US IVs

[BeachBaby]

I'm having difficulty with US guided IVs. I get set up, position, have bevel up, etc - and then as soon as I go in I have no idea where my needle is and if I do see my needle I struggle to reposition it into the vein.Any helpful tips, resources, links, videos etc?

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[bravotwozero]

Start by placing the needle directly under the probe at its center. push down, so you see the skin moving down in the US, which will produce a hypoechoic shadow. Once the needle is centered with the probe, keep watching the center of your screen as you advance the needle. You should see a bright white dot which is your needle. Be sure to advance the probe as you advance your needle. When you see the needle gradually disappear, you know you have gone too far with the probe so retreat the probe just before that point.

 

[doctoroxygen]

Make sure your needle, probe, and screen are all in a line, which usually works best if the machine is across the patient from you. Positioning every patient the same way every time (as much as you're able to in the ED) helps minimize the extraneous variables so you can focus on the microskills of probe and needle movement. Start your needle with a shallow angle half a cm distal to where your initial target it and then scan back to find the tip once it's in the skin. Once you've located the needle tip in the superficial tissues, it's much easier to track the tip into the vein.

 

[bravotwozero]

To each their own, YMMV etc. Works for me.

 

[dadaddadaBATMAN]

Maybe I’m a dimwit, but I’ve always had a slightly different approach with these.

1. Take 30-60 s and make sure you find a good target, not just the first thing you find.

2. If possible, choose one of the spots that doesn’t hurt: ideally forearm volar side, but between painless and good iv go for good

3. Here’s where I speak heresy: If there’s nothing concerning around to hit (nerve, artery) and you really struggle to find the needle tip, just insert the right depth at the right angle to hit the vein and use a semi-blind technique. This isn’t a damn central line where you’re gonna hit the carotid or cause a pneumo. Just take a shot at it, and usually the tissue deformation will guide you

4. All the good stuff above. I got way better at them doing technique in 3, but I now can see my needle tip whole way 90-95% of time. The more you try, the better you get

 

[clibby]

Honestly, we can all give our advice here, but there are 2 things that actually work as we can't see what you are doing wrong:

1. 1:1 bedside teaching by someone skilled in this; not most RNs as I usually see them looking at tissue displacement, not the needle. Your ultrasound faculty should be able to troubleshoot this for you at the bedside so you practice doing it the right way, not just practicing the wrong thing.
2. Once you have the technique, practice, practice, practice.

 

[Fox800]

I also want to add the importance of visualizing the needle tip.

Once you can find that, center the needle tip in the middle of the vessel. Slide the probe a tiny bit proximal and advance the needle. You "walk" the needle tip as far into the vessel as you can before threading the catheter. Just keep sliding the probe up the arm while you advance the needle into the vessel.

Ideally you can advance it all the way until the hub hits the skin.

 

[gro2001]

In addition to what everyone said above, a couple of additional things I've picked up along the way:

-The needle tip is more likely to be seen when the probe is at 90 degrees to the needle. Apart from walking the probe forward, try tipping it so that you are perpendicular with the needle.
-Advance more slowly than you think you need to, like 1 mm at a time.
-The middle of the screen is the middle of your probe. Put your target right in the middle of the screen (use the M-mode line or guide line if you have to) and insert the needle right under the middle of the line on your probe.
-Try long axis (in plane) view. It's harder to get the view, but if you do and can keep your probe steady it's way way easier to see your needle.

 

[MechEDoc]

Do not lose track of the tip of the needle! If you are in transverse plane, make slight adjustments proximally and distally with the ultrasound beam to keep the bright(er) dot that is the needle tip well visualized. Guide that into the vein and then flatten out your needle and advance it proximally in the vein well away from the wall of the vein (you can dissect the vein wall) before pausing to advance your catheter. This is the approach I use ~95% of the time. I think I've missed one IV in 2+ years.

You can use tofu and a straw for practice (tofo representing the inches of adipose tissue you must typically harpoon and the straw being the vessel).

Also, please use appropriate sterility - some sort of probe cover (even a tegaderm is better than nothing) and sterile gel (surgilube works great). Nurses are notorious for not doing either.

