US IV question

[caligas]

Large guy, only decent vein was HIGH in arm abutting large nerve which was maybe the axillary nerve vs ulnar with basilic vein.

I decided not to go for it, fear of hitting nerve or infiltration of agents onto nerve etc.

Thoughts?

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[MirrorTodd]

Large guy, only decent vein was HIGH in arm abutting large nerve which was maybe the axillary nerve vs ulnar with basilic vein.

I decided not to go for it, fear of hitting nerve or infiltration of agents onto nerve etc.

Thoughts?

Nothing wrong with playing it safe. There are always other targets, just got to have the time to look for them.

 

[kb1900]

so then what did you do? Place a CVC? EJ? Or find a new target on a limb? Cannulate the penile vein? is it just a vein to go to sleep with or for volume or for vasoactives?



If there is a low risk trajectory to the vessel and an appropriate catheter I don’t see concern if US skills are strong. I don’t think a CVC is exactly lower risk than peripheral nerve injury under US guidance with a clear track to avoid the nerve(s).

 

[Iso4ane]

Depends on your comfort and skill level. Definitely would try to look elsewhere first, but if I had no other choices, and my trust in my own ultrasound skills, I would go for it. But, it’s your last option, I would also try to make sure everything is as perfect as possible before proceed; this wouldn’t be fun underneath the drapes. Gone for a brachial vein in a dry patient, so the vein is super collapsible, thats sitting next to the brachial artery with a 14G before.

 

[caligas]

so then what did you do? Place a CVC? EJ? Or find a new target on a limb? Cannulate the penile vein? is it just a vein to go to sleep with or for volume or for vasoactives?



If there is a low risk trajectory to the vessel and an appropriate catheter I don’t see concern if US skills are strong. I don’t think a CVC is exactly lower risk than peripheral nerve injury under US guidance with a clear track to avoid the nerve(s).

Elective outpatient.

Limited supplies.

Did Foot iv (on diabetic)

 

[JiPo]

If you are confident that you will never lose the needle tip during the insertion and won't hit anything other than the vein, why not? Definitely use a long catheter and make sure a good length of the catheter is in the vein when you thread it.

 

[nimbus]

If you are confident that you will never lose the needle tip during the insertion and won't hit anything other than the vein, why not? Definitely use a long catheter and make sure a good length of the catheter is in the vein when you thread it.

I like the Arrow brachial aline kit for brachial vein IVs. Basically a midline. But just found out they cost $90. 😮

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[caligas]

Yeah some sort of micro puncture kit seems smart for these, but I haven’t done that many

 

[Beeftenderloin]

If you are confident that you will never lose the needle tip during the insertion and won't hit anything other than the vein, why not? Definitely use a long catheter and make sure a good length of the catheter is in the vein when you thread it.

This is the way. Get good at US. I frequently go high up on the arm: basilic, caphalic, or brachial for quick reliable large bore access with a long 16g. Everyone’s got a big vein somewhere proximal to the elbow. Sometimes it’s in view of/abutting nerves or arteries. Not the ones to practice on for novices, but if you’re confident in your skills, go for it.

 

[gunnershow]

This is the way. Get good at US. I frequently go high up on the arm: basilic, caphalic, or brachial for quick reliable large bore access with a long 16g. Everyone’s got a big vein somewhere proximal to the elbow. Sometimes it’s in view of/abutting nerves or arteries. Not the ones to practice on for novices, but if you’re confident in your skills, go for it.

The problem isn't placement, it's risk of infiltration into a fixed compartment and compression neuropathy.

 

[medicine2wallstreet]

Large guy, only decent vein was HIGH in arm abutting large nerve which was maybe the axillary nerve vs ulnar with basilic vein.

I decided not to go for it, fear of hitting nerve or infiltration of agents onto nerve etc.

Thoughts?

I don't want to be mean but this sort of behavior I have always found funny. My attendings do it all the time with nerve blocks and Central lines. the patient is about to have surgery the least of their worries and risks of complications is anesthesia putting in IVs or doing nerve blocks or Central lines. I think your decision to put one in would have been perfectly reasonable. It's an IV almost negligible risk unless you put it in the artery and inject phenylephrine directly into that.

I see your rationale there I just see literally zero risk. I think it's acrobatic rationale at best. Like others have said if you don't get that what are you going to do put in a central line? I actually would prefer Central Access for patients over the basilic vein if I'm having to worry about access based on my experience but that's purely so that I don't lose access intraop and cause stress. Not because I'm worried about risk of nerve compromise after infiltration.

 

[medicine2wallstreet]

Elective outpatient.

Limited supplies.

