Ultrasound IV's

[244913]

CA-1 here, currently doing time in a cardiac surgery ICU. I'm having trouble with US guided IV's. All of our pts are post CABG, VAD, heart transplants etc. All very obese, edematous and anemic. So the nurses are constantly pinging me and my CA-3 compadre to help with IV's.

What are the secrets to US-guided IV's? I can't get them consistently. I use out of plane view most of the time, get great flash, but then when I drop my angle and try to advance no luck. Seems like I infiltrate half the time. I nailed a damn artery today.

Do you guys advance after you get flash? Do you drop your angle first and then advance? Do you thread at a steeper angle or do you try to come in shallow, in-plane?

I'm pretty confident with conventional IV's, in which I take a very shallow approach. Unfortunately with out of plane viewing I have to come in at a steeper angle it seems, and I think that's part of the problem. Also, I may be going for veins that are too deep because we're stuck using short-ish (1.16 inch) safety catheters. I've heard that longer catheters ie. the old Gelcos are better with US. The edema complicates matters of course.

Any tips or insight is greatly appreciated.

- ex 61N

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[Planktonmd]

I have a tip... do central lines!

 

[chocomorsel]

Long catheters

 

[deleted162650]

I do these all in plane. It really helps if you use the small/short linear probe. Long catheters are nice for deep veins. Same technique for difficult a-lines.

 

[psychbender]

Use the Arrow arterial line needle. Once you get flash, just advance the wire and thread the catheter just like you would an arterial line.

 

[WholeLottaGame7]

Definitely long IVs for the deeper veins. You can do it out-of-plane, but don't advance the catheter once you get a flash. Instead, find the tip of your needle with the U/S and follow it, scanning up with the U/S while advancing the tip deeper into the lumen of the vessel. Once you've advanced the whole thing several millimeters, it should thread off much easier.

Or, central line or PICC consult.

 

[ph8]

Use the Arrow arterial line needle. Once you get flash, just advance the wire and thread the catheter just like you would an arterial line.

+1 to 20G arrow arterial line kit. In-plane or out-of-plane, whichever you prefer. Seldinger technique and done.

 

[Hamhock]

Consider a short "midline". That is, place a 10-12 cm single lumen catheter into a large, deep UE vein (deep brachial and more proximal) using Seldinger technique.

There are plenty of nice kits intended for other vessels and uses, but they all work well for your situation. I especially like the femoral Aline kits.

HH

 

[Jay K]

If we're talking forearm to proximal veins of the upper extremity:

Out-of-plane, shallow angle, long catheter

Trace the path of the vein proximal to know how it runs directionally prior to cannulation.

I thread after I see my catheter/needle complex in cross-section within the lumen of the vein i.e.: donut hole

 

[Lurch]

If we're talking forearm to proximal veins of the upper extremity:

Out-of-plane, shallow angle, long catheter

Trace the path of the vein proximal to know how it runs directionally prior to cannulation.

I thread after I see my catheter/needle complex in cross-section within the lumen of the vein i.e.: donut hole

If you see it in the lumen without a flash, do you attempt to thread? I feel like this is a relatively common occurrence in my hands where you appear to be in but no blood return.

 

[norwood]

+1 to long cannulas. At some hospitals the IV team will have them.

Here's the reason for long cannulas: the fundamental problem with short cannulas is that the u/s lets you get deeper veins. So you get a flash, you thread the cannula in, and then there's just a little bit of cannula in the vein. Pt moves, or is moved by staff, and at some point that bit of cannula manages to come out of the vein.

When I went from 1.25-inch cannulas to 1.75-inchers, this problem went away almost completely.

Oh, and Jay K is right - trace the vein so you know where you're headed. Entering the vein right before it careens off in a totally different direction is not likely to succeed.

 

[norwood]

we're stuck using short-ish (1.16 inch) safety catheters. I've heard that longer catheters ie. the old Gelcos are better with US.

I just read your original post again and saw this. What you want is something like this: http://www.bbraunusa.com/products.html?prid=4252527-02 (No affiliation, other than that I've encouraged places I work to buy them because I like the product.) It's a safety IV even though it doesn't look like one - there's a little clip inside it that auto-safes the needle when you pull it from the cannula.

 

[RxBoy]

Did a ton in residency. You have to use a long catheter. At bare min the 1.8 inch ivs.. Short ones wont work, theyll blow within minutes.. Avoid going for a vessel > 1.5 cm deep or smaller than 1.5 mm diameter. If ur going for vessels (basalic/cephalic) in the biceps, hit it closer to the ac, its usually very shallow. I have also done it in the armpit as its shallow there too but not the most sterile site. Once u have flash, advance a mm and then advance catheter.