 

[Beeftenderloin]

Find a nice target. Ideal characteristics are large caliber (idealy > 0.5mm), less than 1cm deep, and straight. For the last part you need to trace up and down a little bit once you’ve found your target to make sure it’s straight.

Once you’ve got your target, pierce the skin and find your tip right in the middle of your probe. Move probe toward needle and gently wiggle the needle to help find it. Once found, advance needle toward vein a few mm at a time. Slowly advance probe ahead of needle a few mm. Advance needle again so tip is in view. Continue this back and forth advancement until needle tip is tenting the vessel. Pierce through and visualize tip in vessel (looks like a little donut).

Most people that aren’t facile with US guided IVs will screw up here. They get flash and try to thread the catheter. DO NOT thread the catheter yet. Flatten out your angle (flat as you possibly can), still visualizing needle tip in vessel. Now advance probe 1-2 mm till needle tip is just out of view. Now advance needle til tip is in view again within the lumen. Now advance probe again 1-2mm til tip is out of view then advance needle again just til tip is visualized.

Continue this back and forth until at least .5-1cm catheter is in the lumen (sometimes I’ll walk half the catheter in if I have time if I’m not in a hurry), THEN thread off catheter.

 

[dadaddadaBATMAN]

Find a nice target. Ideal characteristics are large caliber (idealy > 0.5mm), less than 1cm deep, and straight. For the last part you need to trace up and down a little bit once you’ve found your target to make sure it’s straight.

Once you’ve got your target, pierce the skin and find your tip right in the middle of your probe. Move probe toward needle and gently wiggle the needle to help find it. Once found, advance needle toward vein a few mm at a time. Slowly advance probe ahead of needle a few mm. Advance needle again so tip is in view. Continue this back and forth advancement until needle tip is tenting the vessel. Pierce through and visualize tip in vessel (looks like a little donut).

Most people that aren’t facile with US guided IVs will screw up here. They get flash and try to thread the catheter. DO NOT thread the catheter yet. Flatten out your angle (flat as you possibly can), still visualizing needle tip in vessel. Now advance probe 1-2 mm till needle tip is just out of view. Now advance needle til tip is in view again within the lumen. Now advance probe again 1-2mm til tip is out of view then advance needle again just til tip is visualized.

Continue this back and forth until at least .5-1cm catheter is in the lumen (sometimes I’ll walk half the catheter in if I have time if I’m not in a hurry), THEN thread off catheter.

Only a couple things I’d add.

Sometimes the deep lines are actually easier (you have longer to find the needle tip, and sensation seems strongest along the skin if you have a low pain tolerance), but they are a lot more prone to blowing or getting tugged out since less catheter is buried in em. I believe this personal observation is also evidence based.

The tip about ignoring flash is gold. Half the time you pierce the vessel but it rolls or you’re just barely outside it after tapping it. It’s also Easy for some micro movement to displace you here. It’s also easy to get a flash from a hematoma if you don’t actually follow the needle tip. I always follow my ring at least a little into vessel, and sometimes change my axis to watch the line go in.

My final bit is don’t give up if you thread and nothing is coming out. 80% of the time when I do this (infrequent these days) I just placed the line a little deep. Occasionally you’re up against a valve.

Ask for a flush: you can try to put a little in and if it goes easy without resistance (and you don’t see a new mass) you’re in. Otherwise, don’t force it. hook it on the line, pull back gently on flush, and slowly withdraw the line a mm at a time. A solid portion of the time you’ll find yourself in the vessel (blood starts flowing) on the way out, and then you can “corkscrew” your way in.

 

[GassYous]

You can use a long catheter with through and through technique for the tough ones. Watch your needle go through the vein on ultrasound, push past and then take the needle out. Pull the catheter back slowly until you get flow, thread a wire then push the catheter in over the wire.

 

[Beeftenderloin]

Sometimes the deep lines are actually easier (you have longer to find the needle tip, and sensation seems strongest along the skin if you have a low pain tolerance), but they are a lot more prone to blowing or getting tugged out since less catheter is buried in em. I believe this personal observation is also evidence based.

This is why I always use the longer IV catheters for US guided IVs and try to keep targets less than 1cm deep.

 

[e30ftw]

Find a nice target. Ideal characteristics are large caliber (idealy > 0.5mm), less than 1cm deep, and straight. For the last part you need to trace up and down a little bit once you’ve found your target to make sure it’s straight.

