I've been doing ultrasound-guided IV's for a while now, and I feel like I'm fairly good at them. I am usually the go-to for difficult IV sticks, and very rarely miss (not bragging), however, lately it seems they are blowing after a few minutes of running. They draw back great when I initially place them and flush without difficult or causing pain, but about 200-300 mls of NS infusion later, the patient's are having pain in the area and I can no longer draw back. Are there any tips you can offer as to why this is happening or how to avoid it? I've never had any formal training; I've just picked it up through watching others and through practice. The only insight I could offer you, readers, is that it seems to always be the deep Basilic veins that blow, I use the 1.88" 20g or 18g IV caths, and I really don't think it's the catheter being pulled back out of the vein. Any other suggestions?
The time it takes an IV to "blow" is directly proportionate to the distance from the catheter tip to the entry point on the vessel. Speculation here, but if I had to say, there is something that approaches a logarithmic increase in IV life the larger this distance is (just my anecdotal observation).
So, it makes sense that your deeper vessels blow because most of the catheter length is taken up just reaching the deep vein. By the time you enter and advance the hub to the skin, there is probably very little catheter in the vein.
It's why picc lines and mid-lines are so reliable and last so long. So what you can do is use long IV catheters or use a femoral arterial catheter (20 gauge, 12 cm) for your IV.
I have no doubt you know most of these tips provided by ACEP
, but they mention catheter length as well (#7); they cite a 14% failure rate w/ long catheter vs. 45% w/ short.
How many cm deep are you usually seeing these failures? The 1.88 are too short beyond ~1.5cm in my opinion, which is at least half of the basilics I measure. Also, if you're even slightly mashing the probe down when cannulating, that vein is artificially brought closer to the skin surface until you're done. You put the probe back, slap a dressing on and walk away, meanwhile the skin recedes back to normal and pulls the catheter out in the process.
The deeper the vessel, more movement of the vein in the tissue (think young healthy patient vs loose old tissue), and the farther from where you entered the skin to when you actually enter the vessel all shorten the time that the IV will work before infiltrating. Using a longer angiocath certainly decreases the risk of infiltration, however that is no guarantee either. Like offlabel suggested I have definitely used a 4 inch arrow before on veins where I need more length and there isn't a better option.
Basilic veins should not be blowing on you regularly, nor any ultrasound attempt. I would suggest that you do not place a tourniquet so tight when attempt a USGPIV, it does not need to be anywhere nearly as tight as you probably use for ordinary attempts. Often when veins blow with US guidance you have actually gone through the vein, punctured the back of the vein, and when you pull back to see the needle again the vein leaks or tears through that puncture hole. I would also recommend against the routine use of basilic or brachial veins as those can be used for PICCs and midlines unlike the cephalic or vasculature of the
forearm. I would also highly suggest that you seek out formal training from PICC nurses, ultrasound fellowship trained ED docs, or IR providers; there is certainly increased risk associated with ultrasound guided attempts over traditional IV access.
At my hospital we utilize PICC nurses when we need US-guided PIVs. From what they tell me, that specific vein (basilic, proximal to the AC) is notorious for
becoming dislodged (primarily due to the bicep muscle and the way that vein articulates under the muscle, or something to that effect), so at all costs they look elsewhere regardless of what length catheter they are able to use.
I always avoid the basilic vein when placing a PIV - that vein may be needed for a PICC, it's generally to deep for a regular PIV and the path isn't always appropriate for a PIV (as mentioned above in posts).
Even if your using a longer catheter the catheter may still be a little short for the vein of choice. So it depends on how straight of a shot you get into the vein. Example - If you stick a 1cm deep vein at 45 degree angle approx 1 cm away from the probe (which is proper technique) then it will take 1.4cm to reach the vein. Best practice I believe is to have at least 1/2 - 2/3 the catheter length in the vein. With that perfect stick/straight shot it is already almost 1/3 if you catheter. ideally you would have the other 2/3 of the catheter in the vein. So imagine if it wasn't a perfect straight shot, you really don't have much wiggle room and that's at only 1cm depth.
Ultrasound IVs are difficult. Not only are the they toughest patients to stick the skill it's self take time to perfect. BARD has a good ultrasound video and I think sonosite does also. The best thing to figure out what exactly is happening to cause complications is going to be learning more about it. Not just he skill but the didactic education too.
I agree with many of the comments....your cannula is too short so by the time you reach the vein you have only a small amount actually in the vein.You have enough to get an intial flashback but once you start using it and their is patient movement it will back out.There is a formula based on vein depth that gives you the correct cannula length that lessens infiltration/extravasation.Also you may need to be saving those Basilic veins for PICC insertion unless you are desperate for access.I will see if I can find the formula for you.A quick rule is if you will be cannulating a vein > 5 mm below the skin's surface, use a longer catheter (> 2.5 inches in length).
Last edit by iluvivt on Apr 30
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