Ultrasound guided peripheral IVs

[Inertia123]

Even when done with a long catheter, a lot of times they eventually infiltrate after getting a good blood draw from it and easy IV fluid flow initially. Why does this happen? It grinds my gears.

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[Libertas]

I like to use an arrow catheter. I think the wire helps you make sure you're in the vein.

 

[RPedigo]

(1) make sure you're using the extra long angiocaths, and (2) try to not do ultrasound-guided IVs. I'm mostly kidding on the second one, but they are very prone to infiltration. I usually just put an EJ in, and occasionally I do an ultrasound-guided EJ instead of a deep brachial if I cannot find any other vein, because the ultrasound-guided EJs tend to not infiltrate on me. The deep brachial IVs in my experience (and the nurses that I work with agree) are heavily prone to infiltration hours after placement.

 

[Groove]

Practice your technique. Use at least a 1.8" angiocath. Find a segment of the deep brachial that is more superficial or put it in the basilic. You need a higher angle due to it's depth with a "leveling out" after cannulation. If you cannulate too low of an angle, you are more prone to infiltrate. Practice makes perfect. I can't remember the last malfunction or infiltration from a deep brachial though you have to educate the pt to keep their arm still. Just keep at it. It's a valuable procedure to have in your repertoire for the common "Doc, WE CAN'T GET A LINE! WE'VE TRIED A GAZILLION TIMES! (translation: #3 between 2 nurses) CAN YOU PRETTY PLEASE WITH SUGAR ON TOP THROW IN A CVL?!?! HUH?! CANYA CANYA?! PUHHHHLEEEEZE?!"

 

[MSmentor018]

Even when done with a long catheter, a lot of times they eventually infiltrate after getting a good blood draw from it and easy IV fluid flow initially. Why does this happen? It grinds my gears.

these are my favorite types of procedures. do you prescan first? go proximal to where you're thinking of sticking and see what the vein does. maybe it constricts, fibrosis, torturous, splits, upstream clot....etc.
also what about drying/securing? I've seen a lot of people place a great IV, draws/flushes then when securing they push the skin away from the cath and the IV slips out of the vein. head of to CT then come back with an arm that looks like popeye.
hope that helps, let me know how it goes next time

 

[deleted92121]

I'm one of two people outside of the MD/DO that do US guided peripheral IV placements in my ED. So I get to do a ton of them but I notice the same thing that a lot of times the line will infiltrate. Here are my tips for what they're worth:

1. Arm up on a mayo stand or bedside table.
2. Find the vein and try both transverse and longitudinal views. If you can master longitudinal, you'll have better success.
3. Lido 1% to area of insertion. If you use a longer needle and have to go deeper, the patient will relax more with some local anesthesia.
4. Don't pull back on skin too far. Like MSmentor18 mentioned, when you release skin and secure, IV slips out. If the patient is numbed up well, just stabilize the skin more than pull it back.

Hope you don't mind a medic's input here, I just do them frequently. I finally organized an upcoming class so others can learn this technique. Protocol is being developed as well. I summarized a few studies done on this topic and presented it to our EM group and CMO and CNO. Shocked that they thought it would be a good idea.

 

[Hair Police]

1) Use an arrow catheter, a 1.88 cm catheter, or one of the wire-guided long catheters.
2) Use the basilic vein - compared to the brachial, it's shallow, easy to find and thread, relatively painless, and you don't have to worry about any nearby nerves or muscle.
3) Use tincture of benzoin as a mild skin adhesive to keep it in place
4) Approach at a 45 degree angle - any steeper it's hard to advance the catheter in the vein, any shallower and you run out of catheter (you want ~1 cm of tubing in the vein to make sure it doesn't infiltrate)
5) Measure twice, cut once - use the US and make sure your target vein has a straight and predictable course before you poke the skin.

It does take time to get good at the procedure, but it is a valuable one. I can't remember the last CVC I placed just for difficult access.