Did Foot iv (on diabetic)

I would not have done foot iv. That is inverting risk benefit versus arm in my opinion.

 

[pgg]

a) have them consult the vascular access service so an RN can come do it
b) if no (a) available, see if there's an easy vein they overlooked and just start the IV they should've started
c) if no (a) or (b), micropuncture kit to whatever fat upper arm vein leaps out on ultrasound

I have zero real worries about one of those long micropuncture catheters infiltrating. They just don't. The tip is so far away from the vein entry point there's no chance of it wiggling free. The wires are very soft.

 

[caligas]

I don't want to be mean but this sort of behavior I have always found funny. My attendings do it all the time with nerve blocks and Central lines. the patient is about to have surgery the least of their worries and risks of complications is anesthesia putting in IVs or doing nerve blocks or Central lines. I think your decision to put one in would have been perfectly reasonable. It's an IV almost negligible risk unless you put it in the artery and inject phenylephrine directly into that.

I see your rationale there I just see literally zero risk. I think it's acrobatic rationale at best. Like others have said if you don't get that what are you going to do put in a central line? I actually would prefer Central Access for patients over the basilic vein if I'm having to worry about access based on my experience but that's purely so that I don't lose access intraop and cause stress. Not because I'm worried about risk of nerve compromise after infiltration.

IDK, only had an angiocath (I think 1.75 in) and this was a fat arm.

 

[caligas]

I would not have done foot iv. That is inverting risk benefit versus arm in my opinion.

Has anyone actually seen a problem from a small foot IV? Maybe it happens, and I do avoid diabetic feet, but not sure if it’s a big risk either.

 

[medicine2wallstreet]

IDK, only had an angiocath (I think 1.75 in) and this was a fat arm.

Yeah if you don't have the catheter length I get it

 

[UscGhost]

Has anyone actually seen a problem from a small foot IV? Maybe it happens, and I do avoid diabetic feet, but not sure if it’s a big risk either.

I don't see it as a particular problem. If the diabetic foot is in very rough vascular shape, then you probably won't find a vein there anyways.

 

[Maz777]

Large guy, only decent vein was HIGH in arm abutting large nerve which was maybe the axillary nerve vs ulnar with basilic vein.

I decided not to go for it, fear of hitting nerve or infiltration of agents onto nerve etc.

Thoughts?

MABC always run parallel to the basilic vein in the upper arm. Just avoid it. You need a pretty long catheter in a big arm otherwise moving the patient will cause your beautifully placed PIV to infiltrate. Should always draw back nicely with aspiration.

The mistake people make is going after one of the brachial veins and piercing the median nerve. Don't do that. Median nerve can always be well visualized running parallel to the brachial artery and vein(s).

If there is nothing in the upper arm (which is extremely rare) and nothing in the foot, do an US-guided GSV PIV.

 

[caligas]

MABC always run parallel to the basilic vein in the upper arm. Just avoid it. You need a pretty long catheter in a big arm otherwise moving the patient will cause your beautifully placed PIV to infiltrate. Should always draw back nicely with aspiration.

The mistake people make is going after one of the brachial veins and piercing the median nerve. Don't do that. Median nerve can always be well visualized running parallel to the brachial artery and vein(s).

If there is nothing in the upper arm (which is extremely rare) and nothing in the foot, do an US-guided GSV PIV.

What do you consider a long catheter, 1.88 inches? (Edited)

Do you mean you don’t use the brachial vein or just be cautious of the nerve?

 

[PpfSuxTube]

This is the way. Get good at US. I frequently go high up on the arm: basilic, caphalic, or brachial for quick reliable large bore access with a long 16g. Everyone’s got a big vein somewhere proximal to the elbow. Sometimes it’s in view of/abutting nerves or arteries. Not the ones to practice on for novices, but if you’re confident in your skills, go for it.

This is the one they do the picc lines on... it's the most reliable but yes does take some practice...

I like it a lot too as it's caliber is sufficient that it's harder to go thru and thru with it... I find once I go through and thru with other arm veins, it blows and I can't recover

 

[nimbus]

Has anyone actually seen a problem from a small foot IV? Maybe it happens, and I do avoid diabetic feet, but not sure if it’s a big risk either.

Unlikely. Especially one placed for an outpatient procedure. It’ll be removed in a few hours tops.

 

[GassYous]

I don't want to be mean but this sort of behavior I have always found funny. My attendings do it all the time with nerve blocks and Central lines. the patient is about to have surgery the least of their worries and risks of complications is anesthesia putting in IVs or doing nerve blocks or Central lines. I think your decision to put one in would have been perfectly reasonable. It's an IV almost negligible risk unless you put it in the artery and inject phenylephrine directly into that.

