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Cheryl Dumont
Ultrasound to guide insertion of short peripheral catheters
Does anyone have a policy/procedure and or competency check list  for use of ultrasound for short peripheral catheters.  If so can you share it with us Thanks
I use US for IV's but am
I use US for IV's but am ambivalent about it.  It is a big learning curve and difficult to teach to others.  It probably took me 5 or 6 months to perfect a technique.  I have tried and can't teach my technique to others... it just takes a lot of practice.  Also, you have to have a good US machine like a sonosite SICU.  It is much more difficult with a site rite.  Also PICC nurses who try it tend to go for veins too deep or go for veins at an angle too high.  It is a completely different technique than doing PICCs.  Never go for a vein deeper that 1cm unless it is an emergency...because they won't last and by the time the floor nurse sees the infiltration it is usually pretty bad.
Heather Nichols
Cheryl,    I have used


   I have used ultrasound for PIV sticks "when needed" for about 7 years now. I do not use it unless it is a must.  It took me about a year to perfect my technique.  I use a Site rite 6 but started out with a site rite 2.  We also have a sonosite I-look.  Ultrasound used depends on personal preference in my opinion.  It is what you can get used to.  I myself do not have a problem using any of them, including the huge GE u/s used in the ultrasound dept when I have to go down there.  I agree that it has a big learning curve, and it is hard to teach others.  You need to have an aptitude for it to begin with it seems, but if you are dedicated, anyone can learn as long as you practice- a lot!  I do not agree with the 1cm deep limit.  I would not go more than 2 usually, but it really depends on the angle you place on your needle.  Needle guides are NOT helpful when placing PIV sites with u/s.  You MUST judge your angle of insertion by your distance of the vein. This is a very debatable topic, but until a reliable answer is found for these problematic patients, it is going to be done, and these particular patiests appreciate it.  We do a full patient assessment on any patient we get called for access on, so we place the correct access in the beginning, but there are always going to be those patients that need a PIV "for a short time", and a PICC or central line is just to much of a risk when the risk/benefit calculation is done.  I am currently writing a Policy and Procedure on PIV's with ultrasound.  I will post it when I complete it.  Good luck, and remember to adjust those angles when you stick!


P&P for PIV with ultrasound


Have you completed your P&P for ultrasound guided PIVs?  I am currently working on this for our hospital and am drowning in info but no actual consistant practice guidelines.  Any tips you can offer would be greatly appreciated!



I do it all the time. I save
I do it all the time. I save the IV catheter in BARD PICC tray for PIV. The catheter is 4cm long. Make sure you have at least 2 cm of catheter inside the vein. If you think the catheter can't make it, then try to look for the other veins that are more shallow. Guide the TIP of the needle with your US. That is my secret. If you can do that, you are invincible PICC nurse!!!!!!!! Throw away those needle guide, it hampers your learning.
Our PICC team inserts 200+
Our PICC team inserts 200+ PIV's per month with ultrasound guidance. Using this technique for five years an currently 100% successful in one attempt. Usually anterior forearm or cephalic if vein is 1cm or less shallow.
Timothy L. Creamer
Needle guide benefits

Needle guide benefits include optimizing needle tip visualization. By visually verifying needle tip in center of vessel then trauma to intima can be avoided, 1st attempt success rates may increase, and patient satisfaction most likely will improve. I have observed needle guides used and not used for PIV's, depending on vein depths and available gauge size of needle guides. Commonly stocked size may be 21g needle guide versus the 20g/1.75" catheter included in kit.

Timothy L. Creamer, RN

Clinical specialist, Bard Access Systems

Florida Division

Timothy L. Creamer RN, CRNI

Clinical Specialist, Bard Access Systems

Florida Division

PIVs with ultrasound

Does your facilty have a P&P for use of ultrasound for PIVs?  I am trying to get one in place and would appreciate any tips.  Sounds like your group has great experience!



Nancy Rose RN IV Team VA

Nancy Rose RN IV Team VA Medical Center Wilmington, DE (800) 461-8262 ext 4830


Any tips about angle of needle insertion would be greatly appreciated. My angle isn't working.

Thank you



Nancy Rose 

Gwen Irwin
Those of you that do US

Those of you that do US IVs,

Is there a limitation on the areas of the arm?  We are finding them placed in the upper arm and not lasting long.  This is probably due to not having a long enough catheter.

