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- PMC9886173
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ATS Sch. 2022 Dec; 3(4): 598–609.
Published online 2022 Oct 26. doi:10.34197/ats-scholar.2022-0029HT
PMCID: PMC9886173
PMID: 36726710
Matthew Gorgone,
1 Timothy P. O’Connor,2 and Stephanie I. Maximous1
Author information Article notes Copyright and License information PMC Disclaimer
See editorial "“How I Teach”: A Novel Guide to Teaching in Pulmonary, Critical Care, and Sleep Medicine" in volume 3 onpage509.
Abstract
Ultrasound-guided peripheral intravenous (IV) placement is often required forpatients with difficult IV access and is associated with a reduction in centralline placement. Despite the importance, there is no standardized technicalapproach, and there is limited ability to attain mastery through simulation. Wedescribe our step-by-step approach for teaching ultrasound-guided IV placementat the bedside using short-axis dynamic guidance, with emphasis on advancing theneedle and catheter device almost entirely into the vessel before threading thecatheter. Our teaching approach allows the opportunity for trainees to maximizethe learning potential of a single insertion experience, which includes focusedpreprocedure hands-on practice, instruction with real-time feedback at thebedside, and a post-procedure debrief with reinforcement of concepts.
Intravenous (IV) access is essential in hospitalized patients,and poor IV access is a common reason for central line placement. Peripheral IVs areassociated with a lower infection risk and fewer placement complications (1, 2).Using ultrasound can reduce the number of attempts required to place peripheral IVs inpatients with one or more failed IV attempts, no visually identifiable vein, or previousdifficult IV placement (3, 4). Ultrasound-guided peripheral IVs (USPIVs) allow clinicians toavoid central lines, remove existing central lines, improve patient satisfaction, andsafely administer vasoconstrictive agents (4–10). Novice members of theteam are often called to place IVs after multiple expert staff have failed, highlightingthe importance of this skill.
Who Are the Learners?
Our technique is aimed at teaching anyone learning USPIVplacement, including but not limited to students, postgraduate trainees, and nurses.There are many techniques described to place USPIVs, including Seldinger technique,long axis, short axis, static, and dynamic guidance (11, 12). Thepublished literature on teaching USPIV placement often includes didactic lecturesfollowed by practicing on models, although these studies focus on teaching medicalstudents, technicians, nurses, or emergency medical services workers and are2–8 hours in length (13–16). Many training programs do not have thebandwidth or experienced faculty to teach this skill in a workshop format tolearners in the intensive care unit (ICU) and on general medicine floors. We presenta method of teaching USPIVs that was developed by one of the authors’experiences teaching residents, hospitalists, and advanced practice providers, whilebuilding, directing, and then handing off a bedside procedure team (17). Our method has been used across multipleinstitutions for many levels of learners, providing a broadly applicable approach ina setting where mastery through simulation may not be feasible.
What Is the Setting?
The teaching is most commonly performed in the inpatientsetting in the emergency department, medical floors, or ICU, typically after failedattempts by members of the healthcare team using conventional IV placementmethods.
What Is the Approach?
Given the limitations in time and resources for teachingthis core skill, we use a “just in time training” (JITT) strategy toefficiently prepare the learner for the combined educational and proceduralexperience they are about to undertake. Procedural JITT facilitates practice of askill immediately before performance of it in a live clinical encounter to improvepatient safety and trainee learning and confidence. As investigators discovered in aqualitative analysis of JITT for pediatric lumbar puncture training, learners foundJITT to be useful for reviewing anatomic landmarks, rehearsing steps, askingquestions, and troubleshooting