1. Ultrasound Guided Peripheral IV Technique
Kevin Arnold RN, BSN

2. + = Precision & Solution for the Hidden Veins
You should develop accurate propriocetion with practice. =

3. Common Difficult Stick
Obese
Edematous
Dehydrated
Diabetic
Dependent on dialysis
Post chemotherapy
A drug abuser
Post mastectomy
In shock

4. Vein Anatomy
Fig. 1
Fig. 2
Fig. 1
Fig. 2

5. Arm Vein Anatomy

6. Upper Arm Vein Anatomy

7. Ultrasound View – Upper Arm
Veins
Basilic
Brachials
Artery
Brachial

8. Ultrasound View – Upper Arm
Nerve Bundle

9. Typical Sizes & Flow Rates
Vessel
Diameter (mm)
Blood Flow (ml/min)
Cephalic 6 45
Basilic 8 80
Axillary 16
300
Subclavian 19
800
Superior Vena Cava 20
2000
& turbid
Vascular Access Device Selection, Insertion, and Management: BARD ACCESS SSYETSMS, p12.

10. Anatomical Performance
Opinion…
Veins in forearms do not tolerate high rates well, but are less likely to dislodge
Veins 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 success
Use warm packs if extremities are cold to touch
Avoid veins in ante-cubital fosa and wrists if possible
Use good judgment
Avoid sticking nerve bundles
Worst case scenario:
Helpful vein dilator – nitro paste between the fingers, with MD order, will dilate veins

12. More “Rule of Thumb” Ulnar, Radial, Cephalic Cephalic Basilic Brachial
Start with forearm
Ulnar, Radial, Cephalic
Then..upper arm superficial
Cephalic
Then..upper arm deep
Basilic
Brachial

13. Ultrasound Equipment Insert your type of machine…
Fig. 1
Fig. 2
Fig. 3
Insert your type of machine…
Include location and instructions for checkout & use.
Fig.1 Photo by Kevin Arnold, RN, BSN.
Fig. 2
Fig. 3

14. Ultrasound Technology
Very high frequency sound waves
Requires fluid medium for oscillating transmission
Visual images are the reflection of echoes of high frequency sound beams from soft tissues
Ultrasound waves do not transmit through air
Sound waves do not penetrate high density areas well

15. Ultrasound Machines Always plug in power adapter
Battery life is unpredictable
Machine must be signed out in log book located at respective nursing station
Clean before and after use
Please take careful care in handling equipment
Very expensive… $15,000 - $25,000
Replacement probe… $3, (don’t drop it)

16. Ultrasound Machines
Hold probe at 90 degree angle to skin surface for best image results

17. Ultrasound – 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 seen
Gain should be adjusted until there is a slight fill in of white pixels in the vein
Fluid filled vessels should
appear black, void of echoes

18. Selecting the Vein
Depress vessels to differentiate veins from arteries
Vein will stay depressed.
Arteries will “pulsate”
NOTE: Patients with low BP may not pulsate.
Trace vein with probe to find
a straight section of the vein
Mark endpoints to visualize vein path
Avoid nerve bundles
Vein depth discussed later…

19. Selecting 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).

20. CC: Vein Depth | Stick Angle | Catheter Length
Probe
IV Catheter
Stick Angle
Skin
Vein Depth
Catheter Length to Reach Vein
Vein
Image created by Kevin Arnold, RN, BSN.

21. CC: 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.

22. Selecting the Catheter
Floor Stock [ Insert your model ]
1.25 inch | 32 mm
18, 20, 22, 24 gauge
U/S Cart Stock [ Insert your model ]
1.75 in | 45 mm
20 gauge
This will require adding tubing
Choose one-handed use products
Fig. 1
Fig. 2
Fig. 1
Fig. 2

23. Stick Technique
Clasp 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.

24. Stick Technique
Stabilize 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.

25. Site 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. 1
Fig. 2
Fig. 1 Image created by Kevin Arnold, RN, BSN.
Fig. 2 Image created by Kevin Arnold, RN, BSN.

26. Site Prep
Using 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

27. Stick Technique
Consider 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.

28. Stick Technique
Place 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.

29. Stick Technique
In 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. 1
Fig. 2
Fig. 1 Image created by Kevin Arnold, RN, BSN.
Fig. 2 Image created by Kevin Arnold, RN, BSN.

30. Stick Technique
Scan 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.

31. Stick Technique-Confirmation
Needle entering and visible in vein
Fig. 1
Fig2 1
Fig. 1
Fig. 2

32. Stick Technique-Confirmation
Side View (Horizontal Plane)

33. Stick Technique-Video 1
Video created by Kevin Arnold, RN, BSN.

34. Stick Technique-Video 2
Video created by Kevin Arnold, RN, BSN.

35. Potential Complications
Arterial puncture
Adjacent nerve damage
Infiltration
Infection – local & systemic
Potential DVT induced by repeated injury to vessel or the presence of a catheter
Injury to vessel preventing arteriovenous fistulas sites for renal patients

36. CC: 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.

37. CC: Common Pitfalls
My 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 outward
You may be too deep. Look for movement below vein
I 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.

38. Common 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.

39. Documentation
Document 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.

40. Questions?