Emergency Nurse Ultrasound Guided Peripheral IV Insertion (USGPIV)

Evidence NK3-3, USGPIV PowerPoint Education

Stephanie C. Mullennix, BSN, RN, CEN Drew Peklo, BSN, RN, CEN Charles Monaghan, BSN, RN, CEN Chad Galdys, BSN, RN, EMT-B

January 16, 2015 Evidence NK3-3, USGPIV PowerPoint Education

Objectives

■ Discuss the clinical significance of difficult IV access

■ Review evidence-based research in support of USGPIV access in the ED

■ Demonstrate knowledge of upper arm anatomy

■ Demonstrate critical safety steps when performing USGPIV access

■ Demonstrate proper technique when using the Bard ® guidewire catheter for USGPIV cannulation

■ Demonstrate proper documentation of USGPIV placement

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Clinical Significance

Why do we need to learn to use Ultrasound Guided Peripheral Intravenous in the ED?

■ Conditions such as obesity, chronic illness, hypovolemia, IV drug abuse and vasculopathy can challenge the emergency nurse in obtaining IV access.

■ Difficulty obtaining peripheral intravenous (PIV) access can delay treatment for patients in the emergency department (ED).

■ Patients who experience multiple PIV attempts in the ED

may receive a central venous catheter (CVC) due to lack of suitable PIV sites.

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Evidence to Support the Use of USGPIV

■ ENA gives the use of Ultrasound-guided access a level A (highest recommendation) as a viable option for nurses for those patients with known difficult access.

■ Empirical support is evident in current literature, including systematic reviews and meta-analysis on the use of USGPIV cannulation by RN’s to increase the success rate of establishing PIV access in ED patients with difficult access.

■ Some studies have presented that there may be a correlation in decreasing central venous catheter insertion rates in the ED with a successful USGPIV program.

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Clinical Indications for USGPIV Use

The use of USGPIV should be considered if the patient has an order for a peripheral IV and meets any of the following criteria:

■ The patient has had two failed attempts utilizing a standard IV insertion method.

■ The patient has a known history of poor vascular access.

■ The patient has no visible or palpable veins.

■ The patient requires venous access for imaging studies with no visible or palpable veins in the appropriate location.

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Criteria

■The RN is limited to using ultrasound guidance to establish peripheral IV with catheters that are at a minimum of 1.75 inches and a maximum of 2.5 inches long (midline catheters are defined as catheters that are > 3cm, midline placement is restricted to physicians)

■18 and 20 gauge catheters are appropriate for US placement

■Veins cannulated with ultrasound guidance should not exceed a vessel depth of 2.0 cm

■USGPIVs are not considered central catheters

■USGPIV should be limited to two attempts. If more than two attempts are unsuccessful, contact the provider for further guidance.

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Ultrasound Technology

■ Ultrasound machines are expensive—take care of our resources

■ Ensure you the clean the ultrasound machine immediately before and after patient use

■ Return to the appropriate location after use

■ Plug it in when your done

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Considerations

■ The preferred area for

establishing USGPIV is

between the distal forearm

and mid arm

■The Brachial Vein should be

used ONLY as a last resort

due to the close proximity to

the Brachial Artery and

Median Nerve

■Utilize the appropriate size http://vascularultrasound.net/wp-content/uploads/2010/08/armveins2-copy.jpg gauge for the appropriate clinical indication

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Preparation and Infection Prevention

Prevent patient-to-patient microbial cross-contamination:

■Immediately prior to patient use the ultrasound probe must be cleaned with a germicidal disposable wipe and allowed to dry completely prior to contact with patient skin and following completion of the procedure.

■ A sterile probe cover will be used for all USGPIV starts (large transparent dressing placed over the thin line of ultrasound gel).

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Site & Catheter Selection

■ Consider range of motion/restricted movement in selecting sites. Avoid points of direct flexion when possible.

■ If upper arm presents the only suitable vessels, often the Cephalic Vein is best, followed by Basilic.

■ Avoid the Brachial Vein due to risk of arterial or nerve compromise.

■ If no appropriate target vessel is identified during the US survey, contact the patients attending physician to determine appropriate access for the patient.

