1. Line everything up. Having your ultrasound, the patient, your hands, and your eyes all in the same line will make your life much easier. This usually means setting up the ultrasound opposite the side of the patient on which you plan to gain access.

2. Bed Up. This can be applied to any procedure. Bring the bed up to a position where you will be comfortable. This is a quick procedure until it’s not. Bring the bed up and your lower back will thank you later.

3. Depth down. The literature suggests abysmal success rates when attempting to cannulate vessels deeper than 1.5cm. For that reason, bring the depth on your vascular probe as low as it will go (usually 1.9cm). This is not to say that there are not circumstances where we need to look deeper, but for the most part for peripheral access, all the veins we need are within the first 1.9cm.

4. Plug in US. It sounds silly, but a dying ultrasound machine mid procedure can be tremendously frustrating.

5. Little gel. You would be surprised how little ultrasound jelly you actually need. Too much can make a slippery mess and make things much more difficult. Play around with this and find what works best for you. Obviously, keep more within reach if needed.

6. All equipment at bedside. Again, this sounds simple, but have your own checklist of what you need and get the same things every time. Getting halfway done only to find you need to shout for help for more equipment is not good for anyone.

7. Guide in. Once you have visualized the needle tip in the vessel, good job, but we are not done. At this point, drop the angle of your needle, and continue to guide the needle into the vessel as far as the anatomy allows. This helps us successfully guide catheters past valves and bifurcations where the catheter might otherwise have not passed or may have kinked had we simply tried to slide it off with just the tip of the needle in the vessel.

8. Lighten up. Just like a pencil. Too often the tendency in a learner is to hold the probe with a death grip when you really only need 2-3 fingers on the probe. This allows the rest of your hand/fingers to act as an anchor on the patient’s skin. Also remember to lighten up with the downward pressure between the probe and skin such that we aren’t collapsing our low pressure targets.

9. Eyes up. Sure, it is ok to take a peek down at your positioning when not moving the probe or needle, but your eyes must be on the ultrasound machine when moving your hands at all. Too often we are caught looking down at our hands, checking for a “flash” while continuing to move the needle. Don’t look for a flash. Contrary to conventional blind IV insertion, a flash can help in tough cases but is meaningless in most. Keep your eyes on the screen and watch your needle go into the vessel.

10. Ask the patient. Chances are this is not the first time the patient has needed an ultrasound guided IV. Ask them where providers have had success in the past. They know.

References:

Witting et al. Effects of vein width and depth on ultrasound-guided peripheral intravenous success rates.  2010.  Ultrasound in Emergency medicine.  Vol 39, No. 1, pp 70-5.