Ultrasound Guided IV insertions

Specialties Emergency

Published

Hi,

I work in a level one trauma centre in an area that sees patients with multiple comorbities and complex health histories. We have a lot of dialysis patients and IVDA patients, so plenty of hard IV starts. I took a course offered my hospital three months ago to learn how to start U/S guided IVs that's as taught by a few of our ER docs as nurses who are certified and signed off on after taking this course are able to perform the procedure. I was doing really well on my own until the last couple weeks and I've hit a rough patch where I wasn't able to get 5 or 6 people in a row. I'm frustrated and unsure how to go about improving. I don't want to turn my patients in to pincushions as U/S IVs can be quite painful. I'm pretty proficient with regular IV starts and did fine learning how to do EJs and rarely struggle with those. Any suggestions or tips would be appreciated. I looked online and there doesn't seem to be many resources to help. Thanks.

I'm guessing you guys have this as a protocol? Lidocaine is viewed as a med and without either an order or as part of a protocol we can't go grab lido for everyone's IV. In the ER that's not really always an option (traumas, emergent cases, etc) very few of our IVs are "routine." I'd be interested in knowing how often this is being used in hospitals. We do use EMLA for peds though if they're stable enough.

It's just a matter of putting a nursing policy in place that gets cleared through all of the usual channels. If the docs don't think it's worth it, it won't happen, but I'd guess they'd want it for someone they cared for.

Obviously, it isn't for the patient with a hole in his liver, but for that poor patient with renal stones, or hyperemesis, or having an MI, it's a good thing. There is this skin refrigerant out there that works real well that you just spray on and it gives great anesthesia for a couple of minutes.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I don't know what HCAHP or USGPIV are, but I know that using lidocaine for any IV in an awake patient is humane, very safe and a good idea. RN's use it on our labor and delivery units, and all of our pre-procedural areas.

It makes a big difference in our patient satisfaction scores that the hospital pays attention to.

HCAHPS Hospital Survey

HCAHP

We have a very well-run and heavily QI'd USGPIV program in our ED. Our docs did a literature review recently and the mean number of sticks needed to achieve 88% success was somewhere between 15-26 sticks. Keep practicing and learn to master long axis.

Specializes in Critical Care.

I hope your rough patch is over! I am fairly new to this skill but can offer a few things: do not look for flash-- get into the vein, advance a good bit before looking to retract and clean/flush/etc. Also, use a ton of jelly, and do not lose sight of the needle tip.

Specializes in Emergency medicine, primary care.

Thanks for all the feedback everyone; I'm a year out now and I probably have about 90% success rate on first stick now. Sometimes I do go through patches where I have to take two attempts but I'm more comfortable. Figuring out how to position people's arms properly for best stability and adjusting the depth and gain better has helped. I asked about lidocaine but because it's a med we would have to get an order every single time to prefreeze the area. We don't even carry the EMLA for port access for patients with port a caths. We do have the freezing spray that I use which some patients like. Usually I just ask people (who often have them done) where to look first and that helps too. I usually find success when I start on the short access, get flash, then switch to long access to guide the catheter.

Thanks everyone :)

Hey there, usgpiv's and midlines are my jam, I am hoping to work towards a position where that is just what I do.. I do help train others as well

A few things....

#1 and most important in my book, is your set-up. Mine consists of-

Mayo stand with towels on it- patients arm extended and rotated to give access to ac,basilic, possibly cephalic or brachial veins. Lift the patient's bed to the mayo stand height. You want the patient's arm to be in a relaxed position that requires no muscle tension. They shouldn't have to be working while you are threading.

#2- use lidocaine, I use 1% or 2%,I don't do a "wheel" unless the vein is super shallow, I infiltrate slowly, retracting my needle till i see a wheel form and then retracting.. (remember to infiltrate/wheel just under 1cm behind your intended insertion site, don't use the same needle track) and i find it immensely valuable. If a patient shifts positions, or tenses, it can shift anatomy. Reduce pain. I understand that this is not part of your capacity, I would push that it be part of a standing USGPIV orderset. Consider warming the solution, or buffering. I personally work in a critical access hospital where the next step after me is calling anesthesia in...

#3-Know what you are going for, in my strategy, cephalic is optimal (but seems to be widely variable), basilic is most reliable, and brachial is for critical pt only(know how to identify nerve bundles). Examine and know the pt's anatomy before you begin, draw a map in your head of the bifurcations and downhill vs uphill nature of their vasculature. Have a 4-6 inch map in your head and know exactly what you are attempting to do.

#4- this is not what is best for everyone, but it is what has been the biggest change in my practice leading to a near 100% success rate. Using short axis view, track your needle down to the vessel wall, puncture the wall, get flashback, and STOP! This has allowed you to enter the vessel at its midline, where there will be the most space from one side of the lumen to the other. At this point, take a deep breath, continue to hold the same forward/downward tension on the needle and shift your view to long axis. Butt the probe up close to the catheter insertion site and find it in long axis, find and visualize how far into the vein the needle is protruding, and push until you see (not feel) it getting close to backwall. At this point, lower your angle as best you can and watch the catheter advance, sometimes is has a little trouble "making the turn" and if you have confirmation that the catheter is no longer on the needle but is pushing against the backwall, retract the needle and push forward/upward at the same time. This is just my 2 cents and what is working for me. I am using 2.5 inch 18g angio's for this.. for more shallow iv's like ac's i would suggest going with your gut with all the other ac's you've done and not switching to long axis...

lol, just saw that you do switch to long axis.... awesome.

Specializes in Emergency medicine, primary care.

Thanks for the advice! I wish we could use lidocaine and I've brought it up to nursing education. I'm trying to get one of our ER ultrasound fellows on board with this too. I figured out the mayo stand after many failed attempts and awkward manoeuvring. I'd like to get more practice with the 18G angiocaths as I've only done a few of them. I usually stick to the 20Gs. Thanks again!

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