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REBELCast Ep62 – US Guided PIVs with Jacob Avila, MD

Marco Torres |

Welcome back to REBELCast.  In this episode we talked with Jacob Avila about US guided PIVs. Difficult IV access in an already busy department can be a frustrating thing, but it doesn’t have to be.  Patients and providers are often frustrated for different reasons.  Patients for multiple IV attempts and providers because of the time it can take to perform the procedure, delays in care, or lack of success. If you want to get better at this all-important procedure, read/listen on.

REBEL Cast Ep62 – US Guided PIVs with Jacob Avila, MD

  • Why Should we be Thinking About Ultrasound-Guided IVs:
    • This occurs about 1 – 2x/shift for Jacob
    • This procedure can take 5 – 10 minutes
    • CAVEAT: US guided IVs are not for all patients.  Most ED patients do fine with landmark technique.  However, there are patients that need extra help (ie obese, ivdu, sickle cell, etc)
    • We covered this topic in Nov 2015 REBELCast Nov 2015 – All Vascular Access Episode
    • US vs Landmark Technique for Peripheral Intravenous (PIV) Cannulation [1]
      • 2-Group, Parallel, Randomized, Controlled Trial of 1,189 Adult ED Patients from a single center
      • Randomized to Landmark vs Ultrasonography
      • Patients also stratified by difficulty of access: Difficult, Moderately Difficult, and Easy
      • If 1st attempt failed, randomized subjects a 2nd time
      • Time of Procedure: Procedure took almost twice as long with US vs landmark (Range of median difference 79 – 97 seconds longer with US)
      • Clinical Take Home Point: If a patient needs peripheral IV access and has visible and/or palpable veins, stick with the traditional landmark technique of IV access as this is quicker and has a better 1st and 2nd attempt rate vs ultrasound guided techniques. However, if you have a patient that has peripheral veins that are not visible and/or palpable consider jumping to ultrasound guided peripheral IVs.


Jacob’s US Guided PIV Protocol & Checklist

  • Are US Guided PIVs Safe?
    • This procedure is as safe as a non-ultrasound guided PIV
    • Use proper technique (clean, semi-sterile technique); Doesn’t have to be completely sterile technique, but as sterile as possible
      • Tegederm on US probe
      • Surgilube packet, not gel that comes in the bottle
      • Sterile or non-sterile gloves
    • Infection rates among US-guided vs traditionally placed PIVs [2]
      • Retrospective review of 804 patients using non-sterile gloves
      • No difference in risk of infection with ultrasound guidance for PIVs
    • Does using Tegederm on US probe damage the probe?
      • Manufacturers of ultrasounds have stated that tegaderm can destroy probes, but not sure what the evidence for this is
      • Michelle Lin from Academic Life in Emergency Medicine likes to use sterile gloves instead of Tegaderm


  • There is literature saying that US guided IVs infiltrate contrast more. (I don’t think this data is real)
    • Retrospective study of ≈40,000 patients undergoing contrasted CT scan [3]
      • 364 patients with US guided PIV
      • Extravasation rate: 3.6% for US guided PIV vs 0.3% for standard IV
    • In order to clearly state that ultrasound guided PIVs are associated with contrast extravasation with US guided PIVs, need a randomized clinical trial of patients with difficult access
    • Patients getting US guided PIVs are mostly difficult access patients and have bad veins at baseline.  So, its most likely not the ultrasound that causing the extravasation.  No data currently exists on this that randomizes this specific patient population to US guided vs traditional IV access in assessing contrast extravasation
    • Also, standard length vs long length catheters will also make a difference simply based on how much of the catheter is in the vein itself. Standard catheters (1.1 – 1.3”) may simply just not be long enough.
    • So its most likely not the ultrasound that is causing the extravasation, but rather the poor veins themselves
  • How is the Procedure Done?
    • Initial Steps:
      • Put the tourniquet as high as you can go on the arm near the axilla (This makes it so you can look at the forearm veins as well as the upper arm veins without having to readjust the tourniquet)
      • Clean the entire medial, lateral, and anterior arm from beneath the tourniquet down to about the mid forearm
      • Prepare transducer (Jacob uses a sterile tegaderm)
      • Use surgilube packet (NOT bottle gel)
    • Probe Selection
      • Linear transducer

  • Selection of vein
    • Most important factors are size and depth of the vein
    • Size matters – look for the biggest vein in diameter
    • Depth matters – look for the most superficial vein (less distance to traverse); CAVEAT: The ideal distance of the skin to vein is probably closer to at least 0.5cm from the skin surface (so there may be times where a more superficial vein will actually not be the best)
    • In antecubital fossa be careful about differentiating artery from vein; also, be aware of the median nerve
  • Cannulation of Vein
    • Needle/Catheter Choice
      • 1.8” catheter on all US guided PIVs
      • Generally, go for 18g catheter…BUT…The way you choose the size of your catheter is that the diameter of the catheter should be less than half the diameter of the vein you are trying to access (Decreases incidence of phlebitis)
    • Long vs short axis vs oblique
      • Jacob prefers short axis as this is a more reliable technique in his experience

