A sound way to insertions

Ultrasound provides visual aid for tough access

Home infusion providers and nurses face a difficulty unlike their peers with inpatients. In the home, it’s often just you and a patient. If you cannot gain vascular access in the home, who can you turn to for hands-on assistance?

Joan Ralph Webber, BN, CRNI, a clinical nurse specialist and PICC educational clinician at Good Samaritan Regional Medical Center in Phoenix, says ultrasound equipment may be just the thing for home infusion providers. Webber has been using the technology for several months and is now a proponent.

"There are not that many nurses using it yet, but the more they hear about it, the more popular it is becoming," says Webber. "The advantage is you can do everything at the bedside. Especially for patients where traveling to radiology for an insertion is a problem. When patients cannot be moved or moving the patient would make it critical, you can see a vein and access an area that you would never be able to feel. This eliminates the guesswork of where a vessel is."

For obvious reasons, Webber says that ultrasound could help a home infusion provider who frequently sees patients with poor venous access.

"Quite often, if a home infusion patient doesn’t have a vein, the only alternative is to admit them back to a hospital to have a central line placed on an outpatient basis," she says.

Webber is quick to note that using an ultrasound for catheter insertion requires a bit of a paradigm shift.

"It is just a different way of accessing the vein than we have ever done," she says. "Usually, it is a tactile thing where you feel for the vein and access it on a more parallel level. But with this, it is almost perpendicular, as it allows the vessel to be seen sharper."

How it works

When looking at vessels through an ultrasound, veins and arteries look the same. Both show up on the screen as a dark, circular area, according to Webber. However, there’s an easy way to tell the difference.

"With the ultrasound probe pressed down, a vein will compress, as will the artery, although the artery will pulsate on compression," explains Webber. "On the screen, you can see the pulsation of the artery; whereas, when you press down on a vein you can’t see it anymore. That’s why you have to be very gentle with the ultrasound probe because when you scan, it will flatten out the vessel and you won’t see it."

She adds that it is critical that you know upper-arm vasculature. For example, you should be aware that an artery usually has a vein lying next to it, and that an artery is typically larger than the accompanying vein. The basilic vein is usually 1 cm to the side of the artery, although that isn’t always the case. And, with ultrasound, you can see if a vein is thrombosed as it will appear to grow narrower or look smaller than expected.

Once you learn how to distinguish veins from arteries onscreen, it’s a matter of learning how to use the ultrasound and its attachments. Webber uses the Site Rite II ultrasound by Dymax of Pittsburgh with a depth finder on the screen marked off in 0.5-cm increments that tells you how far down from the surface the vessel is. But once again, being gentle with the probe is critical.

"If you are compressing hard with the probe, that will alter the depth reading," notes Webber.

Webber has used both the freehand technique for insertion, as well as an attachment called a Needle Guide. The latter holds the needle firmly in place during the process at an angle so the needle will intersect with the ultrasound beam at predetermined depths to reach the desired vessel. The angle is often almost vertical compared to the more horizontal angle most nurses are comfortable with. While helpful, Webber says there is a time and a place for freehand.

"[On some patients,] I have to level out the angle of the needle going in, because the wire may not make the right angle turn and quite often gets caught on the needle bevel on removal," she explains. "That’s why with the free hand I feel a little better because I can tunnel it a bit. "

See how you’re doing

Also, if you use specially designed needles that allow the tip to show up on ultrasound, you can watch the tip of the needle enter the vessel upon insertion. That’s not to say you can’t tell when you insert the needle into the vessel without such needles.

"As you poke the vessel, I liken it to putting a dull needle into a balloon," says Webber. "It pushes it down a little and then springs back [once the needle enters]."

If you use needles that show up on ultrasound, Webber’s most recent attachment is the Navigator.

"This allows you to scan over the patient, identify the tip and confirm the tip placement," she says. "It doesn’t eliminate the need for a chest X-ray, but it allows you to reposition the tip with the site is still sterile."

Webber points out that there is a big difference between being capable and being proficient.

"To get really good, I would give yourself at least a couple of months. But to just use it would take less than a week."

A sales rep gave Webber her initial training, as well as a pretend vein to practice on. From there, she was on her own.

Gaining proficiency

"I had it for two months to see if I liked it, but once you start accessing more challenging veins you run into more problems," she says. "If you are not trained and don’t know what you are doing and what to look for, you can do some serious damage. You need to know what you are looking at and where you’re going. To get your accuracy really good, it would take a couple of months."

The cost may be prohibitive for some, starting at $11,000 and going up from there with attachments. However, for a provider with a high percentage of problematic access patients, such as end stage renal disease patients, oncology patients, or IV drug users, the machine could prove invaluable and a cost savings over the long haul.

"It helps find a vein where you normally wouldn’t be able to find one," says Webber.