Forum topic

There are several good articles on this topic.  Especially, look in JVAD for article by Tim Royer, which was very good. 

Hello, I've been placing u/s guided piv's for years and firmly believe, through much experience, that one should definitely NOT use the deep veins above the a/c fossa for piv's.  Even if one were to place a 1 3/4 inch long piv or similar in the basilic or brachial, it is almost guaranteed that it will go bad quickly and infiltrate, especially if one were to try to power inject contrast through it. Most patients simply do not have enough muscle to stabilize the tissue and the angle is too deep.(On the other hand, though, often the cephalic vein above the a/c is a great place to go, if there are no good vessels in the forearm.)  I have been asked a MD to do this and have flat out refused (while offering to place a picc instead) as I know it is not in the pt's best interests to have contrast infiltrate deep in their upper arm next to their artery and nerve.  He didn't like my answer but I stuck to it. And no harm was done.

Just because you can, doesn't mean you should. 

As far as depth goes, I will rarely consider a vessel deeper than 1 cm or so. I could easily place a line in a deeper vessel, but when it's that deep, it is much more difficult to assess the site for infiltration, phlebitis, etc. Our team mostly uses piv's that are 1 1/4 in long as opposed to more standard 1 inch long catheters. IMO, the extra 1/4 in makes a VAST difference in how long the lines last, giving one much more purchase in the vessel.  We also save a few of the 1 3/4in long piv catheters that come in our picc kits for really obese pt's if there are no other vessels other than deep ones.  It is also very important to place the correct gauge in the vessel for whatever therapy the pt will be having. Smaller gauge is better, everyone doesn't need an 18 gauge. They don't last as long.

Of course keep in mind that each patient is different, there are few black and white rules, but a lot of gray areas. Pt specific assessment by an experienced inserter is of utmost importance.

hope that helps!

Sam

 Here is a study supporting the experiences described in previous messages:

1. Dargin J, Rebholz C, Lowenstein R, Mitchell P, Feldman J. Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access. American Journal of Emergency Medicine. 2010;28(1):338-345.

Basiclic vein in upper arm with a 1.8 inch catheter all placed by MD. 47% infiltrations within 24 hours. We need more outcome data about the catheter, not just insertion success data. 

Lynn

I would agree with Sam.  I place more of these than PICCs when appropriate.   the cephalic is the best shot if the vein can support it.  I place them in the forearm most often.  I often place them just distal to the ac with a 1.75 inch cath.  The patient can still bend their arm without issue and they seem to last the longest.  I have placed them on the rare patient in the brachial a few cm above the ac but the problem is that the arm is no bendable due to the extension getting in the way.  They don't last but it was their only vein or they were not too muscular or obese.  Otherwise it infiltrates quickly.  I have even placed them in the basilic for a hand inject ct patient with no other possible access and need of outpatient CT.  I stay with the patient untill the ct is complete and d/c. 

I have found if the person had too much muscle mass or very loose skin then it is like anchoring the line on a body of water.  It moves too much and is quickly infiltrated.  I especially train the nurse that this IV should NEVER hurt the patient.  Not that another should but you know how some nurses treat PIV.   (it is still flowing, it is okay) 

I have used the B/Braun 1.75 in and the BD  1.75, 1.88 caths.

The BD is nice because you can use a statlock in some cases.  The bad is it does tend to kink right at the hub to catheter junction.

The B/Braun introcan seems to be a little more firm but I have not noticed any other issues with like phlebitis. 

I don't attempt the standard 1.16 inch cath with ultrasound because of the depth and angle of stick the catheter will have very little left to remain in the vein.  (not 50%)

Our policy states only a PICC RN can place in the brachial vein above the AC due to it being considered a deep vein.  Basilic veins are discouraged except for appropriate ICU patients.

And most important is that the right vein/right catheter/right patient rule be added to the choice.

SINCE most of all my position was restructured, I will be without a job in 30 days.  I am a passionate educator/employee and constatly look for ways to improve and make things easier for others :)   

SOOO  I can come to your hospital and train the appropriate person to do this procedure. :)   

http://www.resumemaker.com/DavidKuespert3.resume

Here's my suggestion for what it's worth....Don't do them!.. I can only speak from my experience, and maybe there are folks out there putting lines in using US and the PIV stays for 3-4 days without incident. But, I can tell you in real world application, it doesn't work out well. Lynn quoted a study that showed MD's inserting PIV's in the upper arm using US guidence with a 46% infiltration rate the next day! that is more like the truth.....Ok lets look at that...what if the patient was receiving BID Vanco so that's 2 maybe 3 doses and he happened to get K+ IV middle of the first day. So basically that IV was not securley in the vein. Now the patient has a swollen, red, warm upper arm.

Is that an incident report? Shouldn't someone be called on that?....Gregg, do yourself a favor..stick to PICC's and Midlines. What we do is a specialty. We should never be duplicating effort by starting peripheral IV's. I mean there may be a rare instance but once you become a hybrid PICC Team/IV Team....Then when the cutting pens start writing, who gets cut?.....the IV Team. 

