Ultrasound guided peripheral IVs

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
gman33 said:
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.
Click to expand...

Yep, that's the idea. Certainly not well-described in the literature. Local sterile – like an arthrocentesis or paracentesis. Would encourage inpatient team to replace with PICC at next reasonable opportunity. But, usually these are for patients ultimately getting discharged home (sickle cell, gastroparesis, other droperidol-responsive illnesses).
Members don't see this ad.
 
xaelia said:
Yep, that's the idea. Certainly not well-described in the literature. Local sterile – like an arthrocentesis or paracentesis. Would encourage inpatient team to replace with PICC at next reasonable opportunity. But, usually these are for patients ultimately getting discharged home (sickle cell, gastroparesis, other droperidol-responsive illnesses).
Click to expand...

Mine was a gastroparesis patient.....absolutely the best.
 
There is a young guy who comes to my hospital all the time.
Vascular nightmare.
In this single patient I have placed: regular PIV, u/s guided PIV, IJ CVC, semi-sterile peripheral IJ, IO.

Next time he comes in I'm doing a venous cutdown.
 
  • Like
Reactions: 1 user
Members don't see this ad :)
Braun 2.5cm 18g needles are what I ordered for our ER. They are long enough that if you had to fish around for a vessel, there is still plenty of catheter in the vein. They don't infiltrate if you have enough in the vessel. If you use a shorter catheter, some arm movements will pull out the half cm you had in the vein. One poke from a 18g beats 5 pokes with a 22g any day. Mine never infiltrate but you must make sure there is enough in the vein. 30-45 degrees or else you will kink if using a steeper angle. Use the longitudinal approach to verify the position so you know how much is in the vein. Also, usually you can get the basilic which is more superficial and usually accessible without going through muscle which makes it less likely to come out and infiltrate.
 
  • Like
Reactions: 1 user
A few random thoughts.

18 gauge angiocaths are a bit easier because you can more readily see the needle under ultrasound.

I loved the peripheral IJ idea when I first heard about it. I've never done one and I no longer think it's a good idea. It's just something that's going to cause problems downstream with nurses, and honestly we have no clue about the safety of these things, and won't until we get much higher numbers in the literature.

Finally, I used to love the basilic vein. It's still a reliable choice for many, but increasingly I hesitate to use it unless there is no alternative. My practice has changed because I've been seeing a lot of floor patients during my fellowship, and the thrombosis rate for these vessels seems pretty high. I think our PICC team told us that when they actually do surveillance duplexes they find a thrombosis rate greater than 30%; are shorter catheters less problematic? I don't know but I think the answer may not be what we'd like.
 
Sort of off topic but figured this was as good a place as any.

I place a lot of ultrasound guided pivs or ejs. Usually they are quick but sometimes they take a while. Is this a billable procedure by physicians? If so, how do we document it.

Thanks
 
winkleweizen said:
Sort of off topic but figured this was as good a place as any.

I place a lot of ultrasound guided pivs or ejs. Usually they are quick but sometimes they take a while. Is this a billable procedure by physicians? If so, how do we document it.

Thanks
Click to expand...
From what my US guru has said, if you're credentialed in US you can bill for that... but otherwise a PIV is a PIV is a PIV and not really billable above normal rates.

Now, if it's part of a critical illness, you can use the time towards CC time as it's not a separately billable procedure.

Please, someone correct me if I'm wrong.

-d
 
Any IV placed by a physician even a non US guided PIV is billable. Medicare pays like $40 I think.
 
  • Like
Reactions: 1 user
gman33 said:
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.
Click to expand...

I made a bit of a reputation on my micu month by throwing a few of these. Probably one per call shift, so 6 or 7ish. Had some ID docs who are remarkably influential on the main service and would be get central lines oit the second the pressors stopped.

Lots of times I tried for an IJ, it was a fools errand, and just grabbed the longest needle I could find and cannulated the IJ. Initially I got reprimanded, but the nurses came to my defense since they WORKED and no one had any evidence based reason to actually say I was wrong except they had never thought of violating the sanctity of the IJ before.

Silly medicine residents and their lack of creativity.
 
  • Like
Reactions: 1 users
DocEspana said:
I made a bit of a reputation on my micu month by throwing a few of these. Probably one per call shift, so 6 or 7ish. Had some ID docs who are remarkably influential on the main service and would be get central lines oit the second the pressors stopped.

