Make your 'nightmare' IV cases easier

Ultrasound avoids 'blind' attempts, central lines

Try to remember the most "difficult stick" you ever had when placing a peripheral intravenous (IV) line. If you could have used ultrasound to locate the patient's veins at that moment, imagine how much easier it would have been — for you and your patient.

New research that shows that emergency nurses can save many "hard-to-stick" patients the pain of repeated needlesticks or central line access with ultrasound. Emergency nurses were asked to fill out a survey after an ultrasound-guided IV attempt on a patient. Of 258 sticks rated as "very hard" without ultrasound, 29 still were rated as "very hard" even with ultrasound use, but 43 changed to "hard," 112 changed to "easy" and 137 to "very easy."1

The technique is easy to learn and doesn't require extensive training, according to Michael Blaivas, MD, RDMS, an ED attending physician at Northside Hospital-Forsyth in Cumming, GA. "When nurses utilize ultrasound for peripheral vascular access, it basically turns nightmare access cases into easy or fairly easy ones," he says. The cost of the ultrasound equipment ranges from $10,000 to $15,000, he says.

Blaivas recommends a training course with a lecture covering basic ultrasound physics, machine function, vascular anatomy, and vessel identification. "It is helpful to have as much video as possible, then a hands-on portion during which nurses can actually practice ultrasound guided peripheral vascular access on an inanimate model," he says. The first five IVs done using ultrasound should be supervised to provide helpful hints and answer questions, he advises. "We have found many nurses do great even on their first attempt on a live patient after the course," adds Blaivas.

At University of California-Irvine Medical Center, five ED nurses were given a hands-on tutorial by an ED physician who specializes in ultrasound on how to guide an angiocath into a balloon roughly the caliber of an average adult side peripheral line, says Hanadi Varvais, RN, one of the nurses who received ultrasound training. The first group of nurses now is teaching other nurses at the bedside on patients, she reports.

"The 'see-one, do-one' mantra is proving useful to get many of the nurses up to speed," says Varvais. "This has resulted in a dramatic decrease in central line placement by the physicians."

Tool dramatically cuts delays

With ultrasound, the patient is able to get fluids and medication faster than if the nurse had to try repeatedly to obtain vascular access and eventually rely on a physician who then may place a central line, says Blaivas. He estimates that less than 5% of EDs have nurses using ultrasound currently, but he says that numbers are growing rapidly. "My patients and nurses will tell you that the difficult stick patients coming to those few EDs are quite lucky, as they avoid multiple 'blind' attempts and unnecessary central lines," he says.

At Memorial Hermann Southwest Hospital in Houston, the ED is purchasing a vascular probe for the ED's ultrasound machine, which will be an investment of about $9,000, reports Garry Thompson, BSN, RN, CEN, the ED's clinical educator, who used ultrasound at a previous facility. "I cannot overstate the benefits to the patient when nurses are able to use ultrasound for difficult sticks," he says.

In some cases, difficult sticks take hours to complete, says Thompson. "This contributes to extended lengths of stay and might even result in the patient's disease process getting worse," he says. He gives the example of a septic patient with a systolic blood pressure of 70. "They are going to be a very difficult stick for not only the nurse, but also for the doctor getting central access," says Thompson. With ultrasound, the line could be placed within minutes and fluids started, but without it, it could take 40 minutes to get a central line in place after the ED nurse has tried multiple times, he explains. "This delay at a vital moment in the patient's stay can only lead to detrimental harm," says Thompson.

Difficult sticks are increasing

Since today's patients are sicker with more comorbidities, more are difficult sticks, says Thompson. "When we place lines with one stick for these patients, they are grateful and look at you with admiration and thankfulness," says Thompson.

Even with the most difficult cases, such as obese patients, burn patients, and young children, nurses often are surprised at how many veins are available for cannulation under ultrasound guidance, says Varvais. "This has resulted in increased patient comfort, safety, and improved job satisfaction," she says.


  1. Blaivas M, Lyon M. The effect of ultrasound guidance on the perceived difficulty of emergency nurse-obtained peripheral IV access J Emerg Med 2006; 31:407-410.