Was it you that said your position is being eliminated and that you did put more IV's in than PICC's?....Believe me that model is something we don't want to see. Your bankability relies on your expertise. Look at like this....are you a caution tape cop?.....or are you SWAT....you'll never catch SWAT putting caution tape around a crime scene....sorry just love that analogy!!...LOL

Let's keep this what it is....we didn't go through all that trouble to create VA-BC just so we can be an every nurse. Picc's, Midlines, Axillary Lines, IJ's ...advanced assessment, early access intervention programs,...that's what you do. Leave the bedside nursing to the bedside nurses. 

Sorry Greg...it wasn't you it was Random VAT ....about the elimination of his position. But the point still stands.

I believe in using the right line for the situation.   I am not surprised that the doctor's study has shown that the USG-PIV is a bad choice.  I think every nurse can attest that doctors are the BEST iv people on the planet.  J/K. J  Most ER physicians I have met tend to be "run and gun and get it done kind of people” that is why they do so well with that type of job.  This procedure benefits from more of a surgical strike- the tortoise approach.   Our hospital has not switched to their traditional PIV to remain past the traditional 72-96 hr, I have convinced them to allow my lines to do so.  The lines I have placed have consistently out lasted the traditional PIV when using the right catheter and skill set.  Please keep in mind the patients are ones that no one else was able to gain access and a midline/Picc was overkill. 

As for my position, JackDCD has assumed much. 

Point taken.   But I do believe this can be the right thing for the patient, hospital, and a full service Vascular Access Team.  In this time of Obamacare cuts, I think it will make us increasingly valuable if the right tracking is done.  If the VAT does not perform tracking of all they do, then yes.  It will kill your team when your numbers decline.  But when you can demonstrate how USG-PIV saves cost from decreased CLABSI risk, supplies, etc.... 

I'm standing tall on believing that the upper arm veins are for access points not drug delivery.  We used to believe it was ok to place tips in the subclavian and deliver drugs there.  That is now considered malpractice.  If you have to use ultrasound to insert a short catheter in the upper arm, just go central and cover all your bases.  Too often midline catheters inserted for one intent end up getting used inappropriately because therapy has changed.  There are a very limiited number of upper arm veins and they need to be protected.  Not enough studies have been done on examining these veins at the completion of therapy to determine if there has been permanent damage to the vessel.  Manufacturers of these catheters have jumped on the CLABSI bandwagon and promoted them as the solution.  Their literature sometimes makes outlandish claims.  Don't make your clinical judgements based on a manufactuter's claims.

Why are we having to resort to ultrasound to achieve peripheral venous access?  Because we are not promoting venous preservation.  I say stop the insanity at the upper arm. 

This is just one 30+ years vascular access nurse's not so humble opinion.

 The right catheter for the patient's indications/needs inserted at the right time by the right methods and the right people. That should be everyone's goal. The need for insertion of a short peripheal catheter with US is growing because patient needs are changing due to chronic dieases, multiple courses or prolonged need for infusion therapy, and little attention to the matching the skill level of the inserter to the paitent's level of venous difficulty. The infusion/VA nurse must be involved with correct insertion of SPV by US. I strongly believe that leaving these difficult patients with staff nurses can be patient abuse and insertion of any CVAD when there is no clinical indication is also patient abuse. I think it is great that nursing practice is expanding to include insertion of subclavian/IJ central lines but the experts can not forget patients with difficult venous access but no need for a CVAD. Your knowledge, critical thinking and psychomotor skills are still acutely needed for these patients. Lynn

I use upper arm veins, basilic, brachial and cephalic with success.  I use the BD Insyte, 1.88 inch.  My trick is to be in the 1-2" area just above the AC.  If you are higher the bicep muscle can twist the IV and render it useless and promote infiltration/extravasation.  Angle the IV and extension tubing medially so it is not hampered by the bend of the elbow.  Positioning is everything!  Hold the IV in place while bending the patients arm to find the optimal final position.  Another trick is to use Steri Strips to secure the IV.  That brand.  The securement allows for strong securement and minimal flexibility.  The chevron method works well for me.  The angle of insertion needs to be 45 degrees or less to avoid kinking at the site.  If the vein is 1.5 cm or deeper, or if the vein is small or you need to avoid nerve bundles or arteries, I use MST to enter.  

To access: Have the patient's arm positioned on a tray table as perfectly horizontal as possible.  Hold the u/s probe fully upright.  Angles make this insertion more difficult since you have to compensate for the angle.  Enter the vein.  Feed wire.  Insert dilator/introducer.  Remove the dilator.  With the wire and introducer in place, feed the IV over the wire and into the introducer.  Then begin to withdraw and peel the introducer while simultaneously inserting the IV into the vein via the wire.  Once the IV is fully inserted, remove the wire.  The introducer is larger than the 18 or 20 gauge PIV so pressure may need to be held for a bit to acheive hemostasis.  Sometimes I will fold a 2x2 in half and half again and secure it to the site with Steri Strips to prevent bleeding. 

I use this with radiology CT patients and patients needing access for meds/access/etc. Obviously, the medication and fluids must meet the criteria for PIV access.