterial spores. Examples include chemical sterilants or germicides (e.g., Cidex®) or physical sterilization (e.g., trophon®).

• o   A probe that comes in contact with bodily fluids such as blood or pus should be considered contaminated and high-level disinfection should be considered.
• o   Appropriate probe covers to prevent contamination should have pore sizes of <30 nm, such as the sterile probe covers used for central line access.
• o   Follow individual institutional policies for probe disinfection and infection control.