10Anatomical Performance Opinion…Veins in forearms do not tolerate high rates well, but are less likely to dislodgeVeins in dominant hands tolerate higher rates, but are more likely to dislodge and develop phlebitis
11“Rule of Thumb” Be patient Look for sites that will have the best possible successUse warm packs if extremities are cold to touchAvoid veins in ante-cubital fosa and wrists if possibleUse good judgmentAvoid sticking nerve bundlesWorst case scenario:Helpful vein dilator – nitro paste between the fingers, with MD order, will dilate veins
12More “Rule of Thumb” Ulnar, Radial, Cephalic Cephalic Basilic Brachial Start with forearmUlnar, Radial, CephalicThen..upper arm superficialCephalicThen..upper arm deepBasilicBrachial
13Ultrasound Equipment Insert your type of machine… Fig. 1Fig. 2Fig. 3Insert your type of machine…Include location and instructions for checkout & use.Fig.1 Photo by Kevin Arnold, RN, BSN.Fig. 2Fig. 3
14Ultrasound Technology Very high frequency sound wavesRequires fluid medium for oscillating transmissionVisual images are the reflection of echoes of high frequency sound beams from soft tissuesUltrasound waves do not transmit through airSound waves do not penetrate high density areas well
15Ultrasound Machines Always plug in power adapter Battery life is unpredictableMachine must be signed out in log book located at respective nursing stationClean before and after usePlease take careful care in handling equipmentVery expensive… $15,000 - $25,000Replacement probe… $3, (don’t drop it)
16Ultrasound MachinesHold probe at 90 degree angle to skin surface for best image results
17Ultrasound – Maximize Your Image Depth should be adjusted so that the view of target structures is maximized while allowing structures posterior to the target to also be seenGain should be adjusted until there is a slight fill in of white pixels in the veinFluid filled vessels shouldappear black, void of echoes
18Selecting the VeinDepress vessels to differentiate veins from arteriesVein will stay depressed.Arteries will “pulsate”NOTE: Patients with low BP may not pulsate.Trace vein with probe to finda straight section of the veinMark endpoints to visualize vein pathAvoid nerve bundlesVein depth discussed later…
19Selecting the Catheter Catheter size selection should reflect size of available vessel and type of therapy to minimize/prevent complications and maintain adequate access.NOTE: Phlebogenic drugs are best given through a small catheter in the largest available vessel.Catheter length should be adequate to ensure that ½ of the catheter will reside in the lumen of the vessel. Be sure to take the angle of approach into consideration when determining vessel depth (depth scale available on US screen).
20CC: Vein Depth | Stick Angle | Catheter Length ProbeIV CatheterStick AngleSkinVein DepthCatheter Length to Reach VeinVeinImage created by Kevin Arnold, RN, BSN.
21CC: Vein Depth | Stick Angle | Catheter Length This chart represents the catheter lengths needed just to reach the vein.The length to reach the vein should not be more than one-half of your catheter length.Catheter Length = Vein Depth / [Sin(Stick Angle x (Pie()/180))]Chart created by Kevin Arnold, RN, BSN.
22Selecting the Catheter Floor Stock [ Insert your model ]1.25 inch | 32 mm18, 20, 22, 24 gaugeU/S Cart Stock [ Insert your model ]1.75 in | 45 mm20 gaugeThis will require adding tubingChoose one-handed use productsFig. 1Fig. 2Fig. 1Fig. 2
23Stick TechniqueClasp probe with a “C” grip close to the end… holding the probe far from the end will allow too much movement.Gripping with a “C” allows use of your pinky finger and/or butt of you hand to stabilize your hand against patient arm.Image created by Kevin Arnold, RN, BSN.
24Stick TechniqueStabilize your hand holding probe with one finger or wrist against patient’s arm.Wrap ultrasound cord around arm to prevent dropping probe.Keep ultrasound parallel to skin.Use on-screen guide to align center.Image created by Kevin Arnold, RN, BSN.
25Site Prep Mark endpoints to visualize vein path and insertion area Impressions will stay for a while and not rub off in prep. Vein Direction Fig. 1Fig. 2Fig. 1 Image created by Kevin Arnold, RN, BSN.Fig. 2 Image created by Kevin Arnold, RN, BSN.
26Site PrepUsing friction, scrub the selected site about 3 inches in diameter for 30 sec and allow to dry (Scrub 2 minutes for areas of dense hair)NOTE: Do not blot or wipe on site to speed drying.Prep surface of transducer using chlorahexadine sponge (once prepped, do not allow probe to contact non-prepped areas.)Apply a small amount of sterile gel to probe or above selected insertion site
27Stick TechniqueConsider the concept of catheter length vs. angle of insertion. It is important to balance the two.Use on-screen guide to measure depth of vein and direction. Each dot = ½ cm.Veins around 1.0 cm deep are usually the easiest.Sticks will be easier with a higher angle of insertion, but this must be balanced with the catheter’s ability to bend.Avoid kinking the catheter.
28Stick TechniquePlace probe above where you anticipate needle tip will enter vein. Imagine your needle as the hypotenuse of the triangle you are forming. Drag from above expected insertion site to eliminate gel entering insertion area.Use minimal amount of gel. Too much gel makes stabilizing probe difficult.
29Stick TechniqueIn general it is easier to visualize your needle if you stick in the 45 – 65 degrees range from the skin. Then lower your angle to thread the catheter.Fig. 1Fig. 2Fig. 1 Image created by Kevin Arnold, RN, BSN.Fig. 2 Image created by Kevin Arnold, RN, BSN.
30Stick TechniqueScan probe to view needle tip by moving probe to and from insertion site.You may inadvertently stick through both sides of vein wall. If so, you should see and feel the vein wall “pop” into place when retracting the needle out of the deeper side of the vein wall.You should have excellent blood flow when tip is in the middle of the vein.After visualizing tip of needle in center of vein, it is okay to lessen the angle of the needle as you begin to thread the catheter.
31Stick Technique-Confirmation Needle entering and visible in veinFig. 1Fig2 1Fig. 1Fig. 2
32Stick Technique-Confirmation Side View (Horizontal Plane)
33Stick Technique-Video 1 Video created by Kevin Arnold, RN, BSN.
34Stick Technique-Video 2 Video created by Kevin Arnold, RN, BSN.
35Potential Complications Arterial punctureAdjacent nerve damageInfiltrationInfection – local & systemicPotential DVT induced by repeated injury to vessel or the presence of a catheterInjury to vessel preventing arteriovenous fistulas sites for renal patients
36CC: Common Pitfalls Beware of threading in the “sidewall” of the vein. It is common to get some blood return after threading through part of the sidewall. It is very important to visualize the needle tip in the center of the vein opening.
37CC: Common PitfallsMy needle is under the skin but I cant see the tip?After needle insertion, make sure the probe is close to the insertion area.Move the probe closer to the insertion site and scan outwardYou may be too deep. Look for movement below veinI buried my needle and I still can’t reach the vein?Retract and advance at a steeper angle, but make sure to allow sufficient catheter length left for in the vein. Infiltration is likely if catheter is too short.
38Common Reminders You will constantly have to remind students: Keep your eyes on the screen…not the insertion area.Stick steeper…steeper is much easier dot see tip.Don’t hover over patient with needle…just stick quickly through skin and then use the screen to guide the needle into the vein.Use your wrist/finger to stabilize your probe hand…free handing the probe will allow too much movement. Use a “C” grip.
39DocumentationDocument IV site location and preparation, gauge of catheter, number of attempts, and type of dressing in the medical record.Use of ultrasound for guidance should be included in note.