Lots of times I tried for an IJ, it was a fools errand, and just grabbed the longest needle I could find and cannulated the IJ. Initially I got reprimanded, but the nurses came to my defense since they WORKED and no one had any evidence based reason to actually say I was wrong except they had never thought of violating the sanctity of the IJ before.

Silly medicine residents and their lack of creativity.
Click to expand...

I’ve had a couple blow on me after placing easily so I re-read this thread, here’s my summary:

-Use longer angiocath
-go in-plane
-Ignore flash, see needle entry on US
-advance 1-2 cm into vein before threading
 
  • Like
Reactions: 1 users
Birdstrike said:
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.
Click to expand...

You know, I'm more comfortable with the US lines, than I am with the EJs. I've had the worst luck with them. Half the time I end up creating hematomas. The other problem as someone mentioned is neck blubber. As I'm sure you've noticed, the skin around the neck is thick, like turkey skin, so venipuncture is more difficult.

As for other peripherals, one thing I do is make sure the needle stays in the center of the vein. I also don't thread the IV. I advance the IV with the needle inside all the way, until it's hubbed and I can't advance any more. I've had a lot more success with this approach.
 
  • Like
Reactions: 1 users
I'll occasionally do saphenous cut-downs for unstable patients.

If you are doing a difficult ultrasound guided IV and don't have those longer catheters with the wires, use an a-line catheter. But you should be better than the nurses at IVs and just throw in a regular IV when they say they can't get it in a stable patient. I have to use the ultrasound maybe 1 out of 10 times that the nurses say they can't get an IV.
 
shookwell said:
I'll occasionally do saphenous cut-downs for unstable patients.

If you are doing a difficult ultrasound guided IV and don't have those longer catheters with the wires, use an a-line catheter. But you should be better than the nurses at IVs and just throw in a regular IV when they say they can't get it in a stable patient. I have to use the ultrasound maybe 1 out of 10 times that the nurses say they can't get an IV.
Click to expand...
for the really fat arms you can use a ped central line kit, although a very expensive alternative
 
Members don't see this ad :)
caligas said:
I’ve had a couple blow on me after placing easily so I re-read this thread, here’s my summary:

-Use longer angiocath
-go in-plane
-Ignore flash, see needle entry on US
-advance 1-2 cm into vein before threading
Click to expand...
I've done them for >20yrs. yep that's the best technique. same advice for central lines. I don't use the syringe. just pre load the wire into the needle
 
MSmentor018 said:
I've done them for >20yrs. yep that's the best technique. same advice for central lines. I don't use the syringe. just pre load the wire into the needle
Click to expand...
Wow - no syringe. I've never heard of that. Sounds cool. I want to try it. I guess you need to be using the ultrasound because you won't get the flash right?
 
MSmentor018 said:
I've done them for >20yrs. yep that's the best technique. same advice for central lines. I don't use the syringe. just pre load the wire into the needle
Click to expand...

Hmmm... wasn’t even thinking about a wire, was thinking just get needle/cath deep into vein and then thread the cath off the needle. I dont always have access to a small angio wire at outpatient surgery locations (Anesthesiologist). do you always use a wire?

I’ve done them with the art line “arrow” kits that have the built in wire, but those catheters are pretty short and prone to blowing.
 
n2b8me said:
Wow - no syringe. I've never heard of that. Sounds cool. I want to try it. I guess you need to be using the ultrasound because you won't get the flash right?
Click to expand...
Correct. You load the wire into the needle (but not so far that it sticks out the end) then advance your needle under US. Once you're solidly in the lumen on US and have advanced slightly, thread the wire. You should also be able to see the wire enter the lumen at that point. Then proceed normally.

I've done this technique a few times and it seems to work well. That said, I've never done it as an attending. It didn't seem to offer me much of an advantage by doing it that way, and I now have two separate procedures for when I'm doing a CVL with US guidance vs when I'm doing it without (e.g. subclav, crash cordis). Since I didn't see any significant edge in doing needle in wire, I've decided to keep my muscle memory the same for all CVLs.
 
I have now gone to the "in-plane" technique for all ultrasound-guided subclavians (best line IMO) without a syringe. The syringe is atavistic (ie before EM docs had good ultrasound skills, esp longitudinal access).

----

No longer, but I used to frequently teach EM residents to place single-lumen femoral arterial lines (eg Cook) into the UE using a modified-Seldinger technique...pre-cursor to the RN placed "midline" and much more controlled.

HH
 
Hamhock said:
I have now gone to the "in-plane" technique for all ultrasound-guided subclavians (best line IMO) without a syringe.

HH
Click to expand...

How do you actually do an US guided subclavian? Doesn't the bone shadow your US?
 