 

[deleted92121]

1) Use an arrow catheter, a 1.88 cm catheter, or one of the wire-guided long catheters.
2) Use the basilic vein - compared to the brachial, it's shallow, easy to find and thread, relatively painless, and you don't have to worry about any nearby nerves or muscle.
3) Use tincture of benzoin as a mild skin adhesive to keep it in place
4) Approach at a 45 degree angle - any steeper it's hard to advance the catheter in the vein, any shallower and you run out of catheter (you want ~1 cm of tubing in the vein to make sure it doesn't infiltrate)
5) Measure twice, cut once - use the US and make sure your target vein has a straight and predictable course before you poke the skin.

It does take time to get good at the procedure, but it is a valuable one. I can't remember the last CVC I placed just for difficult access.

Hey Hair Police

Just curious but any problems with going in at a full 45 degree angle? I ask because in a normal peripheral stick, the best angle is more around the 15 to 30 degree angle to prevent going through the vein. When I am doing an US guided stick, I typically use a 1.88 cm catheter but tend to run into the vein from around 30 degrees rather than a full 45 because sometimes the 45 still puts me through the vein. Any thoughts?

 

[JMC2010]

I disagree that they infiltrate more if done correctly.

Use either 2.5 inch 18 G catheters (for veins around 1.5-2 cm deep) or 2 inch 16 G catheters for more shallow veins. These can be inserted in a brachial vein and 2-3 cm of catheter is threaded into the vein itself. When done properly they have very low infiltration rates. Granted, as you are learning to do them you kind of poke and pray and get excited when you get a flash and try to thread the catheter.

Those who know what they are doing don't even look for a flash...they see the needle tip in the vein and then they flatten the angle and insert the needle/catheter together a couple of cm up the vein so you know it will thread without difficulty - this is critical. Make sure you advance the needle tip into the field of the probe so that you know you're looking at the tip of the needle as opposed to the middle of the needle while the tip is sticking in an artery somewhere (longitudinal view).

When you know you have inserted 2-3 cm of catheter into the vein they hardly ever infiltrate unless the patient gets up and does jumping-jacks or something.

 

[Mudpile MD]

JMC2010,

I think you meant to "insert the needle/catheter a couple of mm up the vein so you know it will thread without difficulty"? Seems you would not want to insert the needle 2 cm into the vein.

 

[JMC2010]

No, I meant centimeters. If you insert only a few millimeters the catheter will almost certainly pop out of the vein.

 

[deleted92121]

No, I meant centimeters. If you insert only a few millimeters the catheter will almost certainly pop out of the vein.

If you are using real time longitudinal view, then this makes sense. But if you use the US just to identify where the vein is and how deep, you may end up going through it.

 

[Hair Police]

A few points.

Absolutely go in at 45 degrees. Otherwise I run out of catheter, and as one of the other posters mentioned, you want as much plastic in the vein as possible to prevent extravasation. I don't go through the vein because I go slowly and I attempt to visualize the needle tip 100% of the time. I also don't look for flash - I look to see that I have catheter in the vein on US. Then I try to advance the catheter. If I meet resistance. I readjust and confirm visualization on US before moving the needle.

I have tried long and short axis approaches, and prefer the short. I always follow the needle tip in real time as I move towards the vein. I also always look ahead to judge the anatomy, so I know I have a straight stretch to cannulate.

 

[gman33]

I try to visualize the whole way and advance the needle as far as possible.
Never look for a flash. I usally come pretty close to hubbing the needle.
This way I know I have the whole thing right in the middle of the vein.
I've seen too many people just get a flash and try to slide the catheter.
The depth seems to cause problems with the catheter kinking up with this technique.
It's pretty rare that I don't get a very good IV on the first try with this approach.

+1 for taking the time to look around for a good vein.

