Our facility is looking for an Ultrasound machine to assist with Peripheral IV starts only. We have found the Site Rite 6 for a good price. Would that be helpful to us, as I see it is used more for PICC placement?
Any suggestions on an appropriate machine that is cost effectiive?
Have you looked at Bard Preview?
Will this machine be available to staff in general or reserved for a select group? What kind of training is available for us guided inserters?
My personal preference for piv's is Sonosite. You just can't beat Bard most of the time, but the Sonosite probe is smaller and fits my hand, works very well for a long axis view, and I find the display to be cleaner and more stable. I'm sure your mileage will vary and everyone out there has a different opinion, just sharing mine.
Peripheral catheter insertion requires 2 hands - one to hold the catheter and one to hold skin traction. So how do you hold the probe for venipuncture and catheter advancement? Turn loose of skin traction and you greatly increase the risk of phlebitis and infiltration/extravasation. So, in my opinion, infrared light devices are better suited for the majority of PIV insertions. I don't think either US or infrared should be placed in the hands of any and all nurses. US has a very long learning curve and will demand an alteration in traditional technique due to the issue of holding the probe. Infrared light is hands free and is not associated with the same lengthy learning curve. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Lynn,
One of the medical units in our hospital bought a prevue and intends to start teaching some of their nurses to use it. As you stated above, I don't think US should be placed in the hands of any and all nurses. Do you know of any guidelines, or have examples of policies to help keep the use of US in the right hands i.e. PICC RN's?
Thanks,
Josh Fitch RN, Vascular Access Clinical Educator
Josh
We use the siterite 6 for PICC and USG-PIV. In a hidden menu it has a feature that will adjust the image to a High contrast image. We find this to be most helpful in PIV sticks. I also like the controls on the probe. I can save image etc directly from the probe.
There is defiantly a learning curve and it is something that has to be consistently done to maintain the fine motor skill to be successful.
We have found that most kids under 8 yr old are near impossible to real-time guide with US although I have done a 3 yr old with success. We can mark the path of the vein prior to sticking. If the vein is within 0.5 cm of the surface then the needle tip is already there once you puncture and it is near impossible to see the tip without any movement which makes it too easy to pull out of the skin. At the 0.4 cm to 1.5 cm depth it is awesome.
I am interested in the bard preview because of the needle guide and it can be used with most caths.
It also has gel packs for scanning then a new sterile one for access. I have heard they have had problems with the gel packs not being recognized maybe due to storage in a warm warehouse? and the machine will not work without it ( I think) I hope to get one soon to try for an extended period. I think it has potential to lower the learning curve but I think they would have to turn off the gel pack sensor or at least let you pass by if it is not working properly.
We skip the prescan with non-sterile gel. We currently clean the entire scan area with chloraprep 3ml then open a sterile gel pack into the packaging. We place a small drop on the probe tip then cover it with a 4x6 tegederm to maintain aseptic touching of the skin and protection of the probe. It is also less bulky than a probe cover for non-sterile procedures.
Understand as Lynn said you have to maintain skin traction while accessing so we use a two person PICC team approach.
We numb the skin with 30g and bacteriostatic NS which stops any movement by the patient. We stick the tip of the needle in the skin at the mark made by a sterile marker. Once under the skin we use short axis to line up the needle with the path, then have the second person turn to long axis so we can see the needle tip enter the vein. Once there the inserter gets a real-time view of the catheter entering the vein. Any pressure of the probe tip must be maintained during the entire procedure or the 2 mm it moves will cause a fail.
It is beautiful when it is done correctly but having a run and gun quick nurse doing this has not worked for us. You have to train yourself to fly with the instruments once the needle is under the skin. If you look at the skin you will probably miss the tip of the catheter move. I have found the people that are the best regular PIV sticks are not necessarily the best USG-PIV inserters unless they can go much slower while using it. The screen is deceiving because it magnifies the area.
We have approx. 98% success using this approach and remember this are the people that have be tried by the best PIV inserters. I have tried to train the night supervisors thinking they would get more experience and maintain/gain the skill but so far have not found the passionate person to pick it up.
I find it interesting that in placing a PIV this is considered a non sterile function. I believe no touch was to prevent contamination after prep. An ultrasound probe implies touch to the process. When toucing a preped site with a non sterile probe I find that disconcerting. would you touch the site with your fingers as well for palpation or would that be consdiered touch? I would love to hear Lynn Hadaway thoughts on touching prepped skin with a non sterile ultrasound probe and gel or a probe covered with a now non sterile transparent dressing put on with non steile hands or non sterlie gloves
Please advise me if my infection control background has been hampered in my thinking process? I welcome all dissenters to argue how a non touch procedure may become a touch procedure with non sterile equipment because it is ultrasound. If using ultrasound on prepped skin what are the requrements for patient safety? i welcome clarification of the no touch technique as I cannot understand how it is safe to touch skin with a non sterile device, gel, non sterile dressing (it is now non steile as non sterile gloves or non sterile hands have applied it to the probe).
Ultrasound is great for PIV insertion but I do think maintaing sterile technique if you touch a prepped site might be a patient advantage. Infrared lights have their purpose as well as ultrasound. Depends on patient and veins
I would use sterile probe cover and sterile gel as well as maybe sterile gloves. or a sterile gel cap that actually touches the skin. Oh but PIV infectiions are not tracked and are not reported to NHSN so never mind!