I see your rationale there I just see literally zero risk. I think it's acrobatic rationale at best. Like others have said if you don't get that what are you going to do put in a central line? I actually would prefer Central Access for patients over the basilic vein if I'm having to worry about access based on my experience but that's purely so that I don't lose access intraop and cause stress. Not because I'm worried about risk of nerve compromise after infiltration.

That's the voice of inexperience speaking. I used to think the same way and I do still think that a lot of it is overblown but once you've seen a patient lose a limb after a line, you will think twice before putting the next one in.

 

[nimbus]

a) have them consult the vascular access service so an RN can come do it
b) if no (a) available, see if there's an easy vein they overlooked and just start the IV they should've started
c) if no (a) or (b), micropuncture kit to whatever fat upper arm vein leaps out on ultrasound

I have zero real worries about one of those long micropuncture catheters infiltrating. They just don't. The tip is so far away from the vein entry point there's no chance of it wiggling free. The wires are very soft.

Issue is finding one at an OPSC. I know we don’t have them at ours.

 

[nimbus]

What do you consider a long catheter, 1.88 cm?

You mean 1.88 inch, correct? I’ve had those infiltrate. Thus I always use the longer 12cm catheters.

 

[medicine2wallstreet]

What do you consider a long catheter, 1.88 cm?

Do you mean you don’t use the brachial vein or just be cautious of the nerve?

Long is 4.5 cm or more.

 

[medicine2wallstreet]

That's the voice of inexperience speaking. I used to think the same way and I do still think that a lot of it is overblown but once you've seen a patient lose a limb after a line, you will think twice before putting the next one in.

It absolutely does happen I agree but what's the alternative? Not closely monitoring blood pressure or not having adequate access? That risk dramatically outweighs the other risks during the course of a career. Of course if you never put in an a line the patient will never lose a limb. But I want to monitor the patient safely if I deem it necessary.

 

[Beeftenderloin]

The problem isn't placement, it's risk of infiltration into a fixed compartment and compression neuropathy.

If you’ve placed 3+ cm of catheter in the vein with ultrasound, infiltration is incredibly unlikely. If you don’t feel you can confidently do that, find another site.

 

[nimbus]

Long is 4.5 cm or more.

I think he meant 1.88 inches which is 4.77cm.

 

[caligas]

I think he meant 1.88 inches which is 4.77cm.

Yes sorry was talking about the common 1.88 inch angiocath.

 

[anesthesiadoc]

I’m probably in the minority here, but I love the AccuVein. (ASC’s don’t often have them, but when they do, it’s pretty neat.).

I very rarely need ultrasound anymore for veins other than CVLs.

I DO use US on nearly every arterial line, as 29 years of guitar callous have (joyfully) ruined my ability to precisely palpate a pulse.

 

[pgg]

I DO use US on nearly every arterial line, as 29 years of guitar callous have (joyfully) ruined my ability to precisely palpate a pulse.

I use ultrasound for 100% of my art lines.

I am often surprised at how often radial arteries are tiny or ridiculously torturous. Or thrombosed.

At least a couple times per month I don't even attempt to stick a bad artery, but immediately go to the other side or a brachial based on what the ultrasound shows.

And if my own healthy, large, straight, non-calcified, easily palpated radial artery was going to be cannulated, I'd want the person driving the needle to use ultrasound.

I think it should be standard of care.

 

[Iso4ane]

And if my own healthy, large, straight, non-calcified, easily pallated radial artery was going to be cannulated, I'd want the person driving the needle to use ultrasound.

Hell, I’ll do it myself if I have to.

 

[Simba1711]

I don’t find the accuvein helpful at all. If I have trouble with Ivs I usually put the esmark bandage on. It really puffs the veins up. If I still can’t find anything I will go to ultrasound. The problem is we don’t have the long catheters so I use the Aline arrow catheters. The wire is nice but They are hard to see on us because of the sheath.

 

[DrN2O]

I use ultrasound for 100% of my art lines.

I am often surprised at how often radial arteries are tiny or ridiculously torturous. Or thrombosed.

At least a couple times per month I don't even attempt to stick a bad artery, but immediately go to the other side or a brachial based on what the ultrasound shows.

And if my own healthy, large, straight, non-calcified, easily palpated radial artery was going to be cannulated, I'd want the person driving the needle to use ultrasound.

I think it should be standard of care.

Should we even teach non-US a-line anymore? Some of my colleague don't think so, but they still insist DL should be taught because it can save lives.

 

[coffeebythelake]

I do 95% of my art lines by palpation. The same argument can be made. What if you don't have an ultrasound machine readily available?

