Category: 4. Ultrasound Guided Peripheral IV Insertion

• Using the hand that is not holding the angiocath, push the catheter in
• Remove the tourniquet and retract the needle
• Throw the needle in the designated sharps container

• Hook up the IV tubing to the catheter with the syringe already attached

• Aspirate by pulling on the syringe in order to ensure needle is properly placed
• flush with saline

• Apply a tegaderm and label the time and date
• Clamp the IV tubing and clamp the port covers

• Finally make sure to secure it with Coban

Once you receive flashback avoid the temptation to advance the needle right away, first reduce your needle angle and under ultrasound guidance advance the needle until it is centered in the lumen.

TIP: The reason you want to advance the needle further until the needle tip is at the center of the vessel is because flashback can occur even if only a small portion of the bevel is within the lumen. Through ultrasound guided visualization this will ensure your needle tip is inside the lumen and not just outside the superficial wall.

As you slowly proceed the needle under ultrasound guidance, you will notice some Tenting that occurs on the anterior portion of the vessel. At this point you will want to decrease the angle between the skin and the needle from 45 degrees to about 20 degrees. This will ensure that when additional pressure is applied to penetrate the anterior wall of the vein, the residual force will not puncture the posterior wall.

• Apply to the entire forearm so that you can identify all three veins

Step 4: Apply the Surgilube

• Apply the surgilube along the antecubital fossa evenly

Step 5: Inserting the needle under Ultrasound Guidance

Before we insert the needle, you will want to grip the angiocath between your thumb and middle finger and your index finger on the catheter.

Depending on what technique (Short or Long Axis approach) Step 5 will be a little different. The main difference being the position of the needle and the image casted on to the Ultrasound machine monitor.

Step 5a: Short-Axis Technique

• Place US Probe on patient
• Slide up and down while centering vessel to Map the vein direction
• Bring probe to desired area of vein to cannulate
• Insert PIV needle 2-3 mm away from the transducer at 30-45 degrees (depending on vein depth)
• Visualize the needle tip using creep method advancing only after you visualize the needle tip at every step of the way (see below for the “Creep Method for leading the needle”

TIP: Make sure the needle is being inserted at the center of the transducer where the marker is located this will help to maximize precision and accuracy.

TIP: If you aren’t able to visualize the needle tip make sure to position the needle perpendicular to the ultrasound beam. This allows for you to maximize the amount of wave frequencies transmitted. 

To do this, slightly tilt the transducer away from the needle to maintain a 90 degree angle. The reason why this works so effectively is that by tilting away from the needle and inadvertently maneuvering it toward the operator it will immediately cast its beams and begin highlighting the needle.

Step 5b: Long-Axis Technique

• The Longitudinal technique/approach is very similar to the Transverse approach in the earlier steps.
• Start by finding the vein in short axis and then twist the probe 90 degrees.
• Slide up and down while centering vessel to Map the vein direction
• Insert PIV needle 2-3 mm away from the transducer at 30-45 degrees (depending on vein depth)
• Visualize the needle tip using creep method advancing only after you visualize the needle tip at every step of the way
• You should be able to the visualize the needle as it penetrates the skin and throughout the whole procedure

TIP: if you are having trouble visualizing the needle, gently fan the probe side to side. You should be able to visualize the needle tip, shaft, and vessel at all times. Do not advance the needle if you can’t see it.

Always insert the IV only a few millimeters at a time. If you insert too quickly you are at risk for blowing the vein by penetrating both the anterior and posterior walls.

To visualize the vein you wish to cannulize, first apply a tourniquet proximal to the region you wish to cannulate.

Here are the steps to applying a tourniquet on the right arm:

1. Place the Tourniquet behind the patient’s arm.
2. With each hand hold one end of the Tourniquet
3. Criss cross the tourniquet (Left hand over right hand)
4. Pull tightly across the arm with your left hand, while holding the other end stable
5. Pinch the tourniquet at the cross section with your thumb and index finger of your left hand
6. With the other end of the tourniquet in your right hand, lay it on top of the patient’s arm
7. Using your right index finger, tuck the proximal end (of the tourniquet you just placed on top of the patient’s arm) underneath the crisscross you have in your left hand
8. STOP AND DOUBLE CHECK
9. Before proceeding to the next step remember the moment the tourniquet is on the patient, they are losing blood circulation to the distal extremity. If you ever need to release the tourniquet simply pull on the end indicated by the arrow below.

Now that we patient, ultrasound machine, and PIV equipment set up along with a mapping of the vein (including the depth) we are now ready to go over the steps of the procedure.

Step 1: Apply Tegaderm to Ultrasound Probe

Place the tegaderm on top of the Linear array probe (you could also use a probe cover or surgical glove).