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Ultrasound-Guided Ultrasound-Guided PIV AccessPIV Access

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Study Details…Study Details…

Prospective cohort studyProspective cohort studySt Lukes & Roosevelt sitesSt Lukes & Roosevelt sitesMD’s: residents & attendingsMD’s: residents & attendingsPatients with “difficult access”Patients with “difficult access”

– 2+ unsuccessful PIV attempts2+ unsuccessful PIV attemptsExclusionExclusion

– UnstableUnstable– Unable to obtain consentUnable to obtain consent

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Study Details…Study Details…Primary OutcomesPrimary Outcomes

AttemptAttempt– Skin punctureSkin puncture

RedirectionRedirection– Partial withdrawal, needle advancement Partial withdrawal, needle advancement to change catheter directionto change catheter direction

TimingTiming– Tourniquet placement to successful IV Tourniquet placement to successful IV

placementplacement• FlashFlash• Infuse 5mL salineInfuse 5mL saline

Failure >4 US-guided attemptsFailure >4 US-guided attempts

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Enrollment ProcessEnrollment Process

Identify eligible patientsIdentify eligible patients– All agesAll ages– 2+ failed PIV attempts 2+ failed PIV attempts

Contact AA’s (when available)Contact AA’s (when available)– Consent, assent Consent, assent

Data SheetData Sheet– Demographic infoDemographic info

PIV placement: MD’s Thermal imagePIV placement: MD’s Thermal image2nd 1/2 Data Sheet2nd 1/2 Data Sheet

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Data Sheet(TOP)

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MaterialsMaterials

ConsentsConsentsData SheetData SheetSonosite TitanSonosite Titan

– High frequency linear probeHigh frequency linear probeStop-watchStop-watchTourniquetTourniquetGel/sterile lubeGel/sterile lubeSaline FlushSaline FlushGauze, tapeGauze, tape

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Peripheral IV AccessPeripheral IV Access

Superficial & deep vesselsSuperficial & deep vessels Antecubital regionAntecubital region SaphenousSaphenous

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US-Guided PIVUS-Guided PIVTechniqueTechnique

Linear, high Linear, high frequency frequency transducertransducer– 7.5 MHz 7.5 MHz

Short axisShort axisDynamicDynamic

– Real-time guidanceReal-time guidanceDual operatorDual operator

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Technique: Short AxisTechnique: Short Axis

TransverseTransverse– Cross sectionCross section

Needle is perpendicular Needle is perpendicular to transducerto transducer

OK to use long axis OK to use long axis for confirmationfor confirmation CompressionCompression

– Arteries vs. veinsArteries vs. veins

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Dual OperatorDual Operator

““Probe person”Probe person”• Orient probe, center Orient probe, center

vessel on screenvessel on screen• Tell needle person depth Tell needle person depth

(distance from probe)(distance from probe)• Guide redirectionsGuide redirections

““Needle person”Needle person”• Focus on probe, center Focus on probe, center

needleneedle

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Needle PlacementNeedle Placement

Enter at 45 degree angle… Enter at 45 degree angle… aa22+b+b22=c=c22

a

c b

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What You’re Looking For:What You’re Looking For:Short AxisShort Axis

TentingTenting Ring-down artifactRing-down artifact

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Data Sheet(BOTTOM)

TimingStopwatch (sec)

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Helpful Hints…Helpful Hints…

Flash not always seen, even w/ US Flash not always seen, even w/ US confirmation of intravascular placementconfirmation of intravascular placement

Catheter kinks are frequentCatheter kinks are frequent– 24-gauge needles24-gauge needles– 45 degree angle45 degree angle– Securing catheter flush against skinSecuring catheter flush against skin

• Maintain angle of entry w/ folded gauze under Maintain angle of entry w/ folded gauze under IV catheterIV catheter

Use long catheters when availableUse long catheters when available

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Questions?Questions?

Stephanie Doniger, MDStephanie Doniger, MDWill Bagley, MDWill Bagley, MDUS DivisionUS Division

– Resa Lewiss, MDResa Lewiss, MD– Marina Del Rios, MDMarina Del Rios, MD– Alexis Langsfeld, MDAlexis Langsfeld, MD– Turandot Saul, MDTurandot Saul, MD