What’s the point in using US for SCV lines? They’re reliable anatomically and not having to do us is half the reason I do them over IJ.

I’m really not being argumentative, I don’t know if there is any data regarding benefit like there is for IJ.
 
One of our IR radiologists swears by them and places all SCV lines in plane with US, infraclavicular. The only ones I use US for are supraclavicular lines, but never infra. Honestly, I prefer subclavian lines in general simply because I don't need US. I'd be curious to see any data on decrease in complication rate which is already quite low.
 
caligas said:
Hmmm... wasn’t even thinking about a wire, was thinking just get needle/cath deep into vein and then thread the cath off the needle. I dont always have access to a small angio wire at outpatient surgery locations (Anesthesiologist). do you always use a wire?

I’ve done them with the art line “arrow” kits that have the built in wire, but those catheters are pretty short and prone to blowing.
Click to expand...
no, usually for issues like the big arms that require something longer than the standard 2.5in caths, we just don't have anything longer so a ped picc line kit tends to work pretty well.
for those tiny veins that I know if I could just get the tip in there the cath will slide in, bard? I think is the manufacture has a IV kit with a built in wire.
in a pinch, I've peeled apart the arrow radial kit, cut off the wire from that
 
If you’re going to pull out the US for an IV either put in a regular catheter and feed a midline over a wire, or put the midline in. I agree, this is if your EJ has failed.

Here is my battle plan: meta-stable patient, no veins, EJ. EJ fails, US guided midline - you can use the arrow and Art line catheter if you do not have the equipment. You can also use a pediatric central line (single lumen.)

We stock commercial midlines. Use US and pop it into the cephalic. OR with the kit we are using, do a quick IJ. You can also do a quick IJ using a standard triple lumen kit, evidence supports this use.

Obviously the crashing patient is something different. We all drill. I hope. Then we go fishing.

Don’t fart around with the usual angiocath - it will fail and infiltrate. When i put in a 3” angiocath, (prior to getting midlines), i feed in the wire from the arterial cath kit and we use that.
 
dynamic scanning, needle guide->keep target in center, decrease depth, remember your right triangles, follow the vessel for a few MM with the needle prior to advancing the catheter. I prefer using the 1.88 inch 20's because you can cannulate just about anything, the 2.5 inch 18's I use just for reach.
 
I've been a huge fan of using radial art lines... The self contained arrows with the wire guide... Thing is I've been told they aren't pressure rated for injection. So, no go on PE/dissection. That's said, I LOVE em. Funny enough I hate them for arterial lines lol
 
Nurses should be able to do this, no question. Should have a policy that requires two different nurses to attempt, with at least one of them using ultrasound.
 
  • Like
Reactions: 1 user
Fox800 said:
Nurses should be able to do this, no question. Should have a policy that requires two different nurses to attempt, with at least one of them using ultrasound.
Click to expand...
At my primary ED, nurse tries, then resource/trauma/whatever they call it nurse tries/someone uses ultrasound, and if that fails they have a hospital IV nurse who tries with another US. Then after that I guess they'd ask me.

I can see it coming up more at our smaller places, but it hasn't come up.

Sent from my Moto G (5) Plus using SDN mobile
 
Had a patient with no venous access who needed a CT scan for PE, and our Arrow central lines at the time weren't rated to inject under pressure. I threw an 18g angiocath in the IJ under sterile technique. Was pretty easy, but I got a call from a confused radiologist wondering if he could use the line or not.
 
Very few of our nurses are ultrasound-trained, so it's not uncommon for residents at our program to be asked to place a US-guided PIV multiple times per shift. Can eat up a lot of time searching for veins that aren't crap in locations that the CT techs will accept for use...then the line often fails/infiltrates because it's too danged deep in whatever "acceptable" location it's in, and then we just call the PICC team...

This is a point of great frustration for me. Big 'ol time suck.
 
Cinclus said:
Very few of our nurses are ultrasound-trained, so it's not uncommon for residents at our program to be asked to place a US-guided PIV multiple times per shift. Can eat up a lot of time searching for veins that aren't crap in locations that the CT techs will accept for use...then the line often fails/infiltrates because it's too danged deep in whatever "acceptable" location it's in, and then we just call the PICC team...

This is a point of great frustration for me. Big 'ol time suck.
Click to expand...
solution- peripheral IJ
 
TooMuchResearch said:
At my primary ED, nurse tries, then resource/trauma/whatever they call it nurse tries/someone uses ultrasound, and if that fails they have a hospital IV nurse who tries with another US. Then after that I guess they'd ask me.

