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Lynn,
Ok...I'll see what I can do about putting such a trial together.
Superficial vs Deep: 90% + of the veins I use are .5 cm to 1.0 cm's. I next to never stick peripheral veins deeper than 2 cm's. Only in emergent situations. I'm talking your typical Cephalic vein of the forearm and upper arm 95% of the time. The other 5% its' a medial vein or basilic vein of the forearm. These I believe are classified as Peripheral veins not deep veins, correct? I mean...if you have a heavy set, obese patient and their Cephalic vein is 2.0 cm's down instead of laying right there on the surface easy to see...doesn't change the classification from peripheral vein to deep vein does it? Not being a smart *ss asking...genuinely confirming my assumption on that.
Technique: I am right handed...holding the probe in my left hand (finger tips really) I rest the (for lack of a better way to describe it) the " karate chopping" aspect of this hand firmly on the pt's arm. This is my anchor...keeps my probe steady. :) With my right hand I place the tip of the needle about 1/8 to 1/4 of an inch distal to the probe and apply a small amount of traction with again "karate chopping" aspect of my right hand, as I hold the angio like you would a dart to be thrown at a dart board. Traction really isn't required though. Veins of this depth just dont present a problem with rolling in my experience. Now...if you have a patient with a degree of third spacing and obvious fluid retention in the extremity...then yeah...they "can" float around in this fluid and then traction may be helpful...but honestly...traction is just not an issue with this viens...they do not roll around even as shallow as .5 - 1.0 cm's. A slow insertion...taking 2 - 5 sec's ..watching the tip of the need the whole way down and into the lumen of the vein...it just rarely ever rolls or moves...if it does...you just slightly alter your angle and continue to advance...not an issue to one who has acquired the proficiency with U/S.
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. [EMAIL PROTECTED] >>> Lynn Hadaway <[EMAIL PROTECTED]> 11/02/05 9:16 AM >>> Published data in a well designed, preferably randomized controlled trial, is quite necessary. I am definitely interested in the outcomes of the catheter, not your success rate with getting it in. This would include specific vein used and location (not simply right arm, left hand), catheter gauge, rates of phlebitis and infiltration preferably expressed as the episodes per 1000 catheter days.
Your personal experience is wonderful but it does not quite measure up to the demands of evidence-based practice today. I would strongly encourage you to do such a study and get it published in a peer-reviewed journal. This would be adding to our knowledge base in a truly meaningful way.
You make a good point about the difference between superficial veins and deep veins and their tendency to roll around, but I still do not understand how one person can accomplish holding the probe, the catheter and skin traction all at the same time. Are you saying that because you are using deep veins you do not need to hold traction? I am wondering if you are truly using what the textbooks classify as deep veins, which are located underneath muscle and contained in a protective sheath with an artery and nerve. Or are you using superficial veins that are deeper in connective tissue? Lynn
At 9:04 AM -0500 11/2/05, Brian Gackenbach wrote:
Content-Type: text/html Sorry...gotta reply: quote: US requires that you dramatically alter venipuncture technique to insert a PIV. Reply: Ok...so you have to learn a new technique... quote: There is no way that one person can hold the probe, hold the catheter Reply: Not true...and I'm not saying this as a matter of opinion...I'm saying it as a matter of fact. I do this on a daily basis and have done so for 5 years and have THOUSANDS of PIV insertions under my belt using U/S. I rarely stick w/o it. Quote: This last step is critical to reduce the trauma to the tunica intima - trauma which leads to phlebitis, thrombosis, and infiltration. Reply: Certainly...with shallow PIVs, just mm's under the skin...easily visible, easily palpable...yes...without anchoring (requiring your other hand) yes these viens do have a tendancy to roll around and make cannulation extremely challanging and as such leads to traumatic insertions and the complications you mention. I dont use U/S on visible veins...nearly all I cannulate are .5 - 1.0 cm deep and I do not have any trouble with veins of that depth rolling...as I am observing the ENTIRE process on U/S...I can assure you and anyone watching this...that there is potentially VERY little epithelial injury when done properly. I mean...I watch the TIP of the needle enter the vien...and KNOW I am in the vein and then cannulate. Gone are the days of inadvertently going through the vein or spending more than 5 sec's with a needle in my patient arm. Most often...I'm done in just a sec or two. My patients say, "Oh wow...you're done...really...that quick...and you got it...<insert big smile>...I love you Mr. IV man!". Blind sticks (palpating only) are a thing of the past for me and my patients. Our outcomes are such that we routinely have patients who ONLY allow us to come place their IV's. Phlebitis is not a problem here for us. If it takes an actual study done, where I have to track the PIV's I do and show you guys raw #'s rather than recant personal experience from many years and thousands of sticks, then I may be persuaded to conduct this little study. All of our staff here routinely us U/S for PIV's....if there was an increase in complications from this practice...given the large # of time we do this...we'd have observed it w/o any need for an official study determine it existed. Alas...if need be...I'll <gulp> volunteer to investigate this. Email me with data you'd like to see (Ie: # of attemps, cath size/length...vein used..etc.) I'll whip up a Palm data collection tool and see if I can get my dept. to cooperate and we'll monitor and report on this data for you...possibly seek publishing it if you guys think it warrants it. Brian Brian Gackenbach RN, CRNI
I am so glad to hear someone else with this same concern! US requires
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Title: RE: Ultrasound for difficult PIV placement
- RE: Ultrasound for difficult PIV placement Brian Gackenbach
- RE: Ultrasound for difficult PIV placement Lynn Hadaway
- RE: Ultrasound for difficult PIV placement Leigh Ann Bowe-geddes
- RE: Ultrasound for difficult PIV placement Leigh Ann Bowe-geddes
- RE: Ultrasound for difficult PIV placement Kokotis, Kathy
- Re: Ultrasound for difficult PIV placement Pmpjkg
- Re: Ultrasound for difficult PIV placement Leigh Ann Bowe-geddes
