Ultrasound Guided Peripheral Venous Catheter

Ultrasound Guided Peripheral Venous Catheter

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This video demonstrates ultrasound guided peripheral venous catheter insertion. A useful hospital and emergency procedures, ultrasound guided peripheral line insertion is shown step by step.  Clinical pearls and common pitfalls associated with peripheral lines are discussed in detail.  The video is not downloadable but may be accessed indefinitely by internet from any computer, smart phone, or tablet.  Click below to preview the ultrasound guided peripheral IV video.


One of the most common indications for placing a central venous catheter is lack of peripheral IV access. Unfortunately, the mechanical and infectious risks of central lines make them a more dangerous alternative.

While most patients have palpable and visible veins that can be easily cannulated, some patients have especially challenging venous access. Examples include IV drug users, the morbidly obese and frequently hospitalized patients. 

When peripheral access is difficult, the ultrasound can be used to locate nonpalpable veins deeper beneath the surface of the skin. Such veins are typically larger, less mobile and more easily cannulated using ultrasound guidance.

To reach veins that are more than 1 centimeter below the skin surface, it is advisable to use an IV catheter that is longer than the standard angiocath.
In setting up the ultrasound, use a vascular or high frequency probe. On the ultrasound machine select 2D mode or B mode in a vascular or venous ultrasound setting. Set the depth between 1.5 and 3 centimeters.

Positioning is very important when placing a peripheral line under ultrasound guidance. Seat yourself comfortably at the patient's side, the patient's arm should be supinated and abducted, as this is the position that provides the best exposure of the peri-cephalic and solitary basilic veins. These are the vessels most commonly cannulated under ultrasound guidance.

The ultrasound machine should be placed at the head of the patient's bed in such a way that one can easily look back and forth between the patient's arm and the ultrasound machine. The ultrasound probe should be positioned so that the indicator on the probe and the blue dot on the ultrasound screen are facing in the same direction.

In this video both the probe indicator and the blue dot on the screen are to the left. Hold the probe in such a way that the palm can rest gently on the patient's arm, thus stabilizing the probe in position.

When the probe is held out of plane or transverse to the vessels of the medial arm, the brachial artery can be seen running adjacent to the paired cephalic veins. This is sometimes called theMickey Mouse sign with the brachial artery representing Mickey's head and the two cephalic veins representing his ears.

Here a tributary to one of the cephalic veins can be seen to the right of the screen. Verify the identity of the veins and arteries by gently applying pressure with the ultrasound probe. Veins will easily compress. Arteries will not compress and will have exaggerated pulsations with gentle pressure. Not seen in this video, the basilic vein is another excellent target for ultrasound-guided access and runs medial to the brachial complex.

Veins can be cannulated using either a transverse or a longitudinal view. Here the probe has been rotated 90 degrees to transition from a transverse to a longitudinal view.

In this view, one of the two cephalic veins can be seen running superior to the brachial artery. The cephalic vein is now being cannulated using the ultrasound in a longitudinal view. The skin is punctured at the edge of the ultrasound probe at a 45 degree angle to the skin, taking care to keep the needle directly in the center of the probe and to advance in line with and not oblique to the probe.

On the ultrasound screen the needle is seen approaching the cephalic vein from the top left of the screen and then puncturing the vein under full ultrasound visualization.

Once the vein is punctured, blood can be seen in the flash chamber of the IV catheter. The angle of the needle is then decreased so the catheter is more parallel to the vein. The needle is then advanced another one to two centimeters into the vein under direct ultrasound visualization. This prevents the longer catheter from kinking as it is advanced over the needle.

The catheter should then advance easily over the needle and into the vein. If the catheter does not advance smoothly, it usually indicates a kink in the catheter, not that the catheter tube is out of the vein. In this situation it is often possible to float the catheter into the vein by attaching syringe with saline and carefully advancing the catheter while flushing.

Catheter positioned within the vein is confirmed as aspirating blood into the tubing and then flush. After wiping the ultrasound gel from the skin, the IV is secured to the skin in the usual fashion.

Competence in peripheral IV catheter insertion can be attained quickly. The success rate is over 90% and patients express a high degree of satisfaction with the procedure.