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On your rotation, you will be refreshed on how to perform ultrasound-guided vascular access, both on a gel model and on patients in the ED.
Prior to this education, which may occur during the second week of your rotation, use caution in placing any lines.
When performing any procedure (including an IV placement in the ED), you need to know who your supervising physician is. It may be the ultrasound staff you're scheduled with that day. However, if that US staff is not with you, then it is technically the ED attending caring for the patient that day in the department, and you should make him or her aware that you are performing "a procedure" on one of their patients.
You may, of course, observe and assist with any such procedures that are going on.
It is very important to check with the patient, nursing, & the treating team prior to placing any IV's to ensure which extremities are and are not safe for IV placement, as some patients have "limb alerts" that prevent a line being placed in certain body areas.
It is very important to check with the patient, nursing, & the treating team prior to placing any IV's to ensure which extremities are and are not safe for IV placement, as some patients have "limb alerts" that prevent a line being placed in certain body areas.
Training versus point-of-care
Training versus point-of-care
When placing US-guided lines in the department, you may find patients who require an IV placed with ultrasound-guidance, but also those who are willing to let you practice placing an IV on them.
If a patient is allowing you to place one on them, and it was not requested to be done with ultrasound guidance by the patient's nurse of the patient's physicians due to difficult placement, then it should be entered into Qpath as a training study, "TRAIN - US GUIDED NEEDLE PLACMENT".
If the patient was found to be a "difficult stick" or the nurses were unable to find an IV themselves and are now requesting ultrasound assistance, then an order should be placed for a "POC ED GUIDE VASCULAR ACCESS," and the study should be pulled up through the worklist on the machine.
All lines you place on the rotation should be documented in Qpath, either as a training study or a POC study. Preferably, you will save pre-placement images, and post-placement confirmatory images in two axes. At a minimum, one image needs to be saved.
Point-of-care report
Point-of-care report
There is often confusion on how to fill out the report on a point-of-care vascular access study in Qpath.
The first option shown here implies that ultrasound was used to locate the vessel, but that it was not used during the procedure. This is a "static" method. where the probe was put down, and the line placed without active guidance.
The second option shown describes a line placed with "dynamic" visualization of the needle tip being "walked" into the vessel. This is how 99% of our lines are placed in the emergency department, and should be the button you select in general.
It is also generally recommended to type in what length & size of catheter was placed in the "Other Interpretation / Complication" section.
The "training" version of this report is blank, and all field need to be filled out manually. This is due to the training version being a catch-all procedural study, including paracentesis, thoracentesis, etc,. in addition to vascular access. Refer to the appropriate point-of-care report for appropriate templates to utilize to fill in the fields on this training report.
Failed lines & "blown" IV's
Failed lines & "blown" IV's
Some attempts at IV placement may fail, or may initially be successful but then suffer catheter failure soon after.
These should still be logged with images saved for review & documentation purposes.
These should still be logged with images saved for review & documentation purposes.
However, you should also make the nurses and physicians caring for the patient immediately aware of your failed attempt.
Apply direct pressure over the failed site.
Inform the nurses and physicians caring for the patient where on the patient's body the failed attempt was.
A failed IV at one site means that attempting to place another IV distally ("below") that failed site is dangerous, for if a successful line is placed distally, then the medications given may travel up to the "blown" site and extravasate into the surrounding tissue. Therefore, the patient's providers need to know where your line was attempted before they attempt again themselves.
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