 

[pseudoknot]

I strongly agree with advancing 1-2cm with the needle, under continuous visualization. You can do this in short axis too as long as you fan back and forth so you always know where the needle tip is.

If the vein is more than 1.5cm deep it's probably not going to last long.

The other thing that really helps is to ALWAYS avoid the elbow and the AC area. I usually go a couple inches proximal in the basilic vein, sometimes the brachial or forearm. If you cross the AC with a catheter it will come out the second the patient flexes their arm, I promise you.

 

[gman33]

Long vs. short axis.
Short axis is better when there are structures lateral that you need to avoid.
Long axis is better when there are structures deep that you need to avoid.

Long axis takes more practice, but it is a nice tool to add.

 

[deleted547339]

I only ever use long axis. If you use short axis, you're trying to find a needle in a haystack.

 

[MSmentor018]

if you're doing short axis, tilt the probe distally and follow the tip. you won't see the shaft itself but at least you see the tip (that's what she said!)

 

[Tiger26]

if you're doing short axis, tilt the probe distally and follow the tip. you won't see the shaft itself but at least you see the tip (that's what she said!)

Yup--just the tip ...

 

[deleted92121]

I strongly agree with advancing 1-2cm with the needle, under continuous visualization. You can do this in short axis too as long as you fan back and forth so you always know where the needle tip is.

If the vein is more than 1.5cm deep it's probably not going to last long.

The other thing that really helps is to ALWAYS avoid the elbow and the AC area. I usually go a couple inches proximal in the basilic vein, sometimes the brachial or forearm. If you cross the AC with a catheter it will come out the second the patient flexes their arm, I promise you.

I usually have decent success in the AC, maybe 90%. But this is really good advice. I will sometimes go in the upper arm, not usually the forearm. Quick question though, do you normally numb your patient up with a little lido first or just go for the gusto?

 

[deleted547339]

I usually have decent success in the AC, maybe 90%. But this is really good advice. I will sometimes go in the upper arm, not usually the forearm. Quick question though, do you normally numb your patient up with a little lido first or just go for the gusto?

I never numb up for an US IV. Not gonna take the time to get an RN to get lido from the pixes, find the vein, draw up the lido, inject, wait for it to be numb, then go for it.

 

[deleted92121]

I never numb up for an US IV. Not gonna take the time to get an RN to get lido from the pixes, find the vein, draw up the lido, inject, wait for it to be numb, then go for it.

I normally don't if I am staying in the AC or distally from there but when I go in the upper arm, I tend to use some 1% Lido mostly because the patients like it and a calm, relaxed patient can be helpful.

 

[JMC2010]

I also don't use lidocaine. Way too much of a pain and you're just increasing the number of times the patient is stuck. I also forgo a lot of the prep that people do such as propping up the arm on a table. This just adds unnecessary steps/time to what should be a quick and easy procedure. Usually I just have them hang their arm off the bed, put on a tourniquet, swab some alcohol and get down on one knee and put a nice long catheter in a brachial. Boom, done. Should only take a couple of minutes, tops.

 

[MSmentor018]

I usually have decent success in the AC, maybe 90%. But this is really good advice. I will sometimes go in the upper arm, not usually the forearm. Quick question though, do you normally numb your patient up with a little lido first or just go for the gusto?

they routinely numb in anesthesia even for standard iv. it's a customer service thing. if they have a high weenie titer I do, 99% of patients will just suck it up b/c they know it needs to get done but you always get that 1 that just won't stay still or has a psych component. like yesterday I had a big burly guy that was stuck 8 times with the standard 1" 20ga angiocath. he was fine with them sticking but once I broke out the 1.88 he freaked out and had a panic attack. somehow by injecting "lidocaine" he magically calmed down

 

[deleted547339]

they routinely numb in anesthesia even for standard iv. it's a customer service thing. if they have a high weenie titer I do, 99% of patients will just suck it up b/c they know it needs to get done but you always get that 1 that just won't stay still or has a psych component. like yesterday I had a big burly guy that was stuck 8 times with the standard 1" 20ga angiocath. he was fine with them sticking but once I broke out the 1.88 he freaked out and had a panic attack. somehow by injecting "lidocaine" he magically calmed down

You bring up a good point. The patients who I do US IVs on have already been stuck about a half dozen times. I say tell them "just chill out, I should get it in one stick" and they're usually fine with that.

