US Guided Periph IVs

[Seaglass]

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How do you do it? I'm seeing a lot of techniques and I was wondering if some of you use a probe sheath, bare probe on skin, sterile KY jelly or what. Also, standard angiocath, cath over wire, or something else. Lets hear it!

 

[roja]

This has rapidly become a favorite of mine...


I have become very fond of putting an iv into the basilic vein. (pg 354 I think of the Ma Emergency U/S book). The hardest part is unless the patient is very thin, you will need a longer catheter. I horde them when I find them. If I can't find them, then I crack open a central line kit. No fancy technique. Just pop on some jelly and follow basic u/s line guided technique. (no sterile stuff necessary, its a peripheral line).

Use basic IV technique. I was working with our department chair and we had a bounceback nightmare patient. s/p bka, dialysis, in chf. NO peripheral viens. 3 days before, we had found a 24g in his belly but that was gone. refusing an ej and no central line. He was in APE. The chair asked me if I had done an u/s guided basilic..... I cracked open Ma, started up the GE and voila... access. (I had a longer cath needle in my bag.)

 

[beyond all hope]

I have had mixed success with US guided peripherals. They take just as much time as putting in a central, and despite having a really long catheter they do still fall out occasionally.

I've found that practically, if you're considering a US peripheral, better to just put in a central, especially if you're admitting them. So much less hassle for the admitting team. Yes, central lines have more complications, but they can also be used to draw bloods and they rarely fall out.

That being said, I often drag the US probe into a room with me when I'm getting access. My failed IV access algorithm is usually EJ/other neck veins -> hands/thumb -> look with US for peripheral -> Central line.

 

[EMIMG]

I am a big proponent of them. Much better for pt care rather than sticking them 4-5 times to try to get a 22 gauge.

I use the 18 gauge 2 1/2" catheters.
First I look for the veins in the arm (either AC or bicep area)
Next, will cleanse the skin.
Put gel on the probe
Cover the probe with a glove or some other form of barrier to prevent it from getting bloody
Use sterile gel as conducting medium (surgi-lube)
And find the vein.
I find that the long-axis works much better than the short axis because you can actually see the needle as it enters the vein and can ensure that it truly is in the lumen of the vein and not going through.

 

[basementbeastie]

agree w/ beyond....

use a glove always - keeps hepatits / hiv blood off probe, also keeps alcohol off probe (which damages the crystals).

i use sterile lube but then wipe it off at the puncture site.

hold the 10 MHz linear probe in left hand and looooong iv cath in right hand.

advance under direct visualization.

once i have good venous blood flow through catheter, i put down the probe and continue with regular iv technique.

i always secure the arm with an arm board...even with this and secure taping the catheter seem to dislodge at a rate approaching 50%.

i have not used the long view with the probe. only once have i placed a central line through an ej, never through an arm vein. good ideas though. the catheters that i have available are 2". i have also tried radial art lines with mixed success. perhaps femoral art lines would work.

 

[Seaglass]

I also have had better luck with short axis over long axis - I think it just depends on what you're comfortable with. FYI there was a study that showed short axis as being easier to learn.

 

[bartleby]

If putting in a peripheral IV by ultrasound takes as much time as a cordis or TLC, you just need more practice. You find the vein quickly, throw some surgilube on and go for it. No sterile field, gown, gloves, no need for lido, getting claves, flushes, suturing in place, and xray to cofirm placement (IJ and SCV), let alone time spent actually placing the line.

If you leave a proximal tourniquet on the patient's arm, you should have no trouble at all drawing blood off a properly placed 18ga IV.

There are few things in medicine I love as much as putting in a central line or teaching somebody else to do it right. But the fact of the matter is that as cavalier as we are about doing this, it is far from a benign procedure. Aside from the significant risk of infection and catheter-related thrombosis, there are plenty of complications related to placement (pneumothorax, vessel laceration, inadvertent arterial puncture) which make this a procedure which is not to be taken lightly.

There are plenty of times when you need IV access and blood from someone like a dialysis patient who is likely to be a hard stick but stands even odds of going home or just getting bounced straight to dialysis. Patients who are shocky and headed to the ICU and have no peripheral access are a no-brainer. But if you can spare somebody a central line when you're carrying five other patients and there are ten people in the waiting room, you've done your patient (and yourself) a true service.

I have had mixed success with US guided peripherals. They take just as much time as putting in a central, and despite having a really long catheter they do still fall out occasionally.

I've found that practically, if you're considering a US peripheral, better to just put in a central, especially if you're admitting them. So much less hassle for the admitting team. Yes, central lines have more complications, but they can also be used to draw bloods and they rarely fall out.

That being said, I often drag the US probe into a room with me when I'm getting access. My failed IV access algorithm is usually EJ/other neck veins -> hands/thumb -> look with US for peripheral -> Central line.