Title: RE: Ultrasound for difficult PIV placement
I am not questioning your success rates for getting a PIV inserted. I am questioning the repeated use of US on peripheral veins if the patients therapy will last longer than a week. That is an indication for a PICC or some other CVC, not repeated PIVs, regardless of your success rate with US. My other question is the dwell time of catheter started using US. No one has reported catheter outcomes. What happened with that site? What was the rate of phlebitis, infiltration, etc? Was it higher than without using US due to the fact that US requires a dramatic change in venipuncture and cannulation technique? These questions should be addressed before US is adapted as a wholesale method for starting PIVs. Lynn

At 8:36 AM -0500 11/2/05, Brian Gackenbach wrote:
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Just wanted to throw my 10 cents in here (2 cents for every year I've been using U/S on a daily basis to place regular PIV's as many as 15 or more times a day).  Coming strictly from my personal experience, experience again that includes THOUSANDS of PIV starts using U/S, I can say it is a WONDERFUL option.  Just becouse your using U/S to place a PIV doesn't mean your cannulating vessels that are 4 cm deep.  I can honestly say that 90+ percent of the veins I cannulate in this manner are .5 - 1.0 cms and equally as many times is the cephalic vein of the forearm.  I next to never attempt deeper veins except in extenuating circumstances.  The other 10 percent of the time, if they're deeper...they're in the 1.0 - 2.0 cm...generally much closer to 1.0 than 2.0 still even.  Our machines (Site Rite 2 and Sonosite iLook) are depth marked and we nearly always keep them set at they're most shallow setting...approx 2.5 cm. I cant tell you the last time I had to change this to go deeper and if I did...it wasn't for a PIV, but for a PICC.
I would encourage others to explore this more.  As above...I rarely leave the forearm and when I do...I nearly always am successful in finding a satisfactory Cephalic vein in the upper arm.  These are in the same pt's who the nurses call us on and say..."he/she has been stuck 6 times by night shift and we've tried 4 times ourselves...we dont see anything to try, can you please come help us?".  Most often, these patients that the floor nurses call us on and say.."Oh, they're horrible sticks...they have NO veins at all".  With U/S I find excellant PIV options.   I believe this helps with improved patient outcomes as well.  Historically...someone like this, who may have only been expected to have a few day hospitilazation, might have ended up with a PICC or other CVC if PIV access wasn't establishable.  We find with our experience in using the U/S, we can still provide the most "Appropriate" access for the anticipated therapy...often times saving "unnecesarry" PICC and CVC insertions in these patients, not to mention dozens of sticks by the floor nurses.  We've gone as far as to having implemented a program that includes purchasing 3 U/S to be stationed throughout the house on various floors and training a select handful of nurses in these areas to become proficient in using them for PIV access.  Its been a SLOOW process to date and in my estimation, only a few of the dozen or so nurses that we've trained on them have actually yet become proficient in their use, but...like anything else...it just takes practice.  We certainly dont teach them to stick deep veins.  We teach them to locate the standard veins (Cephalic, medial veins) using U/S and then how to cannulate them.  We expect it will take some time to get a pool of nurses comfortable and confident in their use, but feel it is worth the effort and expenditure...ultimately, again...improving patient outcomes and experiences.  How many times have you heard from a patient that they were stuck 6 -12 times (possibly exaggerating...) and dont think they can take it anymore?  I walk in then and in one stick knock out a PIV and nearly always...the patient has excellant PIV sites...they're just either a bit over weight and you cant see/palpate them.
With practice...U/S can be used VERY successfully to place PIV's.  I can say this without any uncertainty.  Not bragging, but just to illustrate...it isn't at all unusual for me to go 2 or 3 months before I encounter a patient that I have to stick more than once to place a PIV in.  What do  you think that means to your patients?  Your patients that have been stuck all those many times, and in walks in the IV nurse and with his U/S quickly and effortlessly bangs out the PIV.  I get told on a daily basis, "Oh god...where were  you <insert time frame> they stuck me <insert #> times!"  Or this one "Oh wow...I cant believe you got it so easily...they always have to stick me <insert #> times...from now on...I'm only letting you stick me...whats your name again?".  I have even had more than one patient tell me that they come to my facility ONLY becouse we use U/S to get his/her IV and can get it nearly always on one stick whereas had he/she gone to another local hospital...he/she would have been poked <insert # > of time or had to have a CVC placed.  Get this last one MOST often from our frequent flyers such as our Sickle Cell patients...etc.
Well...I could go on and on speaking about my personal experiences with this practice...but I'll spare you banter.  This is just something near and dear to me as I use it daily and KNOW it works.  I'm a quiet lurker here on the list serve generally...I'll now go back to my corner and keep quiet  :)
Brian Gackenbach RN, CRNI
IV Nurse Specialist
U of L Hospital
Louisville, KY 40202
(502) 562-3530  off.
(502) 562-3836  fax.
(502) 336-8816  pgr.

>>> "Kokotis, Kathy" <[EMAIL PROTECTED]> 11/01/05 9:08 AM >>>
Let us all reflect on this:

It is good
Yes if it is an emergency and the patient needs ER meds and a central line cannot be started as these patients are obviously without veins.  It can save a life which is important no matter how one looks at the one time thrombosed vein.  However it is a one time shot!  One time stick!  And then the patient gets a central line as needed as they are out of veins.

Is it bad:
If we are looking at this as Cindy points out very well as a substitute for central lines.  Wrong.  The ability to go deeper and access deeper peripheral veins until we run a patient out of almost all their arm circulation is not smart.  Up to this point with palpation and visual inspection we could only do superficial veins.  Going down 4 cm is not superficial veins anymore.   Remember the irritant and vesicant nature of infusates has not changed even if you go deeper.  The vein size is smaller as they are peripheral veins of the lower arms.

Thrombosing deeper veins as Cindy puts is leads to the question of good practice and lacks judgement in patient safety.  If the patient is a difficult stick and has poor veins it is not rocket science.  Put in a central line if that one accessed ultrasound PIV fails. We do not want to thromobse deeper veins.  Of course not radiology can stent the peripehal veins of the arms and hands as we do the damage.  Just a little joke.



From: [EMAIL PROTECTED] on behalf of Cindy Schrum CRNI
Sent: Tue 11/1/2005 6:13 AM
Subject: RE: Ultrasound for difficult PIV placement

I have a study (the only one I could find on PIV with U/S) which was done in an ER.  They can get the IV's in, but my concern has been who's taking data after they leave the ER?  I've been tracking our IV's with U/S for the past 6 weeks.  I'm not certain it's the best practice to be used routinely.  We've had 2 thrombus out of probably (don't have it with me) IV starts.  A longer, larger angiocath is used to access a vein deeper than you can see or feel.  I'm still not convinced this is a good method.
Cindy Schrum RN CRNI
IVTeam Coordinator
Gaston Memorial Hospital
Gastonia, North Carolina
(704) 834-2707
>>> "Andrea B. Cree" <[EMAIL PROTECTED]> 11/01/05 7:36 AM >>>
Check out the article in October AJN
Addresses PIV in ER.

Andrea Cree, RN, OCN, CRNI
Shore Health System

-----Original Message-----
From: Lori Kelly [mailto:[EMAIL PROTECTED]
Sent: Monday, October 31, 2005 9:01 PM
Subject: Ultrasound for difficult PIV placement

Group question:
Do you have a policy in your facility for ultrasound for PIV placement?
Do nurses other than PICC team use ultrasound for difficult PIV's?

thanks in advance,
Lori Kelly, RN

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