How I Teach: Ultrasound-guided Peripheral Venous Access

Abstract

Ultrasound-guided peripheral intravenous (IV) placement is often required for patients with difficult IV access and is associated with a reduction in central line placement. Despite the importance, there is no standardized technical approach, and there is limited ability to attain mastery through simulation. We describe our step-by-step approach for teaching ultrasound-guided IV placement at the bedside using short-axis dynamic guidance, with emphasis on advancing the needle and catheter device almost entirely into the vessel before threading the catheter. Our teaching approach allows the opportunity for trainees to maximize the learning potential of a single insertion experience, which includes focused preprocedure hands-on practice, instruction with real-time feedback at the bedside, and a post-procedure debrief with reinforcement of concepts.

Figure 1.

Ultrasound probe grip technique. The image on the left labeled “Wrong” displays the ultrasound probe being held away from the patient’s arm and without an anchoring point against the patient. The resultant display on the ultrasound screen is more likely to be like “probe heavy” or “probe moderate,” where the circular vessel is deformed into an oval as a result of the pressure applied by the probe. The image labeled “Correct” shows the probe being held close to the patient’s arm with the operator’s fifth digit anchored proximally on the arm, allowing stabilization and preventing excessive pressure from being applied, resulting in the ultrasound display labeled “probe light.”

Figure 2.

How to hold intravenous (IV) insertion device. (A) The IV catheter being held between the index and middle finger, with the thumb placed on the back to aid in angulation. The fifth digit is extended and used to provide stabilization during IV insertion. (B) Another style of IV catheter in which the grip positioning requires the catheter to be held between the middle finger and thumb in a flexed position, with the index finger placed on the top of the catheter for additional stabilization. The fifth digit is extended and used to provide stabilization during IV insertion.

Figure 3.

Confirming vessel wall tenting. (A) The vessel is being deformed by the catheter and needle. This creates a crescent-shaped anechoic lumen. (B) It can be confirmed that it is the tip of the needle that is tenting in the vessel wall by fanning the ultrasound just proximal to the needle tip, where the vessel resumes its round shape. Note that in B, the vessel is oval shaped, suggesting the operator is applying too much pressure with the probe and is compressing the vessel. The red dotted lines in the center image correlate with the path of the ultrasound beam in A and B.

Figure 4.

Summary of ultrasound intravenous insertion. (A) The needle is inserted into the center of the vessel at a steep angle. Note the catheter or needle tip may not puncture the vessel wall. (B) The angle of the needle is lowered to parallel the course of the vessel while maintaining the tip of the needle in the center of the vessel. (C) The needle is inserted further into the vessel. Note the tip of the needle may pierce the vessel wall, but the catheter is not within the vessel yet, and attempting to thread the catheter at this point would likely result in the catheter threading into the subcutaneous tissue. (D) As the needle is inserted farther, the needle and catheter pierce the vessel wall.

Figure 5.

Images comparing ultrasound appearance of (A and B) needle shaft to (C) needle tip. The hyperechoic structure in the center of the vessel is the intravenous catheter insertion device. The probe location and representative image are shown below. (A) The posterior wall of the vessel is interrupted because of posterior acoustic shadowing, suggesting the probe is positioned over the shaft of the needle, not the tip. (B) The needle is very bright and larger than how you would expect the tip to appear. The probe is positioned over the bevel of the needle, not directly at the tip. (C) Visualizing of this pinpoint structure is the tip of the needle.