Performing USG PIV Access

Performing USG PIV Access

  1. Preparation
    1. Patient: position the patient in a comfortable position that allows the operator access to the area of interest. Don’t forget that commitment to comfort strategies can aid your IV placement whether using a landmark or US-guided approach. Remember to:
      1. Make a plan
      2. Apply numbing cream
      3. Use comfort positions
      4. Breastfeed or use sucrose
      5. Use distraction
      6. Use positive language
      7. Consider using procedural sedation as per local policy
    2. Ultrasound: Place the US machine in a place where both the US screen and patient’s vein can be seen simultaneously.
    3. Set the depth and gain for the anatomy being visualized. Use a vascular preset if available on your ultrasound machine. Ensure both the probe marker and dot on the screen are on the operator’s left.

 

  1. Localize target vessel by ultrasound
    1. Prior to preparing the sterile field, apply a tourniquet and look for preferred sites: consider scanning both arms and saphenous until you find the best site.

TIP: To focus on ideal targets, set the machine depth to its minimum setting.

    1. Using anatomy to guide probe placement identify a site for USG cannulation: the preferred sites include the larger vessels of the forearm, saphenous and in cases of difficult access the distal upper arm.
    2. Remember ideal vessel characteristics include a 0.3-1.5 cm depth, 4 mm diameter (often difficult to ensure in smaller patients) and a straight segment of least 1cm in length.

 

  1. Confirm identification of vein and surrounding structures
    1. Confirm the visualized structure is a vein using compression, lack of pulsatility and if doubt remains absence of pulsatile flow on color doppler to differentiate it from any surrounding structures. Remember if the tourniquet is up a vein may not show any flow, but an artery should have pulsatile flow.
    2. Identify any nearby structures to be avoided including arteries, nerves and tendons.
    3. Consider using a marker to mark the skin to approximate the path of the vessel and planned approach.

 

  1. Preparing for the procedure
    1. Once the site is selected, wipe off any excess gel from the patient and transducer.
    2. Prepare the machine by cleaning the probe, cord and machine. Obtain sterile US gel and apply a thin strip to the US probe followed by a sterile sheath or adhesive dressing. Take care not to contaminate the sterile dressing during application.
    3. Ensure you have the proper catheter dependent on vessel size and depth, tourniquet, IV tubing, saline flushes, tape or dressing to secure the IV and additional people to aid with patient holding, traction on the vein and passing of supplies.

 

 

  1. Introduce the needle
    1. Out-of-plane technique:
      1. Orient the probe so the vein is in the center of the screen, be sure the hand holding the probe is braced on the patient either with the palm or outstretched finger to minimize probe movement. Additionally, wrapping the US cord around the arm can eliminate any “pull” on the probe to decrease movement and slippage.
      2. Note the depth of the vessel and choose an appropriate angle of approach (45 degrees for deep structures, 30 degrees for more superficial structures)
      3. With the needle perpendicular to the center of the probe, advance the needle into the skin aiming for the vein visualized at the center of the probe.
      4. Once the needle and catheter have pierced the skin pause to find the hyperechoic needle tip on the ultrasound screen by fanning the US probe towards the needle. If having difficulty, try gently “jiggling” the needle to identify surrounding tissue movement. Once visualized move the probe slightly forward and continue to advance the needle tip towards the vein until it comes into view. Continue this process, following the tip of the needle by moving the US probe and then the needle until the needle tip enters the vessel lumen. This creeping technique ensures that the needle tip is visualized and helps prevent posterior wall puncture.
      5. As the needle enters the vein the vessel wall will indent or “tent”, at this point advance in small amounts until the vessel wall recoils and the hyperechoic tip of the needle is confirmed in the center of the vessel.
      6. Flatten the angle and advance the needle a little further in the vessel before advancing the catheter.
      7. Confirm the needle tip has not pierced the posterior wall of the vessel by moving the US past the end of the visualized needle prior to advancing the catheter over the needle and securing the IV.

 

Video 3: Out-of-plane technique (creep technique)

 

 

    1. In-plane technique:
      1. Once the vessel is identified in the transverse orientation, rotate the probe 90 degrees while keeping the vessel centered on the screen until the entire length of the vessel is visualized on the screen. Brace the probe hand firmly on the patient so the probe does not move as even small movements can result in losing alignment. Additionally, wrapping the US cord around the arm can eliminate any “pull” on the probe to decrease movement and slippage.
      2. Note the depth of the vessel and choose an appropriate angle of approach.
      3. With the needle parallel to the probe enter the skin adjacent to the end of the probe and advance the needle along the plane of the US beam.
      4. Follow the entire length of the needle as it passes through tissues and advances into the target vessel. If the full length of the needle/needle tip is lost from view DO NOT MOVE THE PROBE as you will lose sight of the vessel, simply withdraw the needle towards the skin, adjust your angle and reattempt.
      5. Once the needle tip is visualized within the vessel lumen, flatten the angle and advance the needle a little further within the vessel lumen.
      6. Ensure you are visualizing the tip of the needle within the vessel lumen by imaging the length of the needle before advancing the catheter and securing the IV.

 

Video 4: In-plane technique

 

  1. Confirm catheter placement
    1. Visualize the full length of the catheter in the vessel.
    2. Confirm with observation of saline turbulent flow within the vessel with flush.

 

  1. After thoroughly cleaning the US gel from the skin secure the catheter. Finally remove sterile cover from the US probe and clean the machine and document the procedure in the chart as per local policy.