ULTRASOUND-GUIDED INTRAVENOUS CATHETER PLACEMENT 101 FOR RESIDENTS
Danielle Brining, MD
Published Jan. 13, 2022
Ultrasound-Guided Intravenous Catheter (USGIV) placement is a great skill for residents to know and utilize, especially for patients with difficult access and during resuscitation. Common reasons for difficult intravenous access include shock, dehydration, frequent access and hospitalizations, chemotherapy, intravenous drug abuse, sickle cell anemia, hemodialysis use, congenital anomalies and contracture, extremity edema, and obesity.1 Ultrasound has been shown to reduce complications and attempts as well as increase the rate of success.2
There are 2 approaches for USGIV access: longitudinal (long) and sagittal (short) axis. But before you start, it’s important to shape your environment for success.
Ultrasound machine (Plug it in and keep it clean! You do not want it turning off during a procedure)
Linear (high frequency) probe (provides the best resolution up to 4cm and can be used for Doppler assessment)3
Alcohol swab or Chloraprep
Needles: sizes as needed, usually 20G long (4.5cm) and standard-length (2.5cm) IV catheters
Clean cover (ex. Tegaderm or nitrile gloves with rubber band)4
Sterile ultrasound gel
Tegaderm and tape for securing
IV tubing, vacutainer, flush, and blood tubes as needed
Position is key: Properly position the patient and get yourself comfortable and ready for the procedure. Raise the bed to an optimal height to keep your back in check.
Place the ultrasound (US) on the opposite side of the patient facing you so you can look straight ahead and do not have to turn your head when placing the IV.
The probe should be positioned with the indicator marker towards the right side of the patient and corresponding to the circular marker on the left side of the screen.
Use a table to your advantage: Place a chuck on the table to help maintain cleanliness and prepare all your equipment and setup. Abduct and externally rotate the patient’s arm on the table perpendicular to his/her body. Externally rotating the arm will help expose your vessels such as the brachial and basilic veins. The best access tends to be on the medial side of the upper arm so having access to it is critical.
Place the tourniquet on the patient’s arm as high/proximal as possible to maximize your space.
Your non-dominant hand will be used to hold the probe, while your dominant hand will navigate the needle. Anchoring your probe hand on the patient’s arm will help keep it steady as you insert the needle.
Check both arms to find your best option. Start at the antecubital fossa and move proximally.
Confirm the vessel is a vein by compressing. The vein will fully compress while the artery will not. The artery will pulsate. If you use color-flow Doppler, both vessels may appear pulsatile but the artery will pulsate more consistently (red artery and blue vein in video below). Here you can see a vein on either side of the brachial artery – see how the vein compresses.
The ideal vein is 0.4 cm or greater in diameter, and 0.3 to 1.5 cm deep. (Though the 20G needle has an external diameter of only 0.11 cm so it can go in smaller veins if needed).7
Once you find a suitable vein, sweep your ultrasound along to ensure it remains straight and there is adequate space. Rotate the ultrasound in the long axis to see in which direction the vein goes and to assess for valves.
The most common veins for US-guided access are the brachial, basilic, median cubital, and cephalic veins. If your options are limited, you can look distally, using a standard, shorter 20-gauge needle.
Basic Steps for Both Long and Short Axis Method
Anchor your hand with the probe on the patient’s arm for stability while maintaining a view of the target vein in the centre of the screen. Turn on the middle line marker on the probe or utilize the M-mode function to help centre your vessel.
Consider your insertion site and your insertion angle: Insert the needle tip beginning 0.5 to 1cm from the probe interface. The deeper the vein, the sharper the angle needed to reach the vein. My favorite approach is always to enter at a 45-degree angle. This way you can find the exact point you want to enter the vessel, then use simple geometry to find the best place to puncture the skin by the Pythagorean theorem.
