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kklarry
Help about ultrasound guided PIV
I work in a radiology department and we have to start IV for pts for CT with IV contrast all the time. I used ultrasound today and started an IV for a pt in the right upper arm, I used 20 GA 1.88 INCH BD Insyte Autoguard. I found a large basilic vein under ultraound,it was 5 cm above the elbow and about 2 cm below skin. There was no artery around and I poked the pt with the needle and I saw the needle went through the vein in the ultrasound screen and I saw blood return in the catheter immediately. I lowered the catheter and advanced it in with no resistence. I flushed the IV with 10 cc normal saline. The flush went well and when I withdrew, I got nice blood return. Pt felt happy that I only used 2 minutes and gave him a good IV. But when pt went to CT scan, the Tech did the injection, there was no contrast in the CT picture. So where does thoese contrast go? Pt didnt feel any pain or discomfort in the right upper arm and I flushed with 10CC normal saline flush twice and it went in smoothly, no problem. I dont understand, everything looks ok but no contrast showed up in the CT scan. I had this kind of situation before. When I started the IV under ultrasound, everything was ok, I got nice blood return and flushed well, but when pts went to CT Scan, pt IV infiltrated. But I used long needle, 20GA 1.88 INCH. That is longer than normal IV needle and the vein was just 2cm under the skin. So I dont understand what I did wrong. How can I improve my PIV under ultrasound? I am really confused. But sometimes I started IV under ultrasound, the techs did the CT angio for the pts with that PIV, it went well. So I got mixed results for my ultrasound PIVs. Can the experts here give me some advice or suggestions? I want to give the pts good IV access so that they can have the test done,how can I improve myself? Any of your inputs will highly appreciated!!
Timothy L. Creamer
There has been a

There has been a significant amount of discussion regarding your question on this thread, might help to perform a search and read past postings. As a PICC nurse and drawing on my personal experience please follow some basic guidelines such as 1cm maximum vein depth and only from the AC Fossa and below. Following these guidelines will help prevent patient injury i.e. infiltration/extravasation.

 Concerning the lack of CT contrast displayed, I would only be guessing. Sounds like the patient experienced no pain, swelling, or other symptons of infiltration. Was the rate adequate?

Hope this helps.

Timothy L. Creamer, RN

Clinical Specialist, Bard Access Systems

Florida Division

Timothy L. Creamer RN, CRNI

Clinical Specialist, Bard Access Systems

Florida Division

kklarry
that pt has no pain or
that pt has no pain or swelling or other symptoms of infiltration. I started another IV without ultrasound in left arm AC area and the CT tech did CT scan again and still no contrast show up in the CT Scan. I talked to the lead tech, that CT tech is kind of new just transferred from X-ray to CT tech and was just off orientation. Probably it is the timing of the contrast. Because the CT tech set the volume of the contrast as 75 CC,but the rate didnt change and timing is 27 seconds, there is another CT tech who are more experienced said the timing should be more than 1 minutes, and the New CT tech used smartprep. I am not CT tech, I dont know what those mean, but the lead tech says next time if this kind of thing happens just ask for another CT tech. After the CT scan finished I flushed that PIV without Ultrasound, it was good and  patient experienced no pain, swelling, or other symptons of infiltration. I think it was not my PIV's problem
Wendy Erickson RN
Probably a dumb question but
Probably a dumb question but are yo sure the new tech actually put dye in the syringe?  Could it have just been normal saline?

Wendy Erickson RN
Eau Claire WI

clhunchusky
I agree with Tim. I will not
I agree with Tim. I will not place a PIV with US for any vein >1.25cm. We also use a 2.5" IV catheter (when needed). I have had much success placing below the AC as well, but it takes practice and LOTS of patience to get it down. Good luck! Cindy Hunchusky, RN, CRNI/PICC Team/Harris Methodist Hospital/Fort Worth, Texas
Diane C Lauer
I agree w Tim.  I place

I agree w Tim.  I place PICC's in radiology in a community hospital.  I have developed skill with Ult placed PICCs over a period of many years.  I find it very difficult to place a PIV w ULT.  I think that if you use usual practice and place a PIV above the a/c fossa the risk is this could infiltrate and because it is so deep the patient does not feel pain?  I am called to do many difficult IV starts, but only use ULT for below or at a/c fossa.  Occasionally I am not able to place the IV.  What about placing a midline above a/c?  The catheter would be inserted only 10 or 15 cm, distal to the shoulder, any thoughts?  Also, this would be a power PICC for injection.

