Ultrasound Guided Peripheral IV

Position: Raise the patient's bed to an adequate height to allow for ease of procedure without hunching over. Put the bed rail down at the side from which you will be performing the procedure. Have the patient supinate and abduct their arm. Note: Ensure you never leave the patient's side with the bed rail down and the bed raised. If you have to leave the room for a second, return the bed to a lower position with the bed rail raised to avoid potential falls.

Tourniquet: Place the tourniquet on the patient to engorge the veins. You will place it proximally on the arm below the patient's armpit. If you can only find an appropriate intravenous insertion site distally in the forearm or hand, then you may place the tourniquet below the elbow (for forearm insertion) or above the wrist (for hand insertion). However, the goal is find one as proximal as possible as those veins are the biggest in diameter and least likely to extravasate.

Ultrasound Survey: Use the transducer button on the ultrasound to ensure it is in the linear probe mode. Using the landmarks detailed below and the linear probe, use the ultrasound to find an appropriate site for intravenous insertion. The probe should be horizontal to obtain the short axis view (cross sectional view of vessel) and the probe marker should be facing YOUR left hand side. Veins will be compressible without any pulsation, and arteries will be pulsatile, thick walled, and non-compressible. Track the vessels up and down to find a vein with the biggest diameter that is most superficial, and where the coinciding artery is not directly under or over the vein to avoid potential arterial puncture during the procedure.

Prepare: Place the drape under the patient's arm to avoid blood from soiling patient's bed. Align the items needed close by in order of how they are needed in the procedure to ensure the procedure goals smoothly (aka "mise en place"). You will need antiseptic swabs/alcohol pad, needle +/- extension, flush, gauze, and tegaderm. If you are using a dual port IV that has the extension component built it, you can prep your IV by screwing in the flush to the port. Clean the insertion site with the alcohol pad or swabstick.

Intravenous Insertion:

1. Position the needle: Using the ultrasound, confirm your intravenous insertion site. The probe marker should face towards YOUR left hand side. Thus, moving the needle right or left will correlate with the orientation of the ultrasound image (if you move your needle towards your left, the needle will move to the left hand side of the ultrasound image). Position the probe so that the vessel is in the middle of the screen. If you press the M mode once, you will see a vertical line in the middle of the screen which can help you align the vessel. If your vessel is aligned properly, when you insert the needle right where the vertical mark on the probe is, you will be directly above the vessel. Ensure that the needle is directly perpendicular to your probe marker (the length of the probe and the length of the needle should make a T).

2. Cannulate: Insert the needle at a 45 degree angle right where the vertical mark on the probe is. Once you have penetrated the skin, look for your IV tip. In order to do this, you will slowly move your probe away from you until you see your needle tip on the screen. Either move your probe or you needle, do not move both at the same time. Once you see your needle tip, start to advance your needle until you can no longer visualize your needle tip on the screen. Now, advance your probe again away from you until your needle tip reappears. Repeat this process until you penetrate the vein, see the needle tip within the center of the vessel lumen, and can see flashback of blood within your IV.

Advance the Catheter: Drop your probe. Without moving the needle itself, advance your catheter. Before retracting the needle, confirm the position of your tip within the lumen of the vessel in both the short and long axis view. Retract the needle. If your are using an angiocath, attach the extension.

Flush: Dispense a few cc's to allow room to withdraw blood into the flush. Attach the flush to the extension, and withdraw. If adequately withdrawing blood, flush the line. When flushing the line, ensure there are no air bubbles. If there is resistance when withdrawing or flushing, the line may be against the vessel wall or have come out of the vessel, use the ultrasound to confirm and try pulling back a few mm.

Secure: Clean and dry the site to ensure the tegaderm will stick. Then, apply the tegaderm dressing.