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Voies veineuses échoguidées

Introduction

**If you would like any changes or additional information, please do not hesitate to write to me: william.bedard.michel@umontreal.ca

Ultrasound-guided intravenous lines (USGIV). Definitely THE technique I use most in the intensive care unit and which brings me the most satisfaction. Our intensive care unit patients are dehydrated (even exsanguinated), polymorbid and therefore much harder to inject than our regular patients. IO/central lines/foot IVs all have their advantages and disadvantages. Once mastered, USGIV allows you to quickly have an extremely reliable and   of good quality ( 14-16-18-20g ) which will allow us to investigate and treat our patient.

On the satisfaction side, what technique...

  • Make your patient happy because he finally stops being stung?

  • Make your nurse happy because finally we stop breathing down her neck and asking her repeatedly if we have a voice?

  • Makes you happy because: good job you saved the day and finally you can start treating your patient!

Convinced? Read on!

Anatomy

-La veine choisi devrait :

  • Être à moins de 1,5cm de profond (plus profond, votre IV risque de se faire arracher de la veine par les movements de tissus mous du patient).

    • Max 2cm.​

  • Avoir un diamètre minimal de 5mm (plus bas le taux de réussite est de <50%).

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- Il existe 3 veines principales (de médial vers latéral) :

  • Basillaire 

  • Brachiale

  • Céphalique

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- Basillaire

  • Positifs :

    • La plus fréquemment utilisé puisque très reproductible d'un individu à l'autre.

    • Très souvent la plus grosse.

  • Négatif :

    • Ergonomiquement la plus difficile à piquer. Celle-ci se trouve dans le gras de poulet et donc, nous devons souvent la piquer en angle et cela rajotue un défi d'orientation spatial et d'échoguidance.

      • Pour contrer cela :​

        • Abduction du bras presque 90° et supination.​

        •  installer des serviettes sous le bras peut horizontalisé la surface à piquer et faciliter la technique. (pas vrmt faisable en salle de réa)

  • Toujours mon premier spot pour trouver une veine.

  • >80-90% des USGIV que j'insère.

 

- Brachiale

  • Positif :

    • Pas mal universallement présent

  • Négatif :

    • ​ Côte à côte avec l'artère et le nerf ce qui rend l'installation de l'IV beaucoup plus risqué. Une échoguidance parfaite doit être maintenue.

    • Sa taille est variable.

  • Je suggère de favoriser ++ les deux autres jusqu'à temps que vous soyez confiant dans votre technique. 

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- Céphalique

  • Positif :

    • Aucune structure dangereuse avoisinante.

  • Négatif :

    • La moins reproductible... Positionnement sur le bras très variable... et voir même inexistante/impossible à trouver chez plusieurs. 

    • Taille et localisation très variable. 

  • Honnêtement, je ne me souviens pas de la dernière céphalique que j'ai installé.

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https://www.veincarecenter.com/arm-veins/

Material

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Tips and tricks

  • When preparing your equipment, imagine the entire sequence of the technique in your head and take it out gradually. This way, you'll be less likely to forget...

  • All your equipment must be ready/open/flushed before you start injecting and must be within easy reach. The exception is in the resuscitation room where you should have a helper who manages the equipment as you go...

Sterility equipment

  • Chlorhexidine stick

  • Tegaderm to cover the linear probe (if your linear probe is normal size, you should use a large tegaderm).

  • Tegaderm to stabilize the venous line (I still recommend a large Tegaderm here since you want to minimize the risk of your hard-working venous line being torn out...)

  • Rectal touch gel (sterile gel)

  • Normal gloves

***It's important to remember that, after all, we're putting in a peripheral IV line. Not a central line, not a piccline. Many nurses inject without gloves... but I still believe that cleanliness must be optimized to keep the infection rate minimal.

Equipment for the technique

  • Tourniquet

  • Compress 2/2 to wipe away blood and gel and help fix your tegaderm

  • Depending on your IV, you may need a small extension that attaches to your track.

  • Medium-sized (4.8cm) or long (6.4cm) intravenous line.

    • I strongly favor the 6.4cm routes because of their reliability and the much lower risk of being pulled out of the vein (see article below). I believe that the 4.8cm are not adequate if the vein is more than 1cm deep... less than 5% of my USGIVs are 4.8cm....

    • Pictured below is the company we use at HSCM. I have no $ or share in the company...

  • Blood Harvest (2 choices):

    1. Simply fill 1-2 10mL syringes (if hemorrhoids definitely 2 syringes) and give them to the nurse to transfer into the appropriate tubes.

    2. Use a barrel and the appropriate tubes.

  • 10mL syringe with NS for flushing

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Sterility and preparation

La première étape est de préparer son matériel. Pour ne rien oublier, j'ai l'habitude de m'imaginer la technique dans ma tête et de noter tout ce dont j'aurai besoin. 

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Préparation de matériel avant de s'approcher du patient :

- Rassembler le matériel requis.

- Installer le tégaderme sur la sonde (cf vidéo plus bas)... vous comprenez le principe... le but est de ne pas toucher le dessus du tégaderme qui sera en contact avec la peau.