  • Looking at the flash (PRO TIP:  Flash doesn’t matter, what matters is making sure that you find your needle tip)
  • The Technique (Sequential Needle Tip Tracking):
    • US machine does not know the difference between the needle tip and the needle shaft
    • Advance needle until you find the tip of the needle
    • Then Slide your US probe distal from you until needle tip disappears (The movements of your needle and probe have to be very small, 1 – 2 mm movements at most each time)
    • Now advance needle until you find the tip of the needle again
    • Repeat until vein is cannulated
    • This is done sequentially not simultaneously
  • Getting the needle in the vein is <50% of the job.  if you don’t successfully cannulate the vein, you’ve failed.
    • Getting flash in the IV is not successful vein cannulation
    • If you are looking at the IV for flash and not at the US screen, it is very easy to lose where your needle tip is at (Don’t look for flash) …Flash = at one point you touched or were in a vessel; Does not mean you are currently in the right spot
    • Even with flash, you could have completely advanced the needle tip through the backwall of the vein.  And now when you advance the catheter you are advancing into the soft tissue behind the vein and not in the vein itself
  • Pro tips
    • How to make it easier to see the vein
      • Put tourniquet on early and high up on the arm
      • Depth of US probe should be just above the muscles of the arm (muscle has striations and subcutaneous tissue has a lacier, less organized appearance) – Want subcutaneous tissue to be 95% of what you see on the screen.  Having the depth too deep, you decrease the resolution of what you are seeing.
      • Gain (Volume of the ultrasound transducer) – Goldilocks concept…not too dark, not too bright, something in the middle
    • How to poke the skin
      • Use a steep angle to poke through the skin (almost parallel to transducer – ≈90 degrees to arm), once the sharp part of the needle has penetrated the skin, then drop the angle (≈30 degrees to arm) of your needle to continue to advance the catheter
    • Bevel up vs Bevel Down
      • Bevel up – Tip of needle is in the vein, but the entirety of the needle opening is not.  Therefore, catheter may not advance into the vein or if you are in the vein more likely to go through back wall of vein
      • Bevel down – Less likely to go through back wall of vein and issue of flash goes away, because if you have a flash you can almost positively ensure both the tip of the needle and the needle opening are both in the vein, making it easier to advance the catheter
      • CVC study shows bevel down approach decreases IV complication rates (i.e. incidence of posterior venous wall damage, and hematoma formation) [4]

Image From Lim T et al. Crit Care Med 2012. PMID: 21983370


  • Taping
    • Don’t put tape over hub of catheter 1st and then Tegederm on top of that – May not be the cleanest way to secure IV (Roles of clear tape usually in pockets and may increase risk of infection)
    • Connect extension tubing to catheter 1st
    • Put Tegederm on over IV after extension tubing connected (Cover the hub of the catheter)
    • Then, take 2 inches of clear tape and cut in half, lengthwise
    • Take the first piece of tape (sticky side up) and slide underneath connection of extension tubing as close to the connection of the hub of the catheter and extension tubing as possible first. Wrap the other two ends of the tape around the catheter – This anchors the hub of the catheter more firmly to the skin
    • Take second piece of tape and place directly over the connection of the hub of catheter and extension tubing(sticky side down)
    • Finally, use a 3rd piece of tape to anchor the extension tubing to the skin as well (This avoids people touching the hub and potentially increasing infection or pulling the catheter out from the vein)
    • Can also additionally add Coban or stretchy tape to wrap around the arm loosely to ensure IV doesn’t come out

  • Final Thoughts from Jacob
    • This technique is the hardest IV procedure you will do, and thus requires practice.  You may not succeed initially, but as you do this more and more you will get better at it

Special Guest

Jacob Avila, MD
Ultrasound Director, Ultrasound Fellowship Director and Assistant Professor
Department of Emergency Medicine, University of Kentucky, Lexington
Creator of the 5 Minute Sono Podcast/Website
Member of the Ultrasound Podcast and Ultrasound GEL podcast
Twitter: @UtrasoundMD 


  1. The Rebellion in EM Clinical Conference is just around the corner. June 28th– 30th, 2019 in San Antonio, TX…This conference is geared to all heath care providers. We also have some exciting pre-conferences: Beginner and advanced EKG & US workshops, a simulation workshop, and what I am most excited about is a cadaver to come and practice all those rare procedures you never get to do.  Go to www.rebellioninem.com to register today as we are capping the conference at 250 registrations.


  1. The Essentials of Emergency Medicine Conference happening in Las Vegas, NV on May 14th – 16th, 2019. This is an absolutely amazing conference that just does an absolutely amazing job combining entertainment and education.  If you register today and put in the coupon code “rebel” you will be invited to a special REBEL EM social event during the conference. Go to www.essentialsofem.com and register today.


  1. Finally, I would like to thank all the nurses and techs who better themselves by learning to do US guided peripheral IVs and helping provide efficient excellent care to our patients. I especially would like to thank one of my techs, Patrick Soto, who goes above and beyond to help with this difficult patient population.


  1. McCarthy ML et al. Ultrasonography Versus Landmark for Peripheral Intravenous Cannulation: A Randomized Controlled Trial. Ann Emerg Med 2015. [epub ahead of print] PMID: 26475248
  2. Adhhikari S et al. Comparison of Infection Rates Among Ultrasound-Guided Versus Traditionally Placed Peripheral Intravenous Lines. J Ultrasound Med 2010. PMID: 20427786
  3. Rupp JD et al. Extravasation Risk Using Ultrasound Guided Peripheral Intravenous Catheters for Computed Tomography Contrast Administration. Acad Emerg Med 2017. PMID: 27151898
  4. Lim T et al. Effect of the Bevel Direction of Puncture Needle on Success Rate and Complications During Internal Jugular Vein Catheterization. Crit Care Med 2012.PMID: 21983370
  5. Gottlieb, M et al. Ultrasound-Guided Peripheral Intravenous Line Placement: A Narrative Review of Evidence-Based Best Practices. WJEM 2017. PMID: 29085536

For More on This Topic Checkout:

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami)

The post REBELCast Ep62 – US Guided PIVs with Jacob Avila, MD appeared first on REBEL EM - Emergency Medicine Blog.

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