Once you’ve got your target, pierce the skin and find your tip right in the middle of your probe. Move probe toward needle and gently wiggle the needle to help find it. Once found, advance needle toward vein a few mm at a time. Slowly advance probe ahead of needle a few mm. Advance needle again so tip is in view. Continue this back and forth advancement until needle tip is tenting the vessel. Pierce through and visualize tip in vessel (looks like a little donut).

Most people that aren’t facile with US guided IVs will screw up here. They get flash and try to thread the catheter. DO NOT thread the catheter yet. Flatten out your angle (flat as you possibly can), still visualizing needle tip in vessel. Now advance probe 1-2 mm till needle tip is just out of view. Now advance needle til tip is in view again within the lumen. Now advance probe again 1-2mm til tip is out of view then advance needle again just til tip is visualized.

Continue this back and forth until at least .5-1cm catheter is in the lumen (sometimes I’ll walk half the catheter in if I have time if I’m not in a hurry), THEN thread off catheter.

this is the way.

I only did like 15 US PIV in residency but have done around 2-3/wk in the community now for the past 6 years.

getting flash is easy, trick is to flatten out after flash and always know where the tip is in relation to the center of the vein as stated above.

also, as with any procedure, maintain the same basic position every time you do it. so make sure the bed is adjusted, your posture consistent, and keep the pts arm the same layout every time.

RNs now do US PIV at our community ED and a common theme in failed attempts is RN sitting on a stool huddled over a vein in a pt w arm lying downward on stretcher, looking up at US screen and back to vein, etc.

I always raise the bed to appropriate height, place pts arm in supination/ext rotation on mayo stand with vein about level to pts heart, then perform procedure from a relaxed standing position.

It's like a CVL/LP or any other procedure; you have to line the anatomy up, including your dominant arm angle and the likely orientation of the vein you're trying to access as well as position the pt for comfort, etc to ensure success.

 

[TheComebacKid]

My biggest tips are:
1) Do a ton of them. I probably had 40+ misses before I hit my first one smoothly. Just give it a time. If you can place a central line with US, you can place an IV, it just requires more fine tuned movements
2) ANESTHETIZE THE HELL OUT OF THEM. Use lidocaine. It will allow you to take your time, the patient won't jerk as soon as you get into the vessel, and you will increase your success overall especially in the beginning when you are struggling more
3) As stated earlier, ignore flash. Flatten out once in the vessel and follow the "bulls eye" sign a little bit once you penetrate the vessel wall

 

[jw3600]

My biggest tips are:
1) Do a ton of them. I probably had 40+ misses before I hit my first one smoothly. Just give it a time. If you can place a central line with US, you can place an IV, it just requires more fine tuned movements
2) ANESTHETIZE THE HELL OUT OF THEM. Use lidocaine. It will allow you to take your time, the patient won't jerk as soon as you get into the vessel, and you will increase your success overall especially in the beginning when you are struggling more
3) As stated earlier, ignore flash. Flatten out once in the vessel and follow the "bulls eye" sign a little bit once you penetrate the vessel wall

Anesthesia is not really necessary. Done hundreds and never used any local/topical.

 

[DrDrummer]

Anesthesia is not really necessary. Done hundreds and never used any local/topical.

Not necessary, but if you're learning and think you might have to redirect a lot or if the person is a squirmer who has been poked 12 times by nurses already, it helps. A 27-30 gauge needle and a skin wheel over the puncture site allowed to diffuse while you're prepping and setting up your stuff will get you a lot of goodwill and patience from the patient. And if you've ever had someone dig around in your subcutaneous tissue with a needle before, it does hurt so why not?

I do this in hyperalgesic IVDU patients who have burnt up all their veins except the deep ones and the older people with a lot of arm fat and tiny mobile veins, just makes life easier and takes an extra 30 seconds.

 

[TeddyBoomBoom]

hmm... not necessarily disagreeing but haven’t ever anesthesitized for US PIV. I’ve done at least 100+ and have never anesthetized. If I have a problem with the US IV, I usually switch sites. I wouldn’t want to start numbing up multiple sites, as much for annoyance factor and additional sticks than anything