How to Start an IV with an Ultrasound Machine: Transverse Mode

[Damon McGill]

This article does not apply to central lines, nor does it go into the theory of ultrasound technology. For in-depth knowledge of ultrasound technology refer to ultrasound textbooks.

Do not be afraid of an ultrasound machine. Yes, it has many knobs, buttons, and probes. It looks intimidating, but once you learn the controls, it's fairly straightforward. Every ultrasound machine has a few different probes. The only probe you need to become familiar with is the linear probe. The linear probe is the "flat" or "straight" probe. Most ultrasound machines have an attached card that describes the probes, buttons, and knobs on that specific machine. Read the card. Several manufacturers make ultrasound machines, it would be impossible to describe each one in this article.

Gather Supplies

Gather your supplies: bedside table, towel, washcloth, ultrasound gel, ultrasound machine, IV start supplies, and a chair. While you are getting set up, explain to the patient what you are doing. Explanations go a long way in helping calm the fears of patients.

Step 1. Power Up

Learn where the power switch is. Press it. Let the machine boot up. Also, always keep the ultrasound machine plugged into a power outlet. Not everyone plugs the machine back in after use and this causes the battery to discharge. You do not want to be mid-insertion and have the machine power off.

Step 2. Clean the Probe and the Patient

While the machine is powering up, clean the linear probe with whatever cleaner your facility has available for the probes. Always clean the probe, but do not clean the ultrasound screen with the same cleaner. Ultrasound screens have special cleaners. Clean the patient's skin as you would for any IV insertion.

Step 3. Configure the Machine

Select the "B" mode on the ultrasound machine. The "B" mode is the brightness mode. When the ultrasound machine is in brightness mode, what you are really seeing on the screen is a two-dimensional gray-scale image of a patient's forearm when you have the probe touching the patient's forearm. You can "brighten" the image by adjusting the "gain" knob. No perfect brightness level exists. It is ultrasound-user dependent.

Step 3A. Select the Highest Frequency

If the linear probe has frequency adjustments, select the highest frequency possible. This allows for the sharpest image possible. Not all ultrasound machines have a linear probe that is frequency adjustable. Either way, even the best images are not that sharp, but you want the sharpest images possible and that means the highest frequency possible on the linear probe.

Step 4. Position the Patient

Position the patient. If your facility has bedside tables for the patient's rooms, use them. Clean the table's top and place the towel over the table. The towel serves three purposes: it keeps the patient's arm off the cold surface, it absorbs any blood that drips onto the surface, and it serves as a quick way to dispose of all your trash when you are done.

If you do not have a bedside table, have the patient adjust themselves in bed so they can place their arm on the bed. If this is the case, place the towel folded long-ways under their arm. When you are finished, any blood that is lost does not remain in bed with the patient.

Step 5. Position the Ultrasound Machine

Place the ultrasound machine directly in front of you so that you can easily view the screen and the patient without contorting your body. You need to be comfortable when placing the IV catheter. If your body is contorted to see the screen and the patient, you are setting yourself up for failure. Do not put the machine on the other side of the bed. Ultrasound screens are just not that large, and you will miss subtle clues that appear on the screen.

Step 6. Sit Down

Starting an ultrasound-guided IV requires coordination and some finesse. You cannot control the probe and the catheter while you are standing with any measure of accuracy. Sit down and allow your body to relax. Imagine trying to lift weights and thread a sewing needle simultaneously. It's almost impossible to do. Your accuracy with the ultrasound machine will exponentially increase when you sit. The one exception is in a code blue situation. In a code blue situation, have someone hold the arm and do your best.

