Common Pitfalls of Ultrasound-Guided Peripheral IV Placement

Placement of an ultrasound-guided peripheral intravenous line (USPIV) is a common and relatively safe procedure. Don't fall into bad habits that lead to unsuccessful placement. Review the most common (and correctable) pitfalls.

Placement of an ultrasound-guided peripheral intravenous line (USPIV) is a common and relatively safe procedure. It has been successfully mastered by many members of the health care team, including residents, medical students, nurses, and ED technicians.^1–3 In cases of failed access, ultrasound-guided peripheral IV placement is more successful than blind external jugular (EJ) placement and reduces the need for central venous catheters.^4–7 Prior literature suggests that the greatest barrier to implementation of this procedure lies in the initial training period.¹ Despite extensive study on the most effective methods for the procedure, and even the optimal ways to teach the procedure, no literature has addressed the common mistakes made by trainees.^5,8 Interestingly, although most USPIV training programs involve some element of bedside observation by an experienced provider (eg, 5-15 supervised IV insertions), no studies have reported on the feedback given during this period.³ To this end, it is possible that common initial mistakes are being corrected during the observation period and subconsciously refined through further practice.

After several months of informally teaching new residents and medical students this procedure, an indisputable theme emerged: Nearly all of my learners' unsuccessful attempts were caused by one of only a few common mistakes. From this emerged the checklist of "Common Pitfalls" of ultrasound-guided IV placement.

The 5 Most Common (and correctable) Pitfalls of Ultrasound-Guided IV Placement

1. Failure of positioning

• Mistake: The ultrasound screen is positioned in such a way that the provider has to turn significantly to see the screen, or has to lean over such that they are looking up at the screen, resulting in challenging ergonomics.
• Fix: Elevate the bed to the proper height with the patient’s arm extended outwards onto a table, with the ultrasound screen positioned over the patient’s shoulder in line with the arm. The provider, the patient’s arm, and the ultrasound screen should form one straight axis.

Pitfall #1 is the easiest to correct. It involves no physical skills, and depends only on the provider to fight the natural urge to skip basic steps. In the scenario of a right-handed provider inserting a right arm IV, a novice trainee will frequently position the ultrasound screen over their left shoulder requiring them to rotate more than 90 degrees. A moment of preparation will likely save time in the end.

2. Failure to identify vein location and course 

• Mistake: The provider correctly identifies a vein, but lacks the 3-dimensional knowledge of where it is and its path relative to the ultrasound probe and probe marker. After skin puncture, they realize their needle tip is not close to the target.
• Fix: Turn on the ultrasound reference lines to indicate the midline of the probe and deliberately note the vessel depth. With 30 seconds of scanning, a vein can be easily mapped in three-dimensional space.

Pitfall #2 is likely to be overcome naturally with experience using ultrasound. Mapping a vein in three-dimensional space requires both visuospatial skills and hand dexterity. This is further complicated by the fact that trainees will frequently map out a vein with their dominant hand, and then realize (only when they finally reach for the needle) that they need to switch hands. Encourage trainees to do all superficial ultrasound with their non-dominant hand so that they are accustomed to manipulating the linear array probe. Ultrasound ambidexterity will confer benefit for other procedures (e.g. central venous line placement, arthrocentesis, etc). Novices are unlikely to cannulate the vein at their exact location of choice, so taking a minute to map out a longer "runway" can maximize success. 

3. Last-minute adjustments in position

• Mistake: The provider holds the needle above the skin. When looking up at the screen at the time of skin puncture, they make a minor unintentional movement just prior to insertion. As a result, the needle (and its subsequent course) is considerably off-target.
• Fix: Rest the needle on the skin, ensuring the midline markers line up with vessel.

Pitfall #3 is subtle, but common and easily correctable. A good teaching analogy: the unanchored needle is like a javelin – it is likely to veer off course! Remind the trainee that simply resting the needle on the skin in the correct position will not hurt the patient.

4. Failure to advance to adequate depth

• Mistake: The initial puncture is too superficial. If the first movement ends at only superficial depth, the needle must then traverse a significant vertical distance during which time there is a high risk of losing the tip. Furthermore, this gentle and prolonged dissection of tissue is painful (and stressful)!
• Fix: Deliberately insert and advance the needle to 80% of the vessel depth.

