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.
Tenting of the anterior wall in Short AxisTenting of the anterior wall in Long Axis
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.
Picture showing the positioning of the 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.
Arrow pointing to the needle tip being visualized with the Short Axis Technique
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
Notice the transducer is in the long axis with the needle being inserted at 45 degree angle.Visualization of the targeted vein in the long axis with the hyperechoic structure being the needle tip as it is penetrating the superficial wall of the vein.
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:
Place the Tourniquet behind the patient’s arm.
With each hand hold one end of the Tourniquet
Criss cross the tourniquet (Left hand over right hand)
Pull tightly across the arm with your left hand, while holding the other end stable
Pinch the tourniquet at the cross section with your thumb and index finger of your left hand
With the other end of the tourniquet in your right hand, lay it on top of the patient’s arm
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
STOP AND DOUBLE CHECK
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).