I'm bad w/ultrasound, any advice?

[deftonez188]

Hello fellow nursefolk!

I'm new to PICC nursing (my facility is military and doesn't have a 'PICC' nurse position, it just happens to be whoever is on that is qualified) and i'm doing great except...

...I'm really bad with accessing my vessels w/ ultrasound. I nail every other part without difficulty, but initial vessel access, I am doing horrible!

I've only been doing basilic veins, and I appropriately pre-mark once I've determined exactly where I'd like to go.

The problem I'm having is I attempt to poke under my probe, but once I get under the skin despite having ultrasound I can simply at best see myself moving tissue but never seem to get right over top of the vessel - I end up left, or right or what appears to be above but gain no flash on attempting to push through. I'm basically always saying in my head, "Ok, where the heck am I? I see tissue moving around the vessel."

All I can think is I'm not using the ultrasound correctly to see where I'm really at or need to go, or maybe I'm not understanding how to correct my stick with what I see on the US. Does anyone have any resources they use that would be helpful or advice?

I wonder if the patient type has anything to do with it - 1st stick was a young healthy marine (maybe 18, completely fit, easy poke), second was a disoriented and very emaciated gentleman, third and this most recent was a very emaciated/thin gal. I find that instead of going in at a 90 degree angle, I really have to be far more shallow.

[Asystole RN]

What ultrasound are you using? Do you have needle guides available to you?

You do not need to mark. Hold your probe over the insertion point, insert your needle and rock the probe to angle it towards the needle. Keep rocking until you find the bevel of the needle, it should look like a brighter area on the end of the needle. Once you locate the bevel keep inserting while rocking your probe and follow the bevel to the vessel.

One thing that can be happening is if you are inserting at too shallow of an angle the bevel could be glancing off of the side of the vessel and appear that you are missing the vessel. Should be able to see the vessel deflect when this happens though.

I would highly recommend that you get involved with your local INS and AVA chapters. They usually are a great source for information once you network.

[deftonez188]

We do not have needle guides (I wish!) - our kits are Navilyst and I know they make them, but they aren't included in the standard kit we use.

I watched a few videos on insertion after reading your post - technique errors I can see myself making are: Holding the ultrasound directly straight down on the skin - no rocking or angling toward my actual point of entry - I'm essentially bringing my needle to the ultrasound, not the other way around (I never actually visualize the tip of the needle on ultrasound, that is another problem). Second, we were taught to poke at a 90 degree angle (mind you by an experienced PICC nurse, so I took it as gospel) but in every video I see, it appears everyone comes in at an acute angle far less than a 90 degree.

I'm going to talk to our supply department about getting needle guides, and I'll try your suggestions with my next attempt. Really appreciate the advice.

[bethchpn]

The angle of insertion is related to how deep the vessel is. More shallow less angle, deeper more angel. Will come with experience.

[Ellie G]

Are you using a percutaneous access needle or a standard IV catheter to access the vein? Some people find the IV catheter to be easier if they're not using the needle guide. A deep vein would be about 90 degrees, a shallower vein would be less of an angle. It takes practice.