US-Guided PIV¶
Indications¶
- Vascular access; large bore (16-18G) is optimal for blood transfusion and faster than central lines (except MAC/Cordis); preserves central access (important for ESRD patients)
Relative Contraindications¶
-
Infection over the site, severe bleeding diathesis
-
Avoid EJs unless have been trained due to airway compromise if extravasation occurs
Consent¶
- Common risks: arterial puncture, nerve irritation/damage, infection, infiltration, thrombus formation
Pre-procedural considerations¶
-
Bleeding risk guidelines: Plts > 10k, no specific INR guidelines
-
Location selection: anuric AKI or ESRD patients – d/w renal, avoid limb with HD access proximal
-
Target selection: Confirm venous choice with compressibility and lack of doppler flow. Should follow the rule of 2s: vein must be at least twice the diameter of the catheter being placed, should be no more than 2 inches in depth from the surface of the skin, and should have at least 2 inches of straight (non-tortuous) length
Procedural considerations¶
-
US Probe: Linear
-
Kit: IV start kit; ideally 18G needle
-
Anesthetic use: Consider EMLA
-
1st choice: basilic, cephalic veins; 2nd choice: brachial vein (caution adjacent artery)
-
Use tourniquet
-
Start at 45° angle, use 45-45-90 rule to determine starting location (start as far from center of probe as the vessel is deep), flatten angle once in the vessel to advance ("walk" your way through the vessel by repeatedly identifying needle tip in the lumen and advancing)
-
Going too shallow could use up too much catheter leaving nothing to put in the vein.
-
Going too steep can cause catheter kinking at the hub where it sticks out of the skin
-
Hold probe close to skin, holding probe far from the end allows too much movement
-
Center the vessel on the ultrasound probe screen prior to sticking, place midline on US screen
-
Use both short axis and long axis views to ensure correct placement
-
Short axis- Vessel looks round like a target, helps to scout out the tip, and is best for ensuring the vein is entered as opposed to a neighboring artery
-
Long axis- The length of the vessel is viewed. This view is intended for the final few millimeters of catheter advancement into the vein to ensure both bevel and plastic sheath lumen traverse the endothelial layer before threading catheter
Post-procedural considerations¶
-
DON’T FORGET TO REMOVE TOURNIQUET!! Remove before flushing to prevent blowing vein
-
Bleeding complication: if arterial, remove catheter & hold pressure at least 5 mins