For instance, if the vein is 1cm deep and you insert 1cm distal from the vein, you will use 1.4cm of the needle reaching the vein. Thus, you should have at least a 2.5cm long catheter in order to have >30% of the catheter in the vessel to decrease the chances of IV failure.8
Ideally >65% of the catheter should be in the vessel, which would require a catheter longer than 2.5cm for a vessel 1cm deep.9 It is imperative with this method though that you flatten the angle to 30 degrees or less as soon as you reach the vessel wall, otherwise you may go through the back-wall posteriorly.
This method is the same as performing a central line and it is more commonly used.
The probe indicator will be pointing to the patient’s right and the vessel will look like a circle.
Find the needle insertion site and angle as above.
Anchor your hand, keep the ultrasound probe perpendicular to the needle, and place the probe just proximal to the insertion site so the needle tip will come into view as soon as it punctures the skin.
As you insert the needle through the skin, you will see the skin tent and then the tip appear in the middle (ideally) of your screen above the vein just below the skin.
If the needle is not in the middle of your screen directly over the vein, come out and redirect.
Once the needle tip is in view, you will be advancing the needle with slow, fine movements. Slide or fan the probe proximally along the vein slowly away from you until the needle tip disappears, while maintaining the probe at the same angle perpendicular to the needle. Advance the needle carefully while moving the probe and following the hyperechoic needle tip, which should remain in the middle. Repeat these tiny movements until you reach the vessel wall. At the wall, drop your angle to approximately 30 degrees to avoid going all the way through (backwalling). Repeat the same steps above leading the needle tip into the vessel lumen. You should feel a “pop” and visualize a flash of blood in the angiocatheter. Advance the needle tip slightly further, as to ensure it is adequately cannulated in the vessel, and it should appear in the centre of the vein like a target or bull’s-eye sign due to ring-down artifact.9
Target / bull’s-eye sign from needle to needle:
- Once the needle is in the centre of the vein, flatten the angle and advance the catheter to the hub, which should be a smooth process if you are in the correct position (the probe can be placed aside if you require 2 hands for securing).
Method 2: Long (Sagittal) Axis Approach:
While it is a little more difficult to master at first as it is necessary to hold the probe still and on the correct vessel, it has a lower risk of penetrating the back wall and it is very satisfying because you visualize the entirety of the needle insertion.
- Identify your target vessel in the short axis so you can confirm your neighbouring structures (and avoid arteries and nerves!), then rotate the probe steadily until you see the entire length of the vein. .
Anchor your hand with the ultrasound probe parallel to the needle directly over the vessel, with the probe marker directed distally facing the operator.
Insert the needle through the skin starting 0.5-1cm from the probe, fan slowly with small movements and ensure it remains in-line and directly under the probe, otherwise it will not appear on the screen.. The hardest part with the in-line approach is holding the probe steady as the needle is advanced.
Once the needle appears where the screen marker is located, advance in small increments as the hyperechoic needle makes its trajectory into the vein. In this view, you will see the entirety of the needle enter the vessel.
Long axis view of catheter in place:
Summary of methods:
If you watched the needle enter the vein, obtained proper drawback of blood and flushed the line without resistance, infiltration, or pain, you are successful! However, if you would like to confirm with absolute certainty, you can utilize these methods.
Place the ultrasound along the vein in either axis and compress the vein and the catheter can be seen within the vein.
Catheter in vein:
- Place the ultrasound along the vein in the longitudinal axis, or in the short axis just proximal to the end of the catheter. Flush the catheter with agitated normal saline and you will see a whirlpool in the vein or the “vanishing target sign”.9
Whirlpool as flush IV:
Pearls and Pitfalls
First, become comfortable with non-ultrasound guided IV placement.
Practice on patients with excellent veins and anatomy, This will help you understand the mechanics and 2D visualization with 3D applications.
Make sure the bevel of the needle tip is up to help see it.
Visualize your path before starting. Do the math!