I would like to have them limit their sticks to AC or lower arms.  What do you think?

Gwen Irwin

Austin, Texas

Cherokee people
I agree with Gwen. I think

I agree with Gwen. I think the deeper veins in the upper arm (Basilic, Acessory Brachials) should be used as a last resort for starting PIV using US.We need to maintain patency &  healthiness of these veins for PICC placement. I've seen some of the Sites infitrate easily . Then you would not be able to use these veins for infusion at that time.I would try using the veins in the lower arm or the ac area first. And If I had to I would look at the cephalic vein in the upper arm it is the most superficial of the deep veins in the upper arm.I try to perserve the deep veins in the upper arm and use them only in emergencies. Thanks, Vickey                                                     

Candee Eisenhart
I wanted to ask a few
I wanted to ask a few questions...When doing US PIV's do you use a sterile probe cover?  Do you use lidocaine at your facilities?  Have you seen more DVT's???  Thanks for your input.

 Candee Eisenhart BSN, CRNI, VA-BC

Robbin George
If you visit the site for

If you visit the site for you will see that a 3 inch power injectable version is

forthcoming--Seems to me that this devise might meet the needs of those patients with

limited peripheral access we encounter in the ED and other short term situations

Robbin George RN

Vascular Access Resource Department

Alexandria Virginia 

Robbin George RN VA-BC

Vera Deacon
We (the PICC team) generally
We (the PICC team) generally use the I-look only on deeper arm vessels (AC and below) and if an IV is being placed for a CT scan (chest) we use a longer 1.88in BD insyte as we found the shorter IVs had issues with infiltration once the power injection was started. We place over 225PIVs/month but only utilize the US for the really difficult inserts usually 20/month max.  The ED nurse have recently started using US as well for difficult PIV inserts as well after going through a competency developed by one of the ED attendings. They are in the process of developing a policy.
Robbin George
I went back and found this

I went back and found this thread from more than 6 months ago--The question about competaency and P&P was never answered--Surely of all the clinicians that are practicing the technique of PIV insertion with US someone has developed a guidance document--Please share it with the community--Thank you

Robbin George RN VA-BC

  Skills Specific


Skills Specific Checklist

                                             SONOSITE DOPPLER COMPETENCY

EVALUATION MECHANISM:  ¨ Simulation   ¨ Clinical Performance






General  Knowledge







     1. Uses two (2) identifiers to verify patient identification



     2.  Explains procedure to patient/family/significant other.



     3.  Identifies and collects supplies



     4.  Washes hands and dons gloves



5.  Obtains image – locates vessels




      6.  Confirms vein by:

a.      manual compression

b.      appearance of valves

c.      phasic, non-pulsatile flow



7.  Prepare sterile transducer field



8.      Choose lateral or transverse approach:

Lateral: keep needle within scan plane

Transverse: image the vessel to find the depth and use triangulation to     

                     estimate needle path.

                     Look for “tenting” of near wall as needle approaches











NAME: ___________________________________________ EVALUATOR: ______________________________



DATE: _______________________                   PASSED _________            REQUIRES REMEDIATION             



COMMENTS: _________________________________________________________________________________

page 1-2


By PICC Nurse

MMC 2009


  1. Learning Objectives:
    • Understand the basic ultrasound technology used in vascular access.
    • Review basic anatomy of veins and arteries.
    • Know how to hold the probe to assess the blood vessels.
    • Differentiate veins from arteries and nerves using ultrasound.
    • Access the vein using aseptic techniques under ultrasound guidance.
    • Understanding possible complications in vascular access.


  1. How does ultrasound machine work, basically?
    • The ultrasound machine basically has a PROBE and a COMPUTER.
    • There is this SiO2 crystal found naturally on earth, called quartz.
    • Quartz crystal has this amazing property called piezoelectric property. That means if you try to apply pressure to change the shape of the crystal, it will produce electrical current. On the other hand, if you try to apply an electrical current to the crystal, it will try to change the shape. 
    • The PROBE has many quartz crystals called piezoelectric crystals. When an electric current, sent from the COMPUTER through the cable, is applied to these crystals, they change shape rapidly. The rapid shape changes, or vibrations, of the crystals produce sound waves that travel outward. When these ultrasound waves hit the tissue, they bounce back. The returning ultrasound waves then hit crystals inside the probe, producing rapid shape changes.  This rapid shape changes of the crystal produce an electrical current, tranferred by the cable back to the COMPUTER. The computer calculates and display the electrical current into image.