Kathy Kokotis RN BS MBA
Bard Access Systems
I can see your concerns with the touch/no touch issue but If your using a 4/6 inch sterile tegaderm over the end of a very small probe like the site rite there is more non touched area even using non sterile gloves than when you use the same non sterile gloves to touch the chloraprep cleaning vial when preping for the insertion. When placing the probe cover we are very careful not to touch anywhere except the tape border and it is then removed. I believe the tegaderm over the probe is as clean as the tegaderm placed onto the PIV. Since it is an aseptic procedure, I feel this when carefully done as any other procedure is done it maintains that asepsis.
I feel the no touch idea is pertaining to the retouching of the prepped skin post by the non sterile glove. I feel this is due to the fact that the hands have touched the outside of the gloves while being placed on the hands and the gloves at this point have touched areas where there was no chloraprep done. I have seen many a nurse prep the site then go back and papate with the non sterile glove prior to insertion. In my case the probe would not have been touched by the hands or anywhere on the skin than had not be prepared already with the chloraprep prior to the insertion.
I also failed to mention we clean the entire scanned area for 2 minutes like we do a PICC. We do follow all PIV for infection and have had no issues.
I hope I made that more clear.
Thanks for making me think! :)
No touch aseptic technique requires all healthcare personnel placing PIVs to rethink the way we have been doing this and the lack of attention to the "aseptic" part. Then combine that with the use of US and many more technique related questions arise. Obviously a transparent membrane dressing that can be deployed by not touching the adherent part is the only way to maintain that dressing as sterile. Use of sterile gel is also imperative. I have discussed this at meetings with many nurses who think that their non-aspetic technique for PIVs is acceptable and others that use sterile dressing and gel. What about the evidence? When I did my intergrative literature search on PIV and infection, I did find a couple of studies addressing this. You will find a short discussion of this with the outcomes of those studies on my website. Click this linke Resources to get to the specific page. Then you can download the article Short Peripheral IV Catheters and Infection, 2012. There could be more studies out since I did this search. I hope so because the studies I found did not adequately answer all questions. "Absence of evidence is not evidence of absense." Just because there is very little data on US-PIV and infection does not mean that infection does not occur when US is used for PIV. Common sense tell us that we must do the safest thing possible until the evidence establishes what is the most appropriate. So for now, we need attention to sterile covering for the probe, sterile gel, and a solid no touch aseptic technique. It is my belief that evidence will support this need eventually. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Great discussion. We did begin with a sterile probe cover but realized that once we handled the probe the sterility was gone near the same level of the large tegaderm dressing border. We found all of the tried probe covers were not as tight and did not allow the user to see in plane enough to be successful for the shallower veins of PIV. The tip of the tegaderm covered probe is easy to maintain in an aseptic form but we did not find this true with the sterile probe covers due to the bulk they added and lack of a large sterile field to lay it down.
Yes EBP will greatly help in this area. Lynn IYO would the larger tegaderm dressing as I have decribed fit your definition of "So for now, we need attention to sterile covering for the probe, sterile gel, and a solid no touch aseptic technique."
thanks!
Yes I think it would. One of the studies I discuss in that lit review now on my website used such a dressing on the probe. I can well understand the issue of the large probe cover getting in the way when doing a PIV. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
a sterile glove makes a fine probe cover. I've heard of using condoms but couldn't report on the sterility.
I use a latex free condom over my US probe so that it never comes into contact with the patients skin for IV starts and PICC placements. It works great, I place a rubber band around the probe while pulling the condom tight around the probe. Doing this will help that the picture is not distorted, just to remember to put jel on the probe before you cover it with the condom. It is not sterile but it is clean, depending on how you place it. You can always clean the surface of the probe with the condom on it with chlorhexidine/alcohol depending on patient allergies.
I clean my probe with the approved disenfectent after each use to make sure it stays clean.
When I place a PICC the condom stays on and it is covered with the sterile probe cover. Again you have to remember to place jel in your sterile probe cover before covering your US probe. With all of the Isolation patients out there i feel it is a safer practice to protect my probe from contact with the patients skin.
CRhodes, RN, CRNI
Vascular Access/PICC
St. Cloud Regional Medical Center
Mary C. rhodes
What do you place over the condom for placment of a PIV? Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I have been placing PIV using ultrasound for many years, and have seen others esculate the process up to one that makes it more of a sterile rather than aseptic or clean process. Placing PIVs is not a sterile procedure. Using ultrasound is an adjunce to assist in difficult access. The transducer tip and substance used for transmission gel should be sterile as the needle entering the patients skin passes through it. I use a 4X6 tegaderm (after placing gel on probe tip). At one location I use the Site Rite 6, but the imiage quality dwarfs compared to Sonosite S-FAST which I use at my other location. There are many manufactures, I would recommend going to a conference where venders have units on display, look at the screen, determine what is affordable, then make a decision.
Bradford A. Dungan, RN, BSN, PHRN, VA-BC
[email protected]
Bradford A. Dungan
There really is no definition for clean technique, but there is for aseptic and sterile - see INS SOP. CDC states to use sterile gloves if the PIV site is to be palpate after application of skin antiseptics. Much attention is now being paid to infection from PIVs although there has been very little attention to this in the past. I am anticipating more statements in guidelines and standards documents in the future. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Standard 35. II C ,calls for No Touch Technique. Also Known as ANTT (Aseptic Non Touch Technique )
antt.org/ANTT_Site/what_is_ANTT.html
Peter Marino R.N. BSN CRNI VA-BC Hospital based staff R.N. with no affiliation to any product or health care company.