- (Optionnel selon votre IV) : Installer la petite extension sur votre seringue de 10mL vide qui vous servira à prélever le sang.

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Préparation au patient : 

- Installer le garrot très proximal et très serré (nous voulons comprimer des veines + profondes).

- Rassembler à distance de bras les éléments nécessaires à votre ponction et déjà ouvrir les enveloppes + préparer votre IV 18 ou 20g.

- Installer votre machine d'échographie le plus possible droit devant vous. (si vous vous tortillez tout inconfortable vous avez plus de risque de manquer votre technique). 

- Désinfecter une très large zone comprenant la zone antécubital + bras. (Presque) tout le monde a des veines dans cette région. Vous devriez en trouver une et lorsque vous la trouverez, vous devez avoir tout votre matériel prêt pour la piquer immédiatement. Pas de temps à perdre.

- Mettre le gel stérile.

- Commencer votre technique!

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Positionnement :​

- Étant droitier, je préfère piquer le bras gauche du patient. En général, cela permet une meilleure ergonomie. 

- Lorsque je ne suis pas en réa, j'adore être assis, cela me donne plus de stabilité et me permet de mieux contrôler le bras du patient.

- Je place la hauteur de la civière à la hauteur de mon tabouret et j'installe, la plus par du temps, le bras du patient sur ma cuisse pour le stabiliser et l'empêcher de ballotter dans les airs.

- Lorsque vous piquez la veine basilaire, il peut être utile de placer un amas de serviettes sous le gras de poulet du bras pour rendre celui-ci plus droit et facile à piquer. 

Technique and pro tips!

Let's start with some pro tips:

  1. If available, use a dedicated IVUS machine. These machines are much smaller and their settings are already optimized for the technique. They also have smaller linear probes to optimize your microdexterity for the technique.

  2. Increase the gain (don't go crazy) but I find that a little more gain helps visualize the needle bevel.

  3. Begin your skin puncture at approximately a 45° angle. The goal is to have as little of the tunneled catheter as possible in the soft tissue and as much of the catheter as possible in the vein . A relatively steep angle allows you to get to the vein as quickly as possible.

  4. Use 6.4cm catheters to maximize the amount of catheter in the vein and reduce the risk of them being pulled out just because the patient's arms were raised during the scan.

  5. Once you puncture the skin, YOU NO LONGER HAVE TO WATCH YOUR NEEDLE FOR A "FLASH". Sorry for the capital letters but nothing annoys me more than someone whispering in my ear that I'm having a flash. I know buddy, you can see the bevel of the needle in the vein on the screen. Looking for a flash only puts you at risk of error since at the moment you objectify the said flash nothing tells you that you are still in the vein and you are at high risk of cannulating into soft tissue.

  6. Once you've punctured the vein, keep going forward and forward until you're completely tired. Penetrating the vein is just the initial step. The most important step is to keep going forward. This ensures you have a significant length already in your vein, and if anything goes wrong with cannulation, it's no big deal; you just have to back off a little.

  7. The biggest lie in the guidance for IVF and central lines is: "you must always see the bevel of your needle." This is completely impossible and you put yourself at greater risk of error. The real trick is to see your bevel 50% of the time. See the animation below to understand.

I realize that the initial technique is pretty well described in the stuff above. Once cannulated now...

  1. Connect your empty 10mL syringe (+/- your extension depending on your IV) and draw 10-20mL of blood. You could also use a barrel with appropriate tubing for this step.

    • Keep your extension in place. Do not remove it when disconnecting your 10mL syringe.

  2. Remove the tourniquet.

  3. Flush your lane.

  4. Use compresses to remove the gel and blood to dry the skin.

  5. Install your large tegaderm. If you have small tegaderms, I strongly recommend adding good old tape to prevent your IV from being accidentally ripped out...

  6. Give the blood syringes to the nurse. (Don't leave them lying around.)

  7. Clean your machine. (important step often forgotten)

  8. Bring your machine back to the designated location (that way the next person who uses it won't have to search for the machine for 15 minutes :) )

But Will! In-plane is so much more beautiful!

Indeed, in-plane is beautiful... but so much more difficult for IVs! The veins are ++ tortuous and it is often difficult to create the perfect plane (probe - IV - vein). I believe the risk of error and failure is much higher with in-plane than with the technique described above.

Video of the technique

Évaluation si l'intraveineuse est belle et bien dans la veine.

Difficulty drawing blood or slight resistance when administering medication? This isn't always because the IV is no longer in the vein. It may be attached to the wall or located in a Y. 6.4cm IVs are very rarely accidentally removed from the vein due to the length of the catheter inside the vein.

To check what's happening with your IV, you can pull out your ultrasound and follow your IV as it travels... and hopefully into the vein! You can also often see the fluid being injected live.

Home simulator

There are several commercial simulator models available. These get the job done but are very expensive. Here's my favorite home simulator for replicating "real life":

  • 1 pork fillet

  • penroses of different widths

  • small clamps/hemosts

  • a scalpel or knife (for the incision in the pork)

  • 10mL syringes (used to fill the penroses)

  • water...!

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Ultrasound capsules

© 2024 by William Bédard Michel.

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