 

[Iso4ane]

Esmar

Should we even teach non-US a-line anymore? Some of my colleague don't think so, but they still insist DL should be taught because it can save lives.

I struggle with this. I fully admit that US may be better in hard patients and that the learning curve for palpation based art-lines can be quite steep, but when everyone wants the US to do an art line, being able to do one with out it becomes very handy.

 

[medicine2wallstreet]

Should we even teach non-US a-line anymore? Some of my colleague don't think so, but they still insist DL should be taught because it can save lives.

God bless the same old argument every time.

I'm 33 years old and you gotta know how to do emergent stuff without ultrasound.

DL is critically important as well.

Get outta here.

 

[pgg]

Should we even teach non-US a-line anymore?

We don't teach non-US internal jugular central lines any more.

I learned to place lines without ultrasound, and to do blocks with nerve stimulator (and the trans-arterial technique for axillary blocks).

I think all blocks and lines should be done with ultrasound. The argument that we should be teaching old, inferior techniques to residents because they may find themselves emergently needing to do something without ultrasound is a poor one. Anyone who's proficient placing a line with ultrasound is going to be able to wing it and get it done without u/s if someone puts a gun to their head in an emergency.

Some of my colleague don't think so, but they still insist DL should be taught because it can save lives.

DL should be taught, and it's a completely different issue than line placement.

I think the arguments that VL should be routine first attempt for all patients are dumb.

A failed DL is not harmful in 99.99% of cases, because you have planned your induction and intubation such that you are confident you can ventilate the patient or secure the airway with plan B, C, D, if method A is unsuccessful. An endotracheal tube placed via DL does not cause injury; neither does a failed attempt with DL cause injury (in competent hands). Intubation is done with the patient asleep, so there's no difference in patient comfort between DL and VL.

Everyone has a trachea. Not everyone has a radial artery suitable for cannulation.

What if you don't have an ultrasound machine readily available?

Honestly, if you're practicing in the United States, this is like asking What if you don't have wall O2 available.

 

[sevo00]

If very small artery on US I go to the micro puncture kit instead of the standard Aline arrow. Def has saved me a lot of times

 

[DrN2O]

God bless the same old argument every time.

I'm 33 years old and you gotta know how to do emergent stuff without ultrasound.

DL is critically important as well.

Get outta here.

I'm on your side. The argument is that if you can't cannulate an a-line (without US) in an emergency is not the same as can't intubate without a VL.

I would teach every resident how to do it with palpation, but most of my colleagues no longer do. So what's the point if those residents not motivated will never get enough practice to become competent.

 

[narcusprince]

We are extremely spoiled at our hospital. We have an IV start team led by interventional rads nurses that gets difficult IVs. They place the mid line or pic or peripheral IV under US. Rarely do we place IVs in preop.

 

[pgg]

I would teach every resident how to do it with palpation, but most of my colleagues no longer do. So what's the point if those residents not motivated will never get enough practice to become competent.

It has been years (6? 7?) since I've put in an a-line without ultrasound. Might even have been prior to my fellowship in 2016-17.

Plenty of emergencies and urgent situations in that time.

If, for some reason, you think art line starting without ultrasound is a skill residents need, have them palpate first and mark the spot they'd stick. Then hand them the ultrasound.

I'm going to bet the lesson they actually learn after doing that exercise a dozen or 20 times is that some radial arteries shouldn't get needled at all, and that the optimal insertion site that's obvious on ultrasound is frequently more proximal or distal to where their fingers were going to lead them to stick. And they'll wonder why you want them to ever do it without ultrasound.

 

[Ronin786]

A failed DL is not harmful in 99.99% of cases, because you have planned your induction and intubation such that you are confident you can ventilate the patient or secure the airway with plan B, C, D, if method A is unsuccessful. An endotracheal tube placed via DL does not cause injury; neither does a failed attempt with DL cause injury (in competent hands). Intubation is done with the patient asleep, so there's no difference in patient comfort between DL and VL.

Everyone has a trachea. Not everyone has a radial artery suitable for cannulation.

99.99% of failed blind arterial lines are not harmful, especially when they're done with the patient asleep.

I just don't see how you can argue ultrasound should be standard of care for arterial lines and at the same time say VL shouldn't be. The complication rate for either one of them is so low that it should be dealer's choice.

CVC went to U/S because it avoids devastating complications like PTX and arterial dilation. The risk just isn't there with arterial lines in an asleep patient. I do all my liver tx arterial lines blind and if I don't get it, I grab the U/S. Nothing bad happens. Same with vasculopaths. We're not shooting the brachial or axillary arteries where you can cause real damage.