Step 7. Orient the Probe Correctly

On the screen and on the probe will be some style of marker so that when they are lined up the probe is oriented correctly in relation to the screen (both markers on your left or right side). Usually in a corner of the screen will be a triangle, dash, or circle and the probe will have the same style of marker. You want to make sure the marker on the probe is on the same side as the marker on the screen (I.e., if the screen marker is on the left side of the screen, the mark on the probe should be on your left as you hold the probe). When you line the screen and probe up in this manner, you have the probe in the correct orientation. Sometimes the markers can be difficult to determine. A simpler way to make sure the probe is oriented correctly is to slide the probe across the patient's forearm to your left, if the screen images move off to the right of the screen, you have the probe oriented correctly.

Step 8. Be a Painter

Apply a tourniquet. Place just a dab of ultrasound gel on the patient's forearm. The ultrasound probe needs the tiniest amount of gel to transmit ultrasound waves through. The more gel you add, the more you must remove, and the more slippery the probe becomes. You will find your optimal amount the more you use the ultrasound machine. A perfect amount does not exist. You want to move up and down the patient's forearm with the probe. Imagine being a painter and painting the patient's arm with gel. The probe must have gel under it to see into the patient's forearm. While you are "painting" with gel, you are looking for veins on the screen and how the paths of those veins change as you move up the patient's forearm. Knowing how a patient's veins change before you advance the needle and catheter will help you have a successful cannulation.

Step 9. Find a Vein

What does a vein or artery look like on the screen? They both look like black circles. (see Figure 1). As you can see in Figure 1, the image even with a 14MHz linear probe is not great. Most older ultrasounds machines only have a 10MHz linear probe. Don't get caught up in technology. A 10 MHz probe will work just fine for peripheral IV cannulations.

How do you distinguish an artery from a vein? Press the probe into the patient's forearm and hold it against the patient. A vein collapses and will remain collapsed, and an artery will pulsate. It's as simple as that, but with one caveat. Patients with extremely weak pulses can fool you. Watch the screen closely for a few seconds to determine if the black circle is pulsating.

Learning how to apply the probe to a limb requires some practice to get both the positioning and the downforce correct at the same time. You cannot just press the probe into a patient's forearm while looking for veins or while inserting the IV. If you press too strongly, you will obscure the veins. You will know you have the probe correctly against a patient's skin when you see a complete image on the screen (I.e., no large solid black areas) and the veins and arteries are circles. If the veins and arteries are not circles, you have too much pressure on the probe. (see Figure 2). Optimal holding of the probe takes time to learn. Practice often. It pays off in the long run.

Step 10. Insert the Catheter

On the screen will be numbers that increase as they go down the screen. Those numbers represent the depth in centimeters into the patient's forearm. The top of the screen represents the skin of the patient's forearm. When you have located the vein you want to cannulate, look over at the depth gauge to find out how deep the vein is in the patient's forearm. Use the center of the vein as a reference point. As an example, let's say the vein's center is one centimeter down from the top of the patient's forearm. Your insertion point for the catheter will be one centimeter back from the probe.

But how do you know where to insert the needle? This is where skill and practice come into play.

In the middle of the screen will be some type of marker. It may be a simple triangle pointed down or a line of dots in the center of the screen. You carefully position the probe so that the image of the vein you want to cannulate is centered on the screen marker. On the side of the probe will be a marker that corresponds to the center of the probe. The mark on the probe matches the center marker on the screen, When the center marker on the screen is exactly over the center of the vein image, the mark on the probe is exactly over the center of the vein. Come back from the probe as far as the vein is deep in the patient's forearm, angle the catheter at a 45 ° angle to the patient's forearm, and insert the catheter in line with the mark on the probe. Make sure you are in line with the probe's marker and the patient's forearm and not angled to one side. It truly is a finesse operation. In time, it will become second nature. Believe it or not.

Never take your eyes off the screen once you are lined up and ready to insert. Taking your eyes off the screen to look down at the insertion site is the biggest mistake new ultrasound users make. No information is gained by taking your eyes off the screen, but much information is lost. When you are using an ultrasound machine to insert an IV, all the information that you need to insert an IV is on the screen. Once you look down at the insertion site and then back up on the screen, you have missed. It is almost impossible to reacquire the needle on the screen when you have taken your eyes away from the screen as a new user. Train yourself to not take your eyes from the screen.