If you can’t see the needle tip in the short axis, make sure the probe is positioned perpendicular to the needle. If you’re inserting the needle at a steep angle, tilting the probe slightly away from you will maintain that 90-degree angle with the needle.
USG IVs have a high rate of failure when only a small portion of the catheter is actually in the vein. Aim for at least ideally >65% of the catheter to reside in the vein.
If you are concerned about extravasation, you can confirm placement with the “whirlpool,” “vanishing target sign,” or compression techniques described above. You can also look for extravasated fluid that appears like edema and infiltration in the soft tissue by US.
In cases of difficult access, there can be a consideration for double tourniquet use, compared to the standard single tourniquet application. Though there is no significant difference between the two techniques for first-pass success, even when adjusted for operator training level and a major limitation includes the variation in the depth and location of the target vessel, it can still be beneficial to attempt when encountering those with difficult anatomy and access in the emergency department.10
 Rodríguez-Calero, M., Blanco-Mavillard, I., Morales-Asencio, J., Fernández-Fernández, I., Castro-Sánchez, E., & Ernest de Pedro-Gómez, J. (2020). Defining risk factors associated with difficult peripheral venous Cannulation: A systematic review and meta-analysis. Heart & Lung, 49(3), 273-286. https://doi.org/10.1016/j.hrtlng.2020.01.009.
 Franco-Sadud, R., Schnobrich, D., Mathews, B. K., Candotti, C., Abdel-Ghani, S., Perez, M. G., Rodgers, S. C., Mader, M. J., Haro, E. K., Dancel, R., Cho, J., Grikis, L., Lucas, B. P., SHM Point-of-care Ultrasound Task Force, & Soni, N. J. (2019). Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine. Journal of hospital medicine, 14, E1–E22. Advance online publication. https://doi.org/10.12788/jhm.3287
 Bukhari, A., Kitaba, A., & Koudera, S. (2010). Postgraduate educational pictorial review: Ultrasound-guided vascular access. Anesthesia, essays and researches, 4(2), 57–63. https://doi.org/10.4103/0259-1162.73507
 American Institute of Ultrasound in Medicine. (2021). Guidelines for Cleaning and Preparing External- and Internal-Use Ultrasound Transducers and Equipment Between Patients as well as Safe Handling and Use of Ultrasound Coupling Gel. https://www.aium.org/officialstatements/57
 Macias, M. (2014, December 22). Ultrasound Leadership Academy: Peripheral IV Placement. EM Curious. http://www.emcurious.com/blog-1/2014/12/14/ultrasound-leadership-academy-peripheral-iv-placement
 Ultrasound Guided Peripheral IV Insertion. Ultrasound Guided Peripheral IV Insertion: IvyLeagueNurse Unlimited Nurse CEUs. (n.d.). https://www.ivyleaguenurse.com/courses/ultrasound-guided-peripheral-iv-insertion/
 Witting, M., Schenkel, S., Lawner, B., & Euerle, B. (2009). Effects of Vein Width and Depth on Ultrasound-guided Peripheral IV Success Rates. The Journal of emergency medicine, 39, 70-5. https://doi.org/10.1016/j.jemermed.2009.01.003
 Pandurangadu, A.V., Tucker, J., Brackney, A.R., et al. (2018). Ultrasound-guided intravenous catheter survival impacted by amount of catheter residing in the vein. Emergency Medicine Journal, 35, 550-555.
 American Institute of Ultrasound in Medicine. (2012). AIUM Practice Guidelines – Use of Ultrasound to Guide Vascular Access Procedures. https://www.aana.com/docs/default-source/practice-aana-com-web-documents-(all)/use-of-ultrasound-to-guide-vascular-access-procedures.pdf
 Price, J., Xiao, J., Tausch, K., Hang, B., Bahl, A. (2019). Single versus double tourniquet technique for ultrasound-guided venous catheter placement. West J Emerg Med. 20(5), 719-725. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6754199/pdf/wjem-20-719.pdf