 

[deleted92121]

Mind if I ask if anyone else in your shops perform US guided peripheral lines?

I work as a paramedic (in-house and response unit) and other than the physicians, we are the only ones allowed to use US, IO, or start an EJ. Currently, only myself and one another medic has the US class under their belt. We are starting a trial using handheld US for FAST in the field. Not sure I think it is worth the time in a urban or even suburban setting, but maybe rural.

 

[MSmentor018]

it all changes on who the current ruler is. 5 yrs ago it was flight RN and paramedics that could do u/s lines and EJ. then just paramedics that are still here that were trained by us. now it's only the physician, residents, and spec ops (military) medic trainees (<1/2 hr of training). granted we do have a hospital wide PICC team that are RN's but they can't always come down. it only makes sense to give the most experienced person (RN) the best possible chance of starting the IV. calling the intern to do a hard stick, who has minimal u/s and IV experience is asinine. I am hoping to change that at my shop by end of the year.

as for the u/s in the field. our city fire/paramedic rigs have them. don't know how often they use it.

 

[deleted92121]

it all changes on who the current ruler is. 5 yrs ago it was flight RN and paramedics that could do u/s lines and EJ. then just paramedics that are still here that were trained by us. now it's only the physician, residents, and spec ops (military) medic trainees (<1/2 hr of training). granted we do have a hospital wide PICC team that are RN's but they can't always come down. it only makes sense to give the most experienced person (RN) the best possible chance of starting the IV. calling the intern to do a hard stick, who has minimal u/s and IV experience is asinine. I am hoping to change that at my shop by end of the year.

as for the u/s in the field. our city fire/paramedic rigs have them. don't know how often they use it.

Purely anecdotal but in my experience, the best folks at starting lines are the medics. Granted, not every shop utilizes medics in their department, but a fair share do. Maybe it is because we start them in the back of a moving rig. I don't know. But like I said, this is based off a small sample size.

As far as the u/s use goes, there was a pretty good research article done that supported peripheral IV being placed under u/s. If I find it I will post it. I had a copy and used it when I presented my case for expanding training for our medics and in the future, nurses.

 

[MSmentor018]

Purely anecdotal but in my experience, the best folks at starting lines are the medics. Granted, not every shop utilizes medics in their department, but a fair share do. Maybe it is because we start them in the back of a moving rig. I don't know. But like I said, this is based off a small sample size.

As far as the u/s use goes, there was a pretty good research article done that supported peripheral IV being placed under u/s. If I find it I will post it. I had a copy and used it when I presented my case for expanding training for our medics and in the future, nurses.

true
there's plenty of articles. I was in the original study by blavis in early 2000's

 

[Akail]

Put one in a quarter ton guy yesterday...anyone have any suggestions on how to prevent the catheter from kinking when you're trying to thread it in?

 

[swamprat]

Put one in a quarter ton guy yesterday...anyone have any suggestions on how to prevent the catheter from kinking when you're trying to thread it in?

Track the needle up the vessel a bit before you thread the catheter

 

[Birdstrike]

How long does it take you to place your ultrasound guided line, from the time the light bulb goes off in your head to do it, to getting the machine set up, all the way through getting the line in, and dressed?

How about external jugular lines? It's there 95% of the time, popping out for all to see, in practically any patient with blown extremity veins, if you put them in a little trendelenburg. Seriously, people. No machine, no lidocaine, no central line protocol nonsense. 5 seconds.

 

[Groove]

I put them in fatties where the EJ is hidden by neck blubber.