I can see it coming up more at our smaller places, but it hasn't come up.

Sent from my Moto G (5) Plus using SDN mobile
Click to expand...
so the nurse who is the most experienced at IV's can't get it ask the nurse who is the most experienced at u/s iv to get it, who then ask you the least experienced to start an IV on the most difficult pt. kinda ironic isn't it?
 
  • Like
Reactions: 1 users
MSmentor018 said:
so the nurse who is the most experienced at IV's can't get it ask the nurse who is the most experienced at u/s iv to get it, who then ask you the least experienced to start an IV on the most difficult pt. kinda ironic isn't it?
Click to expand...
True, but I can put in the peripheral IJ!

Sent from my Moto G (5) Plus using SDN mobile
 
So if you can’t access a peripheral vein, you haven’t practiced. It’s not a “nurses job” good god man did you experience medical school?

I started by analyzing blood as an MT, not as a phlebotomist. But i was also trained as a phlebotomist, and i learned on difficult sticks. It is not “a nurses job” to get blood, it is yours. If you lack expertise in simple phlebotomy then i would question the strength of your “physician” skills. That’s why i do it. I’m a doctor. I do patient care.

I care for patients.

I don’t demean your care. I would ask you delve deep and get better. Practice.

Can’t stick a needle in places? Can’t intubate? Can’t deliver a baby? Can’t run a code? Can’t see a sick kid? Whatever you can’t do, is your own fear - your own lack of practice. And that’s ok.

I can’t take a boring appy laparoscopically.

We don’t need to “just read” we need to get better. To be better doctors.
 
I put an 18g 3.5 inch iv into a L IJ on an obese bull necked man - it actually infiltrated and I ended up putting in a femoral. Not sure how comfortable I would feel power injecting for contrast to be honest. Per our RTs, for reasons unclear to me, they won't power inject even into a TLC.
 
LabMonster said:
So if you can’t access a peripheral vein, you haven’t practiced. It’s not a “nurses job” good god man did you experience medical school?

I started by analyzing blood as an MT, not as a phlebotomist. But i was also trained as a phlebotomist, and i learned on difficult sticks. It is not “a nurses job” to get blood, it is yours. If you lack expertise in simple phlebotomy then i would question the strength of your “physician” skills. That’s why i do it. I’m a doctor. I do patient care.

I care for patients.

I don’t demean your care. I would ask you delve deep and get better. Practice.

Can’t stick a needle in places? Can’t intubate? Can’t deliver a baby? Can’t run a code? Can’t see a sick kid? Whatever you can’t do, is your own fear - your own lack of practice. And that’s ok.

I can’t take a boring appy laparoscopically.

We don’t need to “just read” we need to get better. To be better doctors.
Click to expand...

Nah you’re wrong. It’s a nurse’s job. And your post is way over the top.
 
  • Like
Reactions: 10 users
Angry Birds said:
Nah you’re wrong. It’s a nurse’s job. And your post is way over the top.
Click to expand...

Yep, you are an angry troll. And probably a ****ty doc. I'm sure you're smart. But you're an dingus to your nurses and your patients. Sorry for the delay. Hope you've corrected.
 
LabMonster said:
Yep, you are an angry troll. And probably a ****ty doc. I'm sure you're smart. But you're an dingus to your nurses and your patients. Sorry for the delay. Hope you've corrected.
Click to expand...

A dingus. Not “an dingus.”

And once again, you’ve proved how over the top you are.
 
I don't know any docs that draw their own labs. Techs or nurses everywhere I've been. Unless the nurses can't get it, then I'll show them under ultrasound where to stick. In med school, i rarely if ever drew a lab. The only time i was even offered to start an IV was in practice sessions on dummies, on my ems ride alongs, in the OR on sleeping patients, or in the ED if i asked.

Even in a rural Kenyan hospital, the nurses drew the labs.
 
You must log in or register to reply here.
Next unread thread

Similar threads

lucid_interval
Best ultrasound fellowships at the moment?
2
Replies
88
Views
5K
BoardingDoc
BoardingDoc
EthylMethylMan
Handheld ultrasound?
Replies
9
Views
1K
MechEDoc
MechEDoc
P
ED ultrasound help
Replies
11
Views
1K
Siggy
S
BeachBaby
US IVs
Replies
17
Views
2K
TeddyBoomBoom
TeddyBoomBoom
bearstanley
ultrasound IVs
Replies
45
Views
4K
24GaugeEJ
2
Top