 

[T-burglar]

I do 95% of my art lines by palpation. The same argument can be made. What if you don't have an ultrasound machine readily available?

Why are you doing cases that require invasive monitoring in a place that doesn’t have an ultrasound

 

[T-burglar]

99.99% of failed blind arterial lines are not harmful, especially when they're done with the patient asleep.

I just don't see how you can argue ultrasound should be standard of care for arterial lines and at the same time say VL shouldn't be. The complication rate for either one of them is so low that it should be dealer's choice.

CVC went to U/S because it avoids devastating complications like PTX and arterial dilation. The risk just isn't there with arterial lines in an asleep patient. I do all my liver tx arterial lines blind and if I don't get it, I grab the U/S. Nothing bad happens. Same with vasculopaths. We're not shooting the brachial or axillary arteries where you can cause real damage.

Failed arterial lines can be harmful. You should look up the complications if you really think this.

I also cringe when I walk into a room where a colleague has called for “a line help” and there are multiple holes in one or both arms. It makes you look incompetent (because it is incompetent).

Just use the scanner.

 

[pgg]

99.99% of failed blind arterial lines are not harmful, especially when they're done with the patient asleep.

I just don't see how you can argue ultrasound should be standard of care for arterial lines and at the same time say VL shouldn't be. The complication rate for either one of them is so low that it should be dealer's choice.

CVC went to U/S because it avoids devastating complications like PTX and arterial dilation. The risk just isn't there with arterial lines in an asleep patient. I do all my liver tx arterial lines blind and if I don't get it, I grab the U/S. Nothing bad happens. Same with vasculopaths. We're not shooting the brachial or axillary arteries where you can cause real damage.

If it was your radial artery, would you want an extra hole or two in it, or would you rather the anesthesiologist just one-stick it dead center with ultrasound?

I'm not saying people can't be good with blind art lines, but they can't ever be as good as they'd be with ultrasound. This is self evident.

If you're good, why not be better?

 

[anaesthetic]

I use ultrasound for 100% of my art lines.

I am often surprised at how often radial arteries are tiny or ridiculously torturous. Or thrombosed.

At least a couple times per month I don't even attempt to stick a bad artery, but immediately go to the other side or a brachial based on what the ultrasound shows.

And if my own healthy, large, straight, non-calcified, easily palpated radial artery was going to be cannulated, I'd want the person driving the needle to use ultrasound.

I think it should be standard of care.

If it was your radial artery, would you want an extra hole or two in it, or would you rather the anesthesiologist just one-stick it dead center with ultrasound?

I'm not saying people can't be good with blind art lines, but they can't ever be as good as they'd be with ultrasound. This is self evident.

If you're good, why not be better?

I also use US for 99% of art lines. The 1% is for the in-the-room, cut-skin-now traumas that I no longer do. Same with central access. I’ve done landmark-based in truly emergent situations. It’s okay.

I do high volume, high acuity, tertiary cardiovascular/thoracic now. Agree that multiple times a week, an artery will have stenosis, tortuosities, or abnormalities that would make cannulation challenging/impossible without ultrasound.

My favorite image is a big juicy radial artery on ultrasound because it reassures me that I’ll be able to cannulate it 100% of the time without any complications.

 

[medicine2wallstreet]

Failed arterial lines can be harmful. You should look up the complications if you really think this.

I also cringe when I walk into a room where a colleague has called for “a line help” and there are multiple holes in one or both arms. It makes you look incompetent (because it is incompetent).

Just use the scanner.

You sound like an absolute delight to work with. Would never call you for help. I am my own help.

 

[Iso4ane]

If it was your radial artery, would you want an extra hole or two in it, or would you rather the anesthesiologist just one-stick it dead center with ultrasound?

I'm not saying people can't be good with blind art lines, but they can't ever be as good as they'd be with ultrasound. This is self evident.

If you're good, why not be better?

I definitely am better with ultrasound than without, but even without ultrasound, I have higher first stick success compared to some residents using ultrasound, does that mean I should never let them learn or practice arterial lines.

 

[caligas]

I also use US for 99% of art lines. The 1% is for the in-the-room, cut-skin-now traumas that I no longer do. Same with central access. I’ve done landmark-based in truly emergent situations. It’s okay.

I do high volume, high acuity, tertiary cardiovascular/thoracic now. Agree that multiple times a week, an artery will have stenosis, tortuosities, or abnormalities that would make cannulation challenging/impossible without ultrasound.

My favorite image is a big juicy radial artery on ultrasound because it reassures me that I’ll be able to cannulate it 100% of the time without any complications.

For art do you look for flash or do you use the donut/walk the needle technique?