 

[la gringa]

+1 for the EJ. never had a great experience with US guided IV's in residency, even when the so-called expert attendings did them. as mentioned above, took longer and blew/came out all the time.

i do use US to scout the EJ if i can't see/feel it if i know it hasn't been abused previously.

 

[deleted547339]

How long does it take you to place your ultrasound guided line, from the time the light bulb goes off in your head to do it, to getting the machine set up, all the way through getting the line in, and dressed?

How about external jugular lines? It's there 95% of the time, popping out for all to see, in practically any patient with blown extremity veins, if you put them in a little trendelenburg. Seriously, people. No machine, no lidocaine, no central line protocol nonsense. 5 seconds.

Did 3 today on shift....One took <1m (RN had US machine at bedside). One took <5. One took about 15.....but it kept me from having to put in a CVL.

Some of our nurses do EJs. I only get asked to put in an US guided line if at least 2 RNs can't find one.

 

[southerndoc]

15 minutes but it kept you from putting in a CVL? I can place a CVL in less than 5 minutes from start to finish. If I'm spending 15 minutes hunting for a peripheral line, I would rather just do the CVL. I've placed them before and removed them prior to patient discharge from the ED.

 

[Groove]

Put one in a quarter ton guy yesterday...anyone have any suggestions on how to prevent the catheter from kinking when you're trying to thread it in?

If you're kinking, it's not in the vein. Once you get flash continue to advance while leveling it out and thread in one smooth motion.

 

[Groove]

The US PIVs ala deep brachial, etc.. are not that hard, it just takes at least a 1.8" angiocath which most EDs don't stock unless you ask for them. The 1.5" angiocaths will always blow eventually.

20g 1.8" angiocaths, I'm telling ya. Get them to stock a box of them and your set. I just always feel ridiculous discharging a pt with an invasive CVL along with additional risk of iatrogenic injury for nothing more than "IV access". To each their own though, I certainly see both sides and there's obviously no hard rule.

Since we're on the topic... what's your "go to" for most CVLs? I find myself going subclavian almost 75% of the time. I find myself able to put them in much faster and easier than almost any other line except for a dirty femoral line in a crashing pt, etc.. IJs seem to take me the longest.

 

[deleted547339]

15 minutes but it kept you from putting in a CVL? I can place a CVL in less than 5 minutes from start to finish. If I'm spending 15 minutes hunting for a peripheral line, I would rather just do the CVL. I've placed them before and removed them prior to patient discharge from the ED.

Yea...it took a while. This lady had no veins.....at all.

She was a really soft admit and wasn't particularly sick. I didn't feel good about putting in a cvl in a nonsick person.

 

[Birdstrike]

Yea...it took a while. This lady had no veins.....at all.

She was a really soft admit and wasn't particularly sick. I didn't feel good about putting in a cvl in a nonsick person.

You could have seen an ankle sprain in that 15 minutes, booted the non-emergency/weak-admit upstairs for a us-guided peripheral by some noctor and reduced your length of stay, opened a bed, decreased the bed-to-greet time of the patient who took that one's place, and increased your patients/RVU per hour by 5-10% for that shift. This would have for a moment, caused the angels to sign, caused God to kill one less kitten, brought sunshine and rainbows to one child with cancer, and made your CEO just a bit smidge happier. Just sayin'...

 

[xaelia]

15 minutes but it kept you from putting in a CVL? I can place a CVL in less than 5 minutes from start to finish.

CVLs aren't cheap.

EJ is fine, but if that's gone too, I'll put a long 18g angiocath into the IJ under u/s guidance. Tough to miss that vessel. I think our radiologists will even CTA through it.

Not sure I've admitted someone with that access, but I share the sentiment re: placing a CVL in a patient that ultimately gets discharged.

