Ultrasound Guided IV

Relative contraindications for IV at a given site:

Presence of AV fistula in that extremity.
Anticipated procedure (i.e. surgery) required on that extremity.
Veins that are firm to palpation (sclerosis), or evidence of thrombosis, phlebitis.
Veins that recently had puncture attempt with subsequent hematoma formation.
Vein underneath infected tissue.
Vein under burned tissue or area with severe edema.
Note: caution in placing IV’s in limbs with significant sensory deficit = risk of delayed detection of extravasation.
Note: antecubital fossa = okay for emergent access but long term can cause issues as need limb immobilization, easily kinked/dislodged.

Venous catheter
- Want a long length catheter (i.e. 20-gauge 1.88 inch)
  - Can be found in the D4 Omnicell room, Kidd 2 supply rooms, or ER section A across from the Omnicell. The nurses can help direct you if you ask for assistance.
Saline flush (sterile or not) + saline lock.
Chlorhexidine swab x2
IV Dressing
Sterile gloves
Ultrasound + sterile gel + sterile probe cover.
- Note: repeated chlorhexidine swabs can be used as ultrasound medium as alternative to sterile gel.
Gauze sterile x2.
Sterile surgical towels.
Tourniquet.
Optional: Lidocaine 1% without epi, 3mL syringe, 25 gauge needle, blunt tip needle.

Explain procedure + risks to patient. Keep patient warm.
1. If hair at cannulation site = trim with scissors (not shaving).
2. Note: ideally want to use patients non dominant extremity for cannulation.
Place patient supine + place extremity on stable surface below heart level.
Put on clean gloves + scan target vein with ultrasound.
1. Confirm it is a venous target by compressibility and color doppler flow.
2. Minimize the depth of the ultrasound image (ideally want to target veins that aren't more than a few centimeters deep).
Distend vein as much as possible.
1. Lightly tap the vein + stroking vein along its length (proximal to distal).
2. Ask patient to clench and relax fist.
3. Wipe off gel with gauze.
Apply chlorhexidine to insertion site. Set up sterile field with surgical towels. Drop needle + saline flush + saline lock + gauze onto sterile field + sterile probe cover/gel.
1. At this point lidocaine can be injected if needed for anesthesia.
Place a rubber tourniquet 5 – 10 cm proximal to venipuncture site.
1. Target < 1 minute of time with tourniquet on patient.
Wrap ultrasound with sterile probe cover + add sterile gel. Place ultrasound over target vein.

Hold catheter between thumb + forefinger, bevel up. Angle the catheter at 10-30 degrees from skin surface.
Advance the needle through the skin towards probe.
1. Once needle tip is seen, move probe away until tip disappears.
2. Then advance needle tip until seen on screen, then again move ultrasound probe away.
3. Walk needle into vein.
When in the vein blood will flash into hub, flatten angle, continue to track needle tip in vessel.
Advance catheter over the needle into vein, remove the needle + lock needle.
Remove the tourniquet.
Occlude blood vessel proximally with pressure, then apply saline lock.
Aspirate blood + flush with 0.9% saline to ensure patency of IV line.
1. Examine for swelling or patient discomfort following flush.
Cover the IV line with dressing.
Label the line with date/time/initials + document in chart.

Procedural steps written by: Muraile Vignarajah MD

Staff Reviewed by: Dr. Richard Veldhoen (Internal Medicine, Critical Care).