Agreed with above using aline kit. Specifically the femoral a line arrow kits. We recently just bought arrow fem aline with built in guidewire. Work like a charm. If u have a vessel large enough, u can use a single lumen central line too. Both of these make for bad fluid lines, but they wont infiltrate either. Watch a picc team do it, ull learn some good tips.

Above all else, waste no more than 10 min if ur doing it for a case. Just abondon and go for central. It took many delayed cases in residency to learn this the hard way.

 

[Jay K]

If you see it in the lumen without a flash, do you attempt to thread? I feel like this is a relatively common occurrence in my hands where you appear to be in but no blood return.

Yes.

 

[AppTrail]

don't waste your time with US guided IVs...they only last a day at most, and when they blow/infiltrate it takes longer to recognize.

 

[psychbender]

If they are only lasting a day at most, then you are probably using too short a catheter on too deep a vein.

 

[nap$ter]

if you have to do an u/s guided IV - long catheter, short axis, steep angle of entry, when you get a flash go through and through, remove needle, pull catheter back for flow, wire, advance catheter. biceps veins are great for this. as others have mentioned, in most cases you might as well bite the bullet and do a central line - it'll save time in the long run.

 

[Mman]

don't waste your time with US guided IVs...they only last a day at most, and when they blow/infiltrate it takes longer to recognize.

How does an IV catheter know what method you used to place it? My central lines can't tell if they were placed by U/S or landmark guidance. If your problem is they blow to easy when you place them with an U/S, the problem is you don't thread enough distance into the vessel (using too short of a catheter or attempting too deep of a vein for the catheter you've got).

I rarely find a need for U/S guided PIVs. Maybe once every couple months if I'm trying to save the patient from getting a central line and they have a good vein on U/S that isn't apparent by palpation.

 

[Planktonmd]

If no peripheral IV is feasible after 2-3 conventional sticks the next step should very rarely be screwing around with ultrasound peripheral iv's.
An ultrasound peripheral IV can be reasonable as plan A if the patient is known to have difficult IV access but after failed IV's you need to move to a central line because you know how to do them and because they have a much better success rate.

 

[MoMD]

long time lurker....

my technique....only when nurses can't get IVs and they come asking for help.....linear probe, only long catheters...put tourniquet on pt first thing (more time), upper arm...then always grab a chair and do this sitting down...big chloroprep the whole arm from above AC down....rarely use local....line of gel in AC, start in short axis/out of plane in AC...usually can find viens, usually one is medial or a lot of times a vein is next to artery here...then follow it down as distal as i can...get an idea of trajectory.... then some where distal to AC, as distal as i can, turn probe to be in plane/long axis...(this is more difficult part), keeping vein in full view, whole screen, so vein is fully lined up...then enter skin with long catheter...dont move probe to find needle, instead, move/adjust catheter to get in view (like doing blocks really), then see catheter in vein, and watch as I push off catheter off needle the whole way..... as a last resort, can usually find a medial vein proximal to AC if i had to....but i try to avoid those (pt my need PICC or something later)....

definitely saved some pts from getting CVC...i've tried the out of plane technique described well above, but for me, just seems easier approaching the vein like a block....

 

[norwood]

If no peripheral IV is feasible after 2-3 conventional sticks the next step should very rarely be screwing around with ultrasound peripheral iv's.
An ultrasound peripheral IV can be reasonable as plan A if the patient is known to have difficult IV access but after failed IV's you need to move to a central line because you know how to do them and because they have a much better success rate.

U/S peripherals can be quick and reliable, with practice, even on pts where conventional sticks have failed. At worst, the u/s lets you quickly and efficiently see whether there's anything to be had peripherally.

It's been a long time since I did a central line on a pt where I wouldn't have otherwise done one.

 

[BLADEMDA]

I do Basilic U/S guided lines all the time. I use a 20G or 16 single lumen central line kit. I go out of plane. I also use a tourniquet to increase the size of the vein.

After placing the tourniquet I examine the size and location of the vein. I found that you need a 2 mm diameter vein to pull off the 20G line quickly. If the vein is less than 2 mm I go the central route.

 

[BLADEMDA]

 

[BLADEMDA]

Typically I follow the vein more proximally and look for a spot where the vein isn't right next to the artery. I prefer the largest vein I can find.

 

[BLADEMDA]

This is my "go to" spot 90% of the time. On obese patients consider a pediatric central line kit instead of the usual long 20G IV.

 

[BLADEMDA]

 

[Oggg]

I've had several IVs go in nicely, OOP, tracking the needle tip as it enters the vein several mm, but then blow out after a few minutes. I can only assume that I'm slicing the back wall of the vein inadvertently when I try to place the needle several mm into the vein. Perhaps a long catheter would keep the infusion farther away from such a site. I need to find where we keep the long catheters