 

[Druggernaut]

You could have seen an ankle sprain in that 15 minutes, booted the non-emergency/weak-admit upstairs for a us-guided peripheral by some noctor and reduced your length of stay, opened a bed, decreased the bed-to-greet time of the patient who took that one's place, and increased your patients/RVU per hour by 5-10% for that shift. This would have for a moment, caused the angels to sign, caused God to kill one less kitten, brought sunshine and rainbows to one child with cancer, and made your CEO just a bit smidge happier. Just sayin'...

Except the hospitalist insists that your stable, weak admit without any immediate need for IV access needs some kind of line "just in case," and is unwilling to take them without it.

 

[Birdstrike]

Except the hospitalist insists that your stable, weak admit without any immediate need for IV access needs some kind of line "just in case," and is unwilling to take them without it.

Are you letting the hospitalists manipulate you and push you around?

Don't ever call them to "admit" a patient. Call them for a consult. They can then make a judgement and admit or send them home if they don't think they're sick, without that IV. Usually, after telling them that's what you're doing and how you're doing it, they'll slam down the phone and ask for the nurse to give admit orders. Some of these guys are more burned out than ER doctors. This is another unneeded game of cat and mouse.

 

[e30ftw]

Except the hospitalist insists that your stable, weak admit without any immediate need for IV access needs some kind of line "just in case," and is unwilling to take them without it.

this is easy.. you just respond "the patient meets criteria for admission however he/she is tolerating PO and VS are stable. patient does not meet criteria for emergent CVL and multiple attempts by RN and myself to establish peripheral access have failed. I will consult PICC team on the admit orders to establish access."

works every time.

I like playing around with u/s as much as the next guy but when the waiting room is blowing up and the ED is on the verge of collapse (just another day) if they don't emergently need access there is no reason they can't go upstairs w/o an IV.

 

[deleted547339]

You could have seen an ankle sprain in that 15 minutes, booted the non-emergency/weak-admit upstairs for a us-guided peripheral by some noctor and reduced your length of stay, opened a bed, decreased the bed-to-greet time of the patient who took that one's place, and increased your patients/RVU per hour by 5-10% for that shift. This would have for a moment, caused the angels to sign, caused God to kill one less kitten, brought sunshine and rainbows to one child with cancer, and made your CEO just a bit smidge happier. Just sayin'...

There's a flaw in your argument. The past couple days our boarding has been crazy

Either way, it's a skill I'm glad I have. The nurses know to come to me when they can't get access. There have been many quasi-stable patients that RNs can't get access (EJ included) where I'll throw in an US guided IV in <1min. In the two weeks I threw one in an Afib RVR patient and in an SVT patient very quickly, both of whom were teetering on the edge.

 

[Birdstrike]

Either way, it's a skill I'm glad I have.

Very true. You definitely can't ever have too many of those.

 

[gman33]

If machine is close by, ultrasound line doesn't take me any longer than a usual IV.
We have the longer caths at all my shops.

 

[TBS12]

a

 

[TBS12]

CVLs aren't cheap.

EJ is fine, but if that's gone too, I'll put a long 18g angiocath into the IJ under u/s guidance. Tough to miss that vessel. I think our radiologists will even CTA through it.

Not sure I've admitted someone with that access, but I share the sentiment re: placing a CVL in a patient that ultimately gets discharged.

please tell me more about this. Do you perform this with sterile technique? How long do you leave this in the IJ? I'm interested because this could be easy to do, but wondering about the specifics of it.

 

[gman33]

please tell me more about this. Do you perform this with sterile technique? How long do you leave this in the IJ? I'm interested because this could be easy to do, but wondering about the specifics of it.

http://www.emlitofnote.com/2012/07/the-peripheral-ij.html
Small study.

The theory is that this is not a central line, it's just going into a big vein.
Some call this semi-sterile. Clean as you can get things, but not gowning up, full sterile technique etc.
I've done a few. Easy to do.
The floor doesn't know what to do with this kind of line.