As the needle tip pierces the vein, you will see the vein tent down then a white dot or white angular image will appear inside the vein (see Figure 3). At this point, you have pierced the vein; but again, do not look away from the screen, you still must advance the needle and catheter into the vein. Slightly move the probe forward until the image inside the vein almost disappears. It changes color from bright white to dull gray as the probe moves away from the needle tip, then hold the probe stationary and slightly advance the needle and catheter forward, making whatever adjustments it takes with the needle to keep the needle image in the center of the vein. Repeat this procedure of moving the probe slightly then the needle slightly until you feel confident you can advance the catheter the rest of the way in. You can absolutely insert the needle completely into the vein using this procedure. Once you feel confident you can insert the catheter all the way in, do so.

To verify you have a solid insertion, occlude the vein above the catheter, remove the needle and just ever so slightly release pressure and you will see blood back up into the catheter hub. Then re-occlude the vein, attach the pigtail or hub, and use the washcloth to clean all the excess gel from the patient's skin while you hold the catheter. Next, use alcohol swabs or chlorapreps around the cannulation site to ensure you reduce the bacterial load as much as possible. At this point, dress the IV site as you would any new IV. Don't forget to take the tourniquet off.

Things to Think About

New ultrasound users should practice inserting the needle and catheter all the way in before removing the needle. Nothing is worse than removing the needle too soon and then not being able to advance the catheter. Practice, Practice, Practice. Your technique will improve.

Practice using the ultrasound on patients that do not require an ultrasound-guided IV. Being able to see a patient's vein when you are learning the ultrasound technique is invaluable. Attempting to learn the ultrasound-guided technique on a patient that truly needs the technique is a recipe for disaster. You need to practice on patients with easily located veins first, to develop your targeting skills.

You can cannulate much smaller veins than you think you can. Become proficient in the ultrasound-guided technique and your days of not being able to acquire IV access almost go away, but you must practice and practice often. If you enjoy the feeling of helping patients; wait until you can gain access on almost any patient with one attempt.

People who claim to be "hard sticks" usually have veins that do not follow a straight path. Using the needle to insert the catheter completely makes hard sticks easy sticks.

Rarely will you need to use anything but an 18G catheter when using the ultrasound technique. This at first may seem bizarre or even insane, but if you examine a 22G or 20G catheter, they are just not that much smaller than an 18G. With the ultrasound machine, you can see how big the vein is and you will feel more confident using the 18G catheter. Using an 18G catheter ensures the patient can get any radiologic studies they need as well as blood transfusions or fluid resuscitations.

Longer catheters are your friend. The longer the catheter, the less chance the catheter will dislodge.

Patients with large arms with loose skin need to be reminded to keep their arms still. Catheters are secured to the skin, but nothing keeps the catheter in the vein while the skin is moving. Even long catheters will dislodge.

The more you practice with an ultrasound machine the better you will become. Hard sticks become fun challenges when you master the transverse ultrasound technique. YouTube has great videos on ultrasound IV insertions. Do not give up on yourself if you miss the first few times. Your brain is learning a new skill. It takes time to master, but it is so worth it in the end. Good Luck.

Figure 1

Figure 2

Figure 3

[Hanniel Ortiz, CNA]

I am open to constructive criticism Damon. I am so glad you were willing to read my entire reply. Let me know where you disagree. 

[chare]

Damon McGill said:

Mr. Ortiz,

I enjoyed reading your response. You are obviously patient about patient care. I will have to disagree with your comments.

[...]

Really?  You disagree with his entire post?

Damon McGill said:

[...]

... After you have worked for almost two decades as a trauma nurse, let's talk.

Best regards,

Damon

Are you actually, based on his not having "worked for almost two decades as a trauma nurse" going dismiss his post?

