Peripheral

Consider the following:

Preparation

For preparation:

• Sterile setting
• Long cannula over needle, or appropriate Seldinger cannula
• Sterile sheath for ultrasound probe
• Standard gel within the sheath and sterile gel outside can use catheterization lignocaine
• Use a high-frequency linear transducer. Set appropriate depth, gain and focus
• Reduce to most shallow depth possible

Positioning

Positioning is key for peripheral access and taking the extra time to appropriately position the patient and the US machine in your line of sight is well worth it. The basilic vein in the medial upper arm is usually patent and relatively large in most patients. Care should be taken to avoid injury to the ulnar nerve which travels in close proximity and usually easily visible. Many patients (particularly with larger body habitus) may also have good veins in the antecubital fossa or forearm that are simply difficult to visualise with the naked eye or palpate.

For basilic vein cannulation in the medial upper arm, positioning the patient supine with arm abducted and externally rotated optimises access. Placing the machine on the opposite side of the patient in your line of vision and sitting down (or raising bed height) optimises ergonomics.

Procedure

Image 1

Image 2

Image 3

Click the images to see larger versions

The procedural technique for peripheral is as follows:

1. Use normal gel inside and sterile gel outside
2. Secure with a sterile band
3. In cross section, find the basilic vein (in the recess medial to the biceps muscle) (image 1)
4. Rotate the probe to see the vein in longitudinal section (image 2). Check it is still compressible
5. Use a local anaesthetic (if time allows, particularly for larger bore cannulas)
6. Introduce the needle through the skin bevel upwards in short or long-axis depending on preference/skill.
7. If using short-axis technique, ensure sequential needle-tip tracking by advancing needle and probe in sequence to chase the needle tip and see it enter the vein.
8. When blood/flashback is obtained, do not immediately thread the cannula over. Flatten the needle angle slightly and advance the cannula a bit further to ensure the entire bevel is within the lumen. Better yet, rotate the probe into long axis whilst keeping the needle steady to visualise/guide the needle in the lumen and thread the catheter into the vein under direct vision (two-axis technique). If using a long line, midline or PICC line with a Seldinger technique, feed in the wire (should pass without resistance) and similar to a central line, confirm wire position in the vein in long axis.
9. Observe progress on the screen (image 3)
10. Check the wire remains in the lumen
11. Beware of acoustic shadow
12. If Seldinger, feed the cannula over the wire
13. Secure the line