After blood return has been identified, the catheter will be advanced as usual, labs can be drawn as needed, and the line should be secured using standard techniques.

Complications

Whether placed by standard techniques or with ultrasound guidance, peripheral intravenous access can be associated with common complications, including local infiltration, cellulitis, and thrombo-phlebitis.6 Arterial puncture is another potential complication, and has been documented to occur approximately 2% of the time when attempting to cannulate the deeper veins of the arm via ultrasound guidance.¹ Hematoma formation is also possible; it may be avoided with the application of firm pressure after an unsuccessful cannulation attempt.

Pitfalls

Ultrasound-guided venous access can be a more time-consuming process, including time to set up the machine and locating a second health care provider if using the dual-operator technique. The process also may be more time consuming until operators become more familiar with the ultrasound-guided technique.

When viewing the vein in short axis, the needle may be seen only as a small hyperechoic ovoid structure, making it difficult to determine which part of the needle is being visualized. Making small adjustments in the transducer angle can bring the needle tip into view. Visualizing the needle tip will reduce the chance of overinsertion and penetrating the deep wall of the vessel. It is also possible to misidentify an artery for a vein, because they often travel together.

Deeper veins (e.g., the deep brachial) may be located 1-2 cm beneath the skin, and standard intravenous catheters may not be long enough. This is also a concern for the superficial veins of very obese patients.

If too short a catheter is used, it may come out of the vein and infiltrate when the patient moves the extremity. Longer catheters should be used to avoid this complication, or a steeper angle can be used to minimize catheter travel through the skin and soft tissues before vessel puncture.

Contributors

Dr. Bagley is associate fellowship director of the ultrasound division, department of emergency medicine at St. Luke’s-Roosevelt Hospital Center. Dr. Lewiss is director of the ultrasound division, department of emergency medicine at St. Luke’s-Roosevelt Hospital Center. Dr. Saul is fellowship director of the ultrasound division, department of emergency medicine at St. Luke’s-Roosevelt Hospital Center. Dr. Travnicek is a former ultrasound fellow at St. Luke’s-Roosevelt Hospital Center who currently practices emergency medicine at Avera McKennan Hospital & University Health Center in South Dakota. Medical Editor Dr. Robert C. Solomon is an attending emergency physician at Trinity Health System in Steubenville, Ohio, and clinical assistant professor of emergency medicine at the West Virginia School of Osteopathic Medicine.