Are you aware of just what exactly a Navy corpsman does?  And what their training entails?  If he was FMF, independent duty, or special operations qualified it's possible that he's started many IVs.

@Hanniel Ortiz, fair winds and following seas.

Semper fi!

[FiremedicMike, RN, EMT-P]

Damon McGill said:

Mr. Ortiz,

I enjoyed reading your response. You are obviously patient about patient care. I will have to disagree with your comments. After you have worked for almost two decades as a trauma nurse, let's talk.

Best regards,

Damon

Bruh, that aggression is inappropriate and unneeded.  The dude said he was a corpsman and that he's been starting USIV for 18 years, his input is just as valid as anyone elses.

At the end of the day, USIV is a skill, not some mystical procedure.

[Hanniel Ortiz, CNA]

chare said:

Really?  You disagree with his entire post?

Are you actually, based on his not having "worked for almost two decades as a trauma nurse" going dismiss his post?

Are you aware of just what exactly a Navy corpsman does?  And what their training entails?  If he was FMF, independent duty, or special operations qualified it's possible that he's started many IVs.

@Hanniel Ortiz, fair winds and following seas.

Semper fi!

Greetings chare!

I was an FMF hospital corpsman, trained extensively in tactical combat casualty care (TCCC), as well as other tactical trauma skills. I was very proficient in the following skills: insertion of a nasopharyngeal airway, insertion of an extraglottic airway, performed cricothyroidotomies, I assessed for signs of tension pneumothorax, assessed for hemorrhagic shock,  I was able to administer blood products for shock, I reassessed the casualty after each unit of blood products, I assessed for head injury (TBI) and eye trauma, I administered appropriate analgesics and antibiotics, inspected and dressed known wounds, and other vital skills necessary to care for the casualty. I was routinely certified in BLS, ACLS, and PALS. Unfortunately, the Navy would not certify hospital corpsmen for NREMT status. Only the Army and I believe the Air Force did allow medics to become NREMT certified. 

I worked side-by-side with so many trauma nurses, both civilian and active duty, as well as trauma doctors. I learned so much from them.

You are correct that I started many PIVs. I inserted conventional PIVs in the clinical setting and in the field. The FMSS training was brutal and we had to be able to insert PIVs under fire, in the dead of night with little visibility, only being able to depend on touch. I got so used to putting in PIVs in the dark that now I close my eyes every time when I'm trying to palpate for veins, especially if the patient's veins are deep or are a "hard stick."  My first duty station was at Walter Reed National Military Medical Center in Bethesda, Maryland. I was there for 2 years and I was able to insert over 1,000 PIVs for patients who either needed an ECHO w/bubble study or CTAs of the heart. I also was on-call every night for inserting PIVs for the inpatient wards with patients who were hard sticks. I loved it.

The command leadership noticed my contributions and skills and they wanted me to start training new hospital corpsmen, new Army medics, and nursing officers out of OCS and USUHS on how to insert PIVs. I trained hundreds of service members while I was at WRNMMC. It was here that I learned how to insert US-guided PIVs. I became quite proficient at them while I was there, however, I didn't get the chance to insert many or train anyone myself. I was then transferred to Oceanside, CA to train with the U.S. Marines. That's where I was trained in tactical combat care. It wasn't until after many years later (about 4 years) when I moved back to Maryland that I got the chance to practice inserting USGPIVs again. I hadn't inserted one in that entire time,  just regular PIVs without US. When I started to work at GWUH and found out that they were allowing PCTs to insert USGPIVs I jumped at the opportunity. I did some of my own re-training and refreshers by reading up on the latest research and practices, saw YouTube videos, and practiced on vein blocks.