  1. Quick review of Arteries and Veins. Where can you find a vein on the arm?
    • Both arteries and veins have a similar construction and consist of three major layers. The tunica intima is the inner layer lined with endothelium. The tunica media is the middle layer and in arteries contains an extra layer of smooth muscle that allows for increasing or decreasing the size of the artery. The outer layer is called the tunica adventitia in both vessels.
    • Arterial wall is thicker than the venous wall.
    • The veins start on the back of the hand in a dorsal plexus and become two major veins. The cephalic vein empties into the last part of the axillary vein in the pectoral region and the basilic vein joins the brachial vein to become the axillary vein in the mid-arm region.
    • If you can feel the vein with your finger, you should stick it without ultrasound. If you cannot find a vein by direct visualization or by feeling, then use the ultrasound machine. Ultrasound machine helps you better with deeper veins.





  1. Left-handed? Right-handed? How do you hold the probe?
    • Hold the probe with your NON-dominant hand. The IV needle is in your dominant hand.
    • The probe will look straight down into the tissue. If the probe leans away from this perpendicular position, the returning signal will be weak and the image will not be clear.
    • Always use enough ultrasound conductive gel. Ultrasound waves cannot travel through air. Hold the probe so that the guiding point (the arrow-shape point) facing you at all time. Gently touch the skin with the probe.  Remember, there should be always a thin layer of gel between the probe and the skin.


  1. So, how do the blood vessels look like on the ultrasound machine?
    • Fluid inside the body (blood, body fluid…) will absorb the ultrasound waves. That means there is NOT much returning signals to the probe. With the cross sectional view, the lumen of the vessel appears as a dark or black hollow hole on the ultrasound machine screen. On lateral view, the lumen of the vessel will look like a black or dark strip.
    • To distinguish the vein from the artery, gently press the probe down. With gentle pressure, the vein should easily collapse and non-pulsatile. Keep your eyes on the screen; you will see one of the round hollow shapes collapsing.
    • The one that still stays open, and most importantly, is pulsating, is the artery. If you turn on the color Doppler, the color spot will also pulsating.
    • From the transverse position, slowly turn the probe counter clockwise to the lateral position, trying to keep the vein image in the middle of the screen. The vein now should look like a dark band across the screen.
page 3-4
    • Choose the vein that is isolated to avoid arterial injury. Lower mid-forearm to below the antecubital area is preferred for patient comfort.  
    • The nerve normally runs along the artery and it appears to be a small bundle of shiny round cluster of grape-like shape.





  1. Now that you find your target vein, how are you going to get it?
    • After you pinpoint the place that you are going to use, mark it with a pen then clean up the gel on the probe and the skin with a towel. Disinfect the area with ChloraPrep. Use an alcohol swab to wipe the tip of the probe several times. Put just one drop of gel back onto the probe.
    • Now position the probe 1 cm proximal to the intended entry site.  Adjust the probe so that the vein stays right in the middle of the screen.  Remember to keep the probe touching the skin very gently. Estimate the depth of the vein (the depth indicators is on the right hand side of the screen). The deeper the vein is, the steeper the needle should be held. Hold the needle on your dominant hand; insert the needle at about 15° angle. When the needle comes in about ½ cm, you should see a bright white dot appearing on the screen. That is the tip of the needle. Try not to lose its image on the screen. If it is in the middle of the vein and you have flash of blood in the IV catheter hub, advance the catheter at this time. If it is not in the vein, try to guide it in, using hand and eye coordination. Be careful to not contaminate the IV catheter during the insertion.
    • This is the most difficult part of the procedure. Practice makes perfect. 1% Subcutaneous lidocaine injection, 0.5 mL, is a relief to the patient if possible.


  1.  What can happen during the procedure?
    • If the patient complains of pain, “an electrical shock” down to the finger, you hit the nerve. Just find another place.
    • If you pull the needle out and the bright red blood squirts out from the catheter rhythmically, you enter the artery. Quickly pull the catheter out and apply pressure directly onto the site at least 5 minutes, then apply pressure dressing.
    • Patient complains of pain at the site when you flush the catheter. It is infiltrated.
    • It appears to be inside the vessel on the screen but you cannot advance it. It is in between the intimal layers. Pull back a tiny bit then increase the angle up a very tiny bit then try to insert the needle in.


  1. Reference:


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