1. Kevin Arnold RN, BSN Coordinator, PICC Program VA Long Beach, CA Medicine & Inpatient Healthcare Group | Spinal Cord Injury | Community Living Center Ultrasound Guided Peripheral IV Technique

2. Precision & Solution for the Hidden Veins + = Ultrasound Guided PIVs

3. To learn when to utilize ultrasound technology for peripheral IV starts and blood draws To understand peripheral venous anatomy To become familiar with the basics of high frequency-low depth - ultrasound machines To be familiar with potential complications To understand vein/catheter selection To learn technique required to cannulate a deep vein To be familiar with common pitfalls Objectives

4. Common Difficult Stick Obese Edematous Dehydrated Diabetic Dependent on dialysis Post chemotherapy Post mastectomy A drug abuser In shock

5. Vein Anatomy http://www.daviddarling.info/images/vein.jpg

6. Arm Vein Anatomy http://vascularultrasound.net/wp-content/uploads/2010/08/armveins2-copy.jpg

7. Upper Arm Vein Anatomy http://vascularultrasound.net/wp-content/uploads/2010/08/armveins2-copy.jpg

8. Ultrasound View – Upper Arm Basilic Brachials Veins Artery Brachial http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-104340-1433943-1464224.jpg

9. Ultrasound View – Upper Arm Nerve Bundle http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-104340-1433943-1464224.jpg

10. Typical Sizes & Flow Rates VesselDiameter (mm)Blood Flow (ml/min) Cephalic645 Basilic880 Axillary16300 Subclavian19800 Superior Vena Cava20 2000 & turbid Vascular Access Device Selection, Insertion, and Management: BARD ACCESS SSYETSMS, p12.

11. Anatomical Performance Opinion… Veins in forearms do not tolerate high rates well, but are less likely to dislodge Veins in dominant hands tolerate higher rates, but are more likely to dislodge and develop phlebitis

12. “Rule of Thumb” Be patient Look for sites that will have the best possible success Use warm packs if extremities are cold to touch Avoid veins in ante-cubital fosa and wrists if possible Use good judgment Avoid sticking nerve bundles Worst case scenario: Helpful vein dilator – nitro paste between the fingers, with MD order, will dilate veins.

13. More “Rule of Thumb” Start with forearm Ulnar, Radial, Cephalic Then..upper arm superficial Cephalic Then..upper arm deep Basilic Brachial http://vascularultrasound.net/wp-content/uploads/2010/08/armveins2-copy.jpg

14. Ultrasound Equipment Insert your type of machine… Include location and instructions for checkout & use. http://www.bardaccess.com/assets/images/products/ultrasound/siterite6_unit_hero.jpg http://65.36.201.165/instrumentpics/sonositeiLook.jpg Photo by Kevin Arnold, RN, BSN. kev1999@gmail.com

15. Ultrasound Technology Very high frequency sound waves Requires fluid medium for oscillating transmission Visual images are the reflection of echoes of high frequency sound beams from soft tissues Ultrasound waves do not transmit through air Sound waves do not penetrate high density areas well

16. Ultrasound Machines Always plug in power adapter Battery life is unpredictable Machine must be signed out in log book located at respective nursing station Clean before and after use Please take careful care in handling equipment Very expensive… $15,000 - $25,000 Replacement probe… $3,500 + (don’t drop it)

17. Ultrasound Machines Hold probe at 90 degree angle to skin surface for best image results http://vrassoc.com/Page24_Figure2.gif

18. Ultrasound – Maximize Your Image Depth should be adjusted so that the view of target structures is maximized while allowing structures posterior to the target to also be seen Gain should be adjusted until there is a slight fill in of white pixels in the vein Fluid filled vessels should appear black, void of echoes http://www.ivteam.com/wp-content/uploads/2008/11/ultra.jpg

19. Selecting the Vein Depress vessels to differentiate veins from arteries Vein will stay depressed. Arteries will “pulsate” NOTE: Patients with low BP may not pulsate. Trace vein with probe to find a straight section of the vein Mark endpoints to visualize vein path Avoid nerve bundles Vein depth discussed later… http://www.ivteam.com/wp-content/uploads/2008/11/ultra.jpg

20. Selecting the Catheter Catheter size selection should reflect size of available vessel and type of therapy to minimize/prevent complications and maintain adequate access. NOTE: Phlebogenic drugs are best given through a small catheter in the largest available vessel. Catheter length should be adequate to ensure that ½ of the catheter will reside in the lumen of the vessel. Be sure to take the angle of approach into consideration when determining vessel depth (depth scale available on US screen).