Once training was available I only needed a few minutes to practice on the hospital's vein block using their specific IV catheters (BD AccuCath Ace Intravascular Catheters). It was sort of weird that per hospital education guidelines, in order to be signed off on the skill you needed to do a minimum of 10 successful USGPIV sticks without guidance from the preceptor. When I was in the Navy I was expected to have 40 successful USGPIV sticks before I could be signed off to do them independently. The BD rep at the time was the person providing the training and signing people off which was ridiculous because she had no IV or US guidance experience. She had a master's in communication. However, just after 5 successful sticks she told me I was good enough to do them on my own. Shortly after that she confronted my leadership at GWUH and recommended that I be a super user for those specific USGPIV catheters and that I was skilled enough to even train RNs and other PCTs. That definitely surprised me. I was not expecting that. She was highly impressed with my attention to detail, my level of skill, and vast knowledge of PIV insertion and vasculature by just doing 5 sticks, HA! I would go on to train over 40 RNs (only 10 were signed off) of different specialties, 3 PCTs, and 4 MDs. I had very strict standards for signing off RNs and PCTs before they could do USGPIVs without guidance. Out of the 40 RNs I trained, only 10 were able to grasp the finesse required for the skill. I realized after training so many people there that not everyone was capable of doing USGPIVs. No matter how skilled they were at inserting conventional PIVs, some of them were just not able to grasp it. Some of them failed in the didactic portion of the training before even attempting to a live stick. 

I was there for about 2 years before I had to quit because of school. Now I work at the NIH Clinical Center. Once in a while I am able to do an USGPIV on a patient in my clinic but not as often as I used to at GWUH in DC. 

I will not say that I am some super expert at doing USGPIV, however, I had done a lot of research and have invested countless hours on how best to insert them using evidence-based methods and personal experience. The way I train my students is very different from how students are traditionally taught. I incorporate basic geometry in my teaching which is not standard. The way I was trained is very different from how I train my students.

I have reinserted USGPIVs after an RN who has been inserting USGPIVs their entire career (20+ years) because of antiquated methods or shortcuts they've acquired over time. I've had some USGPIVs last over 3 weeks. My most memorable USGPIV was in an ICU patient (60 y.o. female, morbidly obese) who was nonresponsive. The only vein I could find was the median cubital vein the left AC. It was 1.5cm deep and it was about 0.35cm in diameter. I was able to insert an AccuCath 22Ga x 2.25in catheter. Hospital policy at the time stated that PIVs (both conventional and USGPIV) were only good for 72 hours and had to be replaced. I told the ICU RN and the attending MD not to remove her USGPIV because she had nothing left. I examined her upper arms to see if the PICC team could potentially insert a CVAD but her veins were so small (<0.3cm) and 5cm deep that she was not a prime candidate for a PICC line. It took me so long (>30 min) to insert it because the patient was not able to lay down flat due to her obesity. She was in a seated position in the hospital bed. Her arm had a limited ROM so I had to insert her PIV is such an awkward position I nearly thought I could never insert one. Sure enough I was able to insert it successfully and it worked flawlessly. Three weeks later I received a patient on my home unit that needed a blood draw. They informed me she was hard stick and would probably need US-guided venipuncture for just a PT/PTT. When I walked into the room I realized who she was and I was surprised. I noticed immediately that she had the same USGPIV in the same location that I had inserted 3 weeks prior. She as A&O x 4. I wasn't sure if I could draw blood from her USGPIV so I attempted to. To my amazement, I was able to draw blood from it without any resistance. It flushed flawlessly afterwards. I had never experienced a PIV (no matter the insertion method) to be able to draw blood which had a dwell time of 3 weeks. She was discharged 1 week later. The ICU has to also take credit for the USGPIVs amazing patency. They flushed her PIV every hour without fail for 3 whole weeks. 

So yes, I have inserted many conventional PIVs and many USGPIVs, somewhere in the thousands. Thank you for your support. I appreciate it.

[Delia37, MSN]

Very informative post. I wish that skill was part of the teaching curriculum for ICU and ED nurses; there had been evidence-based research that correlates a decreased in the need of PICC/central line when nurses are able gain access with USGPIVs. 

Really appreciate everyone's input.