Pitfall #4 is the most common. Trainees will cite procedural timidness, fear of hurting the patient, or prior experience placing standard peripheral IVs which require only superficial skin puncture. Frequently, the tip will become lost and subsequent attempts to locate the tip are either unsuccessful or unsalvageable due to hematoma formation. Although a sense of depth will come naturally over time, it is greatly accelerated by explicit mindfulness of the target depth. Consider practicing by inserting an angiocath into gauze at specific depths.

5. Looking for a flash

• Mistake: The innate – seemingly unavoidable - tendency is to look down at the hub to check for a flash. Looking away from the screen causes subtle movements of one or both hands, leading to loss of the needle tip and inadvertent advancement of the catheter.
• Fix: Do not look away from screen until the catheter has been fully advanced inside the vessel and you are ready to put down the ultrasound probe. Identifying a flash is not part of successful USPIV placement.

Pitfall #5 is an exercise in fighting instinct. The urge to look for a flash is nearly universal, likely because of experience with placing standard peripheral IVs. In the event that a flash is identified, the celebratory moment ends when attention is redirected to the screen and the target sign has vanished due to a subtle inadvertent movement of the probe. If no flash was present, the needle tip is usually buried in the vessel wall creating a hematoma. Instead, encourage learners to pursue "ultrasonic flash" (the target sign) and then continue with advancement without taking their attention from the screen until the catheter has been fully advanced. Even when reminded mid-procedure to never look down, trainees find it nearly irresistible. Continual reminders are needed to overcome this temptation.

Conclusions
For this limited educational undertaking, we identified a list of the most common pitfalls demonstrated by novices learning ultrasound-guided peripheral IV placement. Although there are numerous unique steps in the procedure, failure seemed to stem almost universally from a small set of common mistakes. Following this educational intervention to target these errors, the majority of trainees reported significant improvement in mastery through awareness, and the greatest benefit was made through discussion of pitfalls 4 and 5.

By making trainees overtly mindful of the most common mistakes, perhaps we can accelerate the process of gaining mastery for this procedure. Future research will be aimed at implementing a formal training curriculum for EM Interns with a quantitative analysis of skill acquisition in this procedure.

Take-Home Points

• Take time to position the patient, the ultrasound, and yourself. Map out the target vein and ensure your needle is properly lined up.
• When it’s time to puncture the skin, don’t be timid! Make a sufficient first puncture, and stay focused on the screen.

References

1. Ault MJ, Tanabe R, Rosen BT. Peripheral intravenous access using ultrasound guidance: Defining the learning curve. JAVA - J Assoc Vasc Access. 2015;20(1):32-36. doi:10.1016/j.java.2014.10.012
2. Bauman M, Braude D, Crandall C. Ultrasound-guidance vs. standard technique in difficult vascular access patients by ED technicians. Am J Emerg Med. 2009;27(2):135-140. doi:10.1016/j.ajem.2008.02.005
3. Duran-Gehring P, Bryant L, Reynolds JA, Aldridge P, Kalynych CJ, Guirgis FW. Ultrasound-guided peripheral intravenous catheter training results in physician-level success for emergency department technicians. J Ultrasound Med. 2016;35(11):2343-2352. doi:10.7863/ultra.15.11059
4. Costantino TG, Kirtz JF, Satz WA. Ultrasound-guided peripheral venous access vs. the external jugular vein as the initial approach to the patient with difficult vascular access. J Emerg Med. 2010;39(4):462-467. doi:10.1016/j.jemermed.2009.02.004
5. Au AK, Rotte MJ, Grzybowski RJ, Ku BS, Fields JM. Decrease in central venous catheter placement due to use of ultrasound guidance for peripheral intravenous catheters. Am J Emerg Med. 2012;30(9):1950-1954. doi:10.1016/j.ajem.2012.04.016
6. Bahl A, Pandurangadu AV, Tucker J, Bagan M. A randomized controlled trial assessing the use of ultrasound for nurse-performed IV placement in difficult access ED patients. Am J Emerg Med. 2016;34(10):1950-1954. doi:10.1016/j.ajem.2016.06.098
7. Dargin JM, Rebholz CM, Lowenstein RA, Mitchell PM, Feldman JA. Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access. Am J Emerg Med. 2010;28(1):1-7. doi:10.1016/j.ajem.2008.09.001

8.         Jung CF, Breaud AH, Sheng AY, et al. Delphi method validation of a procedural performance checklist for insertion of an ultrasound-guided peripheral intravenous catheter. Am J Emerg Med. 2016;34(11):2227-2230. doi:10.1016/j.ajem.2016.08.006