21. Selecting the Catheter Floor Stock [ Insert your model ] 1.25 inch | 32 mm 18, 20, 22, 24 gauge U/S Cart Stock [ Insert your model ] 1.75 in | 45 mm 20 gauge This will require adding tubing Choose one-handed use products http://www.mtrhealth.com/ImageViewer.aspx?img=~/public/images/425-2543.jpg&w=150 http://catalog.bd.com/ecat/images/f10/bdnexiva.jpg

22. Vein Depth | Stick Angle | Catheter Length Vein Depth Catheter Length to Reach Vein Skin Stick Angle Probe IV Catheter Vein Image created by Kevin Arnold, RN, BSN. kev1999@gmail.com

23. This chart represents the catheter lengths needed just to reach the vein. The length to reach the vein should not be more than one-half of your catheter length. Vein Depth | Stick Angle | Catheter Length http://www.ispub.com/ispub/ijms/volume_2_number_2_62/a_needle_guide_device_is_better_than_a_free_hand_technique _for_ultrasound_guided_cannulation_of_the_internal_jugular_vein_results_from_a_simulation_study/guide-fig3.jpg Chart created by Kevin Arnold, RN, BSN. kev1999@gmail.com

24. Site Prep Mark endpoints to visualize vein path and insertion area Impression will stay for a while and not rub off in prep. Image created by Kevin Arnold, RN, BSN. kev1999@gmail.com

25. Site Prep Using friction, scrub the selected site about 3 inches in diameter for 30 sec and allow to dry (2minutes for areas of dense hair) NOTE: Do not blot or wipe on site to speed drying. Prep surface of transducer using ChloraPrep sponge (once prepped, do not allow probe to contact non- prepped areas. ) Apply a small amount of sterile gel to probe or above selected insertion site

26. Stick Technique Consider the concept of catheter length vs. angle of insertion. It is important to balance the two. Use on-screen guide to measure depth of vein and direction. Each dot = ½ cm. Veins around 1.0 cm deep are usually the easiest. Sticks will be easier with a higher angle of insertion, but this must be balanced with the catheter’s ability to bend. Avoid kinking the catheter. http://www.bardaccess.com/assets/images/products/ultrasound/supporting/product-siterite-needles.jpg

27. Stick Technique In general it is easier to visualize your needle if you stick in the 45 – 65 degrees range from the skin. Then lower your angle to thread the catheter. Image created by Kevin Arnold, RN, BSN. kev1999@gmail.com

28. Stick Technique Grip probe with a “C” form. Stabilize your hand holding probe with one finger or wrist against patient’s arm. Wrap ultrasound cord around arm to prevent dropping probe. Keep ultrasound parallel to skin. Use on-screen guide to align center. Image created by Kevin Arnold, RN, BSN. kev1999@gmail.com

29. Stick Technique Place probe above where you anticipate needle tip will enter vein. Imagine your needle as the hypotenuse of the triangle you are forming. Use minimal amount of gel. Too much gel makes stabilizing probe difficult. Scan probe to view needle tip by moving probe to and from insertion site. http://www.bardaccess.com/assets/images/products/ultrasound/supporting/product-siterite-needles.jpg

30. Stick Technique You may inadvertently stick through both sides of vein wall. If so, you should see and feel the vein wall “pop” into place when retracting the needle out of the deeper side of the vein wall. You should have excellent blood flow when tip is in the middle of the vein. After visualizing tip of needle in center of vein, it is okay to lessen the angle of the needle as you begin to thread the catheter.

31. Stick Technique-Confirmation Needle entering and visible in vein http://www.bluephantom.com/product_thumbs/t_basilic_vein_ultrasound_needle_cannulation_PICC_training.jpg http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-104340-1433943-1464756.jpg

32. Stick Technique-Confirmation Side View (Horizontal Plane) http://www.bluephantom.com/product_thumbs/t_brachial_vein_ultrasound_needle_insertion_model.jpg

33. Stick Technique-Video 1 Video created by Kevin Arnold, RN, BSN. kev1999@gmail.com

34. Stick Technique-Video 2 Video created by Kevin Arnold, RN, BSN. kev1999@gmail.com

35. Potential Complications Arterial puncture Adjacent nerve damage Infiltration Infection – local & systemic Potential DVT induced by repeated injury to vessel or the presence of a catheter Injury to vessel preventing arterio-venous fistulas sites for renal patients

36. Common Pitfalls Beware of threading in the “sidewall” of the vein. It is common to get some blood return after threading into the sidewall. It is very important to visualize the needle tip in the center of the vein opening. http://www.daviddarling.info/images/vein.jpg

37. Common Pitfalls My needle is under the skin but I cant see the tip? After needle insertion, make sure the probe is directly above the insertion area. Move the probe closer to the insertion site and scan outward You may be too deep. Look for movement below vein I buried my needle and I still can’t reach the vein? Retract and advance at a steeper angle, but make sure to allow sufficient catheter length left for in the vein. Infiltration is likely if catheter is too short.

38. Common Reminders You will constantly have to remind students: Keep your eyes on the screen…not the insertion area. Stick steeper…steeper is much easier. Don’t hover over patient with needle…just stick quickly through skin and then use the screen to guide the needle. Use your wrist/finger to stabilize your probe hand…free handing the probe will allow too much movement.

39. Common Reminders You will constantly have to remind students: Clasp probe with a “C” grip close to the end… holding the probe far from the end will allow too much movement. Image created by Kevin Arnold, RN, BSN. kev1999@gmail.com Gripping with a “C” allows use of your pinky finger and/or butt of you hand to stabilize your hand against patient arm.

40. Documentation Document IV site location and preparation, gauge of catheter, number of attempts, and type of dressing in the medical record. Use of Ultrasound for guidance should be included in note.

41. Questions? Call… Kevin Arnold RN, BSN PICC RN, VA – Long Beach Medicine & Inpatient Healthcare Group | Spinal Cord Injury | Community Living Center Bldg 126, 562.826.8000 Ext 5827 Pager: 562.683.1200