Ultrasound-Guided Procedures

Abstract

• (a) Procedure Indications

  • Difficult intravenous (IV) access:

    • Risk factors for difficult IV access include:

      • Dialysis patient

      • Sickle cell patient

      • Diabetic patient

      • Chemotherapy patient

      • Dehydration

      • Obesity

      • Edema

      • IV drug abuse

      • History of difficult access

  • Multiple previous attempts without successful IV placement

• (b) Procedure Complications

  • Infection, phlebitis, hematoma

  • Extraluminal placement

  • Dislodgement and infiltration

• (c) Transducer Selection

  • Linear array

• (d) Equipment

  • IV needle with angiocatheter:

    • Long catheters are preferred if available.

    • Figure 18.1—Long and short IV catheters.

  • Ultrasound gel:

    • Sterile surgical lubricant is recommended for deep vein access or when drawing blood cultures.

  • Antiseptic swab:

    • Chlorhexidine is recommended for deep vein access.

  • Tourniquet

  • Luer lock adapter

  • Saline flush

  • Adhesive dressing

  • Gloves

• (e) Patient Position and Anatomical Landmarks

  • The patient should be supine with their arm extended and externally rotated:

    • Figure 18.2—Patient position for PIV placement

  • Blood vessels appear anechoic:

    • Veins are thin walled and compressible.

    • Arteries have thicker walls, typically pulsate, and are not compressible.

    • Figure 18.3—Ultrasound of the artery and vein.

  • The brachial vein runs adjacent to the brachial artery and median nerve within the upper medial arm.

  • The basilic vein runs medial to the brachial vessels.

  • Figure 18.4—Brachial and basilic vein positions.

• (f) Preparation

  • Universal precautions should be utilized at all times.

  • Apply tourniquet.

  • Identify the vessel with ultrasound:

    • Success rate increases when the vein is less than 1.5 cm from the skin surface [1].

  • Clean transducer with antiseptic cloth.

  • Hold transducer with nondominant hand and place over the vessel:

    • Be careful not to apply pressure with the transducer as this will displace the vessel deeper within the arm and can compress the vein.

    • Figure 18.5—Transducer placement.

  • Adjust depth so that the vessel is in the center of the screen.

  • Increase gain so that needle will show up bright on the screen.

  • Figure 18.6—Ideal image for ultrasound-guided peripheral IV placement.

• (g) Technique

  • Two approaches (in-plane or out-of-plane):

    • Figure 18.7a—In-plane

    • Figure 18.7b—Out-of-plane

  • Out-of-plane:

    • The vein will be imaged using a transverse or cross-sectional view.

    • The transducer marker should point in the same direction on the patient as on the ultrasound monitor.

    • Identify the vein in cross section:

      • Make sure the vessel is compressible before attempting access.

    • Insert the needle just distal to the transducer and enter the skin at a 15–30° angle:

      • Figure 18.8—Needle position relative to transducer

    • Needle tip will be visualized in the subcutaneous tissue as a small bright white dot:

      • Figure 18.9—Needle tip

    • As the needle is advanced closer to the vessel, the transducer should slide with the advancement to keep the needle tip visualized at all times.

    • Once the needle tip enters the vessel, drop the angle of the needle, and advance at least 2 mm to ensure the needle and the catheter are within the vessel lumen:

      • Figure 18.10—Needle in the vessel.

      • Remember: catheter tip sits back slightly from needle bevel so at the initial flash, it may not be far enough into the vessel to advance the catheter.

    • Stabilize the needle and slowly advance the catheter until it is completely within the vessel lumen.

    • Video 18.1—Out-of-plane peripheral IV placement.

  • In-plane:

    • The vein will be imaged using a longitudinal view of the vessel.

    • Place the transducer over the vessel with the marker pointed toward the needle:

      • This can also be done with the marker pointed away from the needle.

    • In this view, the vein will appear as an anechoic tube.

    • Insert the needle just distal to the leading edge of the transducer and enter the skin at a 15–30° angle:

      • Figure 18.11—Transducer and needle placement in long axis

    • If the needle is directly under the transducer beam, it will reflect the entire needle, and you can visualize it along its course into the vessel:

      • Figure 18.12—Long axis of needle toward the vein

    • Once the needle tip enters the vessel, drop the angle, and advance 2 mm to ensure the needle and the catheter are within the vessel lumen:

      • Figure 18.13—Needle in the vessel, long axis.

      • Remember: catheter tip sits back slightly from needle bevel so at the initial flash, it may not be far enough into the vessel to advance the catheter.

    • Stabilize the needle and slowly advance the catheter until it is completely within the vessel lumen.

    • Video 18.2—In-plane peripheral IV placement.

  • Completing the procedure:

    • Remove the tourniquet.

    • Flush the luer lock and tubing with saline to remove air bubbles, attach it to the catheter, and secure it in place with Tegaderm adhesive.

    • Flush the catheter once inside the vessel:

      • The IV should flush easily.

      • If there is resistance or pain with the flush, the catheter is likely outside the lumen of the vessel and needs to be removed.

• (h) Key Points

  • Ultrasound improves efficiency of IV access when blind landmark attempts have failed and decreases the number of needle sticks [2].

  • Tissue movement can help localize the approximate location of the needle tip prior to actually visualizing the needle tip [2].