Ultrasound guided peripheral intravenous cannulation

Ultrasound (US) guided peripheral intravenous cannulation (IVC) is the placement of a cannula into a peripherally located vein under the direct vision of ultrasound. This process allows the cannulation of veins that are unable to be visualised or palpated without ultrasound. In trained individuals this method of cannulation results in higher first-pass and overall success rates with fewer complications 1,2

For cannulation in general: 

  • repeated blood sampling
  • IV administration of fluids, contrast, medications, chemotherapy, nutritional support, blood or blood products

For ultrasound guided cannulation specifically:

  • unable to visualise or palpate veins due to
    • body habitus
    • oedematous skin
  • multiple unsuccessful blind insertion attempts
  • severe dehydration
  • multiple previous cannulations (e.g. intravenous drug use, chemotherapy)

No absolute contraindications but avoid IVC if:

  • previous lymphoedema / lymph node dissection of that limb
  • local burns
  • local injury
  • local infection
Preprocedural evaluation
  • review indications for peripheral cannulation
    • assists with decision of what gauge cannula to use
  • review relevant past medial history
Positioning/room set up

Patient

  • comfortably lying or sitting
  • arm well supported; arm board (if available) with limb in abducted, externally rotated position 
  • adequate exposure for clean field

Operator

  • ergonomically positioned: sitting or standing
  • align ultrasound monitor, patient and patient's peripheral access point within the operator's line of sight
  • equipment close, reachable and in order to be used
Equipment
  • ultrasound machine
    • linear transducer (7.5-10 MHz): superficial structures
    • curvilinear transducer (2-5 MHz): deeper structures
  • probe cover
  • sterile gel
  • tourniquet
  • gloves
  • cannula bung
  • syringe of normal saline (flush)
  • skin preparation - alcohol / antiseptic wipes
  • cannula
    • check required flow rate to determine gauge required
    • standard vs longer cannula dependant on depth of vein being accessed
  • adhesive transparent dressing (e.g. tegaderm)
  • +/- blood vials for pathology (as required)
Technique
Initial scout 

Using the ultrasound survey potential vessels for cannulation.

  • start in the antecubital fossa with transverse probe
  • confirm identified vessel is venous
    • patent peripheral veins easily and completely collapse with gentle probe compression
    • non-pulsatile
    • colour doppler can be used if available
  • appropriate vein: large diameter, achievable depth, straight path of vein
Preparation
  • clean probe after initial scout
  • place a cover directly on the clean probe
  • apply a tourniquet to the upper aspect of the patients arm
  • sterilise area of previously identified venous target
Needle Insertion
  • gloves donned
  • US probe held in non-dominant hand with stable grip
    • apply sterile gel
    • check probe orientation
      • touch one end of probe and watch for reaction on monitor
      • align for use on patient so that medial is medial and lateral is lateral. 
  • relocate venous target
    • probe approach
      • transverse
        • advantages: improved ability to centre needle to midline of vessel
        • disadvantages: loss of direct needle tip visualisation each time the probe or needle are moved
      • longitudinal
        • advantages: entire needle visualised throughout procedure with better perception of depth within the vessel
        • disadvantages: inability to identify if needle is off the midline of the vessel
    • optional confirmation of position prior to insertion of needle by placing needle between transducer and skin to illicit shadow artifact
    • note depth of vessel to approximate final insertion depth
  • insert needle through skin at a 45 degree approach angle
    • concentrate on monitor after initial insertion
    • find needle tip through fanning or small movements of ultrasound prior to further movement
  • progressive targeted movement of needle towards vessel
    • 1mm movements at a time directed towards vessel
    • process of moving ultrasound probe forward off the needle tip, stabilising and then moving the needle further forward into the ultrasound's view
Confirmation of cannulation
  • visualisation of cannula and needle within the lumen of the vessel
    • on transverse orientation: bull's eye sign
    • on longitudinal orientation: needle seen entering and lying within lumen 
  • flashback of blood through cannula

Ultrasound probe can be put down at this point so that both hands can be used to advance the catheter, remove the needle, attach the bung, flush the cannula, clean the surrounding skin and secure in place with a transparent dressing. 

Complications

In comparison to blinded techniques, complications associated with peripheral IVC insertion under ultrasound guidance are typically minor but include:

  • nerve injury: median or median cutaneous nerve
  • arterial cannulation: highlights importance of confirming venous characteristics on ultrasound prior to cannulation. 
Share article

Article Information

rID: 47036
Tags: refs, cases
Synonyms or Alternate Spellings:

Support Radiopaedia and see fewer ads

Updating… Please wait.
Loadinganimation

Alert accept

Error Unable to process the form. Check for errors and try again.

Alert accept Thank you for updating your details.