Peripheral IV placement is one of the most common procedures performed in hospitals, with hundreds of millions performed each year. For the most part, IVs are successfully placed in the traditional way - using landmarks and visualization/palpation of the vessels. But as we all know, there are several patient factors that can make peripheral IV placement more difficult, including obesity, edema, a history of IV drug use, sickle cell disease, lupus, diabetes, etc.
Ultrasound-guided IV placement is increasingly used in the emergency room, medicine floors and ICUs in patients with difficult IV access, but the research is clear that there is a higher premature failure rate with ultrasound-guided IVs (1).
This practical guideline details several considerations that may help reduce the premature failure rate of ultrasound-guided IV catheter placement.
What are key concepts to help reduce ultrasound guided peripheral IV catheter complications, prolong life of catheters, and increase rate of successful placement?
Methods & Study Design
There are six key concepts to help minimize complications and increase duration of ultrasound-guided peripheral IV catheter placement.
Strength & Limitations
Potential limits to these guidelines include ultrasound experience level of a person placing IV catheters, whether the necessary equipment is routinely available at lower resource centers, and the setting in which IV cannulation takes place (e.g. trauma or non-trauma). The access and cost of ultra-long peripheral and midline catheters may limit use given potential for high utilization.
“Practitioners should consider several issues when inserting intravenous peripheral catheters under ultrasound guidance, aiming to improve success rate, avoid complications and lengthen the survival of the catheter. Based on available data and everyday practice, all indicate that catheters longer than standard size are needed for US-guided peripheral venous cannulation, with the purpose of minimizing premature catheter failure. This is a call for attention to catheter manufacturers, since a more affordable solution at hand is expected from them shortly.”
For placement of ultrasound-guided peripheral IVs consider these rules:
- Always use a long IV catheter, preferably 6 cm or longer
- Choose veins that are:
- At least 4 mm in diameter
- At most 1.5 cm deep
- As distal as possible, preferably distal to the antecubital fossa
- At last 2.75 cm of the catheter should be in the vein
- Check IV placement by flushing saline and use the ultrasound to watch a proximal vessel for turbulent flow
The Bottom Line
When identifying an appropriate vein for ultrasound guided IV access, choose a superficial, patent, large, distal vein to minimize distance needed for the catheter to travel. Ensure adequate catheter length and confirm catheter position after placement to decrease failure rate.
This post was written by Tori Speck, MS4 at UCSD School of Medicine, Charles Murchison, MD and Amir Aminlari, MD.
Blanco, Pablo. “Ultrasound-Guided Peripheral Venous Cannulation in Critically Ill Patients: a Practical Guideline.” The Ultrasound Journal, Springer Milan, 17 Oct. 2019, www.ncbi.nlm.nih.gov/pubmed/31624927.
1. Bahl, Amit, et al. “Ultralong Versus Standard Long Peripheral Intravenous Catheters: A Randomized Controlled Trial of Ultrasonographically Guided Catheter Survival.” Annals of Emergency Medicine, Mosby, 16 Jan. 2020, www.sciencedirect.com/science/article/pii/S0196064419313836.
2. Gottlieb, Michael et al. “Comparison of Short- vs Long-axis Technique for Ultrasound-guided Peripheral Line Placement: A Systematic Review and Meta-analysis.” Cureus vol. 10,5 e2718. 31 May. 2018, doi:10.7759/cureus.2718
3. Presley, Brad. “Ultrasound Guided Intravenous Access.” StatPearls [Internet]., U.S. National Library of Medicine, 31 July 2020, www.ncbi.nlm.nih.gov/books/NBK525988/.