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Review of Vein Anatomy-Middle Upper Arm

11 http://www.ultrasoundpaedia.com/uploads/53003/ufiles/dvt-arm/dvt%20arm%20normal/upper-arm-vein-anatomy.jpg Evidence NK3-3, USGPIV PowerPoint Education

Site Selection-Ultrasound View

Basilic Vein

Brachial

Nerve Bundle

Brachial Brachial Artery

12 http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-104340-1433943-1464224.jpg

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Artery vs. Vein

Ivy Leauge Nurse.com Meer, Medscape, 2011, pg 5

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Can you recognize a thrombus within a vessel?

■ Clot in upper arm vessel

■ Hallmark feature is the lack of compression in the vessel

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Tips for Success

■ Hold the probe perpendicular to the

skin to obtain the best image. Don’t tilt

the probe.

■ Track the needle on the Ultrasound

Screen, not on the patients arm.

■ 15-30 degree angle for insertion. U

■ Avoid extreme steep angles as this S may kink the catheter

■ Use a “C” grip to hold the probe,

using your wrist /fingers to stabilize the probe hand Skin ■ Don’t overdo it with the gel! Vein ■ Practice, Practice, Practice.

■ Simulators will be available. 15

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Sustainment of a Successful USGPIV Program

■ Policy

■ Education

■ Training

■ Competency

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Competency Plan

■ Nurses will participate in an initial class consisting of didactic and hands on learning.

■ Nurses will successfully cannulate 5 simulated USGPIVs.

■ Staff will successfully perform 3-5 peer validated USGPIV insertions.

■ Educators will keep record of documented education and competency.

■ Nurses who have attended the initial training will demonstrate 2 peer validated competencies on an annual basis.

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Policy

Review and Reference SH Clinical Policy

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Documentation

Documentation: I-View (“Lines” documentation band)

■ IV site/location

■ Gauge

■ Site condition

■ Site Dressing

■ IV patency

■ Use of Liquid Adhesive

■ Use of Ultrasound for guidance

■ Number of attempts

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References

Arbique, D., Bordelon, M., Dragoo, R., Huckaby, S., (2014). Ultrasound-Guided Access for Peripheral Intravenous Therapy. Academy of Medical-Surgical Nurses, 23, 3, 9-14. Retrieved from http:///search.ebscohost.com.proxy2cl.msu.edu/login.aspx?direct=true&db=rzh&AN=2012637663&site=ehost-live

Au, K., A., Rotte, M., J., Grzybowski, R., J., Ku, Fields, J., M. (2012). Decrease in central venous catheter placement due to use of ultrasound guidance for peripheral intravenous catheters. The American Journal of Emergency Medicine, 30, 1950-1954. doi: 10.1016/j.ajem.2012.04.016

Egan, G., Healy, D., O’Neill, H., O., Clarke-Moloney, M., Grace., P., A., Walsh, S., R. (2013). Ultrasound guidance for difficult peripheral venous access: systematic review and meta-analysis. Emergency Medicine Journal, 30, 521-526. doi:10.1136/emermed-2012-201652

Emergency Nurses Association (2011). Clinical Practice Guideline: Difficult Intravenous Access. Institute for Emergency Nursing Research, 3, 1-15. Retrieved from www.ena.org

Ismailoglu, E., G., Zaybak, A., Akarca, F., K., Kiyan, S. (2014). The effect of the use of ultrasound in the success of peripheral venous catheterization. International Emergency Nursing. doi: 10.1016/j.jen.2014.07.010

Maiocco, G., Coole, C. (2012). Use of ultrasound guidance for peripheral intravenous placement in difficult-to access patients. Journal of Nursing Care Quality ,27, 1, 51-55. doi:10.1097/NCQ0b013e31e31822b4537

Miles, G., Salcedo, A., Spear, D. (2012) Implementation of a successful registered nurse peripheral ultrasound-guided intravenous catheter program in an emergency department. Journal of Emergency Nursing, 38, 353-356. doi: 10.1016/j.jen.2011.02.011

Ultrasound Guided PIV Placement: Retrieved on August 15, 2013 from http://www.ivyleaguenurse.com/courses/Ultrasound_Guided_PIVs.pdf

Weiner, S., G., Sarff, A., R., Esener, D., E., Shroff, S., D., Budhram, G., R., Switkowski, K., M., …Darvish, A., H. (2013). The Journal of Emergency Medicine, 44, 3, 653-660.doi:10.1016/j.jemermed.2012.08.021 20

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