Celia Brown

MM668
Hi Diane, I noticed that you

Hi Diane,

I noticed that you said maybe a midline should be inserted. I am not aware of any midline that is power injectable, and as Lynn has said because the vein is so deep you don't know that if you have an infiltrate until maximum damage is caused to the upper arm and vein. At our facility we sometimes leave a Bard Power PICC midline if we are unable to pass the shoulder. When we decided to do this we called Bard to confirm what would be acceptable to put through it and they said absolutely no power injection because that would be considered an "off label use" because it wasn't in the SVC, and we would be liable if something happened. We are hesitant to leave these in even though we put bright orange stickers around the tubing of each port that states its a midline (2 week PIV).  We don't want people to be confused that its a power picc because it looks like one. So the few patients that occasionally end up with one are monitored very closely by our team.

pmcmahon
If you are not sure if there

If you are not sure if there is a contrast extravasation you may want to ask your radiologist for an order to scan the arm where the IV contrast was given.  It is very easy to see if the contrast has extravasated and then you will be able to confirm the problem.

 

Paula McMahon, RN, CRNI, CRN

Paula McMahon, RN, CRNI, CRN

lynncrni
There could be several

There could be several issues as others have identified. Infiltration or extravasation with a large quantity of contrast under high pressure injection should produce at least some patient discomfort. I don't think you stated which agent was being used, so you will need to learn the contrast agent and determine if it is hypertonic or isotonic. If isotonic, there might be no discomfort. All sites above the AC with US will create a situation where an infiltration can easily go undetected. The veins are deeper and edema is not easily seen because of the depth in the tissue. However, the risk is greater. This site, along with the use of a midline catheter, leaves a catheter tip close to large arteries and nerves. Infiltration/extravasation in these locations could produce serious tissue damage before you could stop the injection or even know that there is a problem. Midline catheters are not indicated for high pressure injections, so I would never advise their use for this purpose. A poster at the INS meeting last week also showed some evidence of the damage that high pressure injection can do even with a power-injectable CVC. I think we have a long way to go before we can say these high pressure injections are safe! 

 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Timothy L. Creamer
I have had the opportunity

I have had the opportunity to review this poster as Lynn references that was presented at INS recently. Also was privileged to attend a local AVA chapter meeting including a presentation of infusion induced catheter movement. Initially, everyone should understand there is a significant difference between the porcine heart and that of mans. Differences include practically a nonexistent Brachiocephalic vein and the Superior Caval Vein (SCV) and the Inferior Caval Vein (ICV) both entering the Right Atrium at 90 degree angles (INS poster states tip positions at CAJ) to each other. One presenter confirmed the length of a Porcine SCV approximately 4cm. Another presenter stated they were more concerned over the effects of saline flushing than power injection. The following 2 references are worth review and easily found with a net search.

J. Anat. (1998) 193, pp. 105±119, with 13 ®gures Printed in the United Kingdom 105

Anatomy of the pig heart: comparisons with normal human

cardiac structure

SIMON J. CRICK1, MARY N. SHEPPARD2, SIEW YEN HO1, LIOR GEBSTEIN3

AND ROBERT H. ANDERSON1

Departments of " Paediatrics and # Pathology, National Heart and Lung Institute, Imperial College School of Medicine,

London, UK, and $ Cardiovascular System Laboratory, The Bruce Rappaport Faculty of Medicine, Technion ± Israel

Institute of Technology, Haifa, Israel

Anatomical study on the surgical technique used for xenotransplantation: porcine hearts into humans.
Siepe M, Martin J, Sarai K, Ihling C, Sommer P, Beyersdorf F.

Clinic for Cardiovascular Surgery, University Hospital, Freiburg, Germany.

 Accordingly, the thin-walled pulmonary artery and the superior vena cava (in bicaval technique) tend to kink and narrow.

 

 

 Power injectable catheters are offered by practically all manufacturers. I can only speak for Bard, proprietary internal testing of power injectable products went beyond burst pressure and flow rates of fluids and contrast medium. Anatomically correct models and venous conditions were duplicated for testing. Personal opinion, but maybe the others did as well.

A search of the MAUDE database will provide reported failures. None that I reviewed were related to power injection or catheter tip migration for various manufacturers.

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/search.cfm

Is it possible that infusion induced catheter movement could be causing unknown vessel damage resulting in subsequent negative outcomes? Anything is possible depending on multiple variables, however vessel dissection and SCV syndrome etiologies should include correlation of past treatments/procedures (personal opinion).

Timothy L. Creamer, RN

Clinical Specialist, Bard Access Systems

Florida Division

Timothy L. Creamer RN, CRNI

Clinical Specialist, Bard Access Systems

Florida Division

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