Ultrasound capsules
Ultrasound-guided venous lines
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
The chosen vein should:
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Be less than 1.5 cm deep (if it’s deeper, your IV is at risk of being pulled out of the vein due to the patient’s soft tissue movements).
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Maximum depth: 2 cm.
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Have a minimum diameter of 5 mm (below that, the success rate is <50%).
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There are 3 main veins (from medial to lateral):
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Basilic
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Brachial
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Cephalic
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Basilic Vein
Positives:
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The most frequently used because it’s very consistent between individuals.
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Very often the largest vein.
Negatives:
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Ergonomically, the most difficult to access. It’s located in the “chicken fat” area, so we often have to puncture it at an angle, which adds a challenge in spatial orientation and ultrasound guidance.
To counter this:
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Abduct the arm almost 90° and supinate.
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Placing towels under the arm can level the puncture surface and make the technique easier (though not very feasible in the ICU).
This is always my first choice when looking for a vein.
I place 80–90% of my US-guided IVs in the basilic vein.
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Brachial Vein
Positives:
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Almost universally present.
Negatives:
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Lies side by side with the artery and nerve, making IV placement much riskier.
Perfect ultrasound guidance must be maintained. -
Its size is variable.
I suggest strongly favoring the other two veins until you’re confident in your technique.
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Cephalic Vein
Positives:
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No nearby dangerous structures.
Negatives:
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The least consistent — its position on the arm is highly variable, and in many patients, it’s absent or impossible to find.
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Size and location are very inconsistent.
Probably less than 5% of my USGIV
Material
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):
Simply fill 1-2 10mL syringes (if hemorrhoids definitely 2 syringes) and give them to the nurse to transfer into the appropriate tubes.
Use a barrel and the appropriate tubes.
10mL syringe with NS for flushing
Sterility and preparation
Step 1: Prepare Your Equipment
To avoid forgetting anything, I usually visualize the procedure in my head and write down everything I’ll need.
Equipment preparation before approaching the patient:
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Gather all the required materials.
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Apply the Tegaderm to the probe (see video below)… you get the idea — the goal is not to touch the top of the Tegaderm, which will come into contact with the patient’s skin.
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(Optional, depending on your IV setup): Attach the small extension to your empty 10 mL syringe, which you’ll use to draw blood.
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Patient preparation:
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Apply the tourniquet very proximally and tightly (we want to compress deeper veins).
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Place all necessary items within arm’s reach, open the packages, and prepare your 18G or 20G IV catheter.
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Position your ultrasound machine directly in front of you. (If you’re twisted or uncomfortable, you’re more likely to miss your target.)
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Disinfect a wide area including the antecubital region and arm. (Almost everyone has veins in that area.) You should be able to find one, and when you do, you need to have all your equipment ready to puncture immediately — no time to waste.
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Apply sterile gel.
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Begin your technique!
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Positioning:
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Being right-handed, I prefer to puncture the patient’s left arm — it’s generally more ergonomic.
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When I’m not in the ICU, I love to sit down — it gives me more stability and better control of the patient’s arm.
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I adjust the bed height to match my stool, and most of the time, I rest the patient’s arm on my thigh to stabilize it and prevent it from moving in the air.
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When puncturing the basilic vein, it can be helpful to place a stack of towels under the “chicken fat” of the arm to make it straighter and easier to access.
Technique and pro tips!
Let's start with some pro tips:
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.
Increase the gain (don't go crazy) but I find that a little more gain helps visualize the needle bevel.
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.
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.
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.
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.
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...
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.
Remove the tourniquet.
Flush your lane.
Use compresses to remove the gel and blood to dry the skin.
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...
Give the blood syringes to the nurse. (Don't leave them lying around.)
Clean your machine. (important step often forgotten)
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
Assessment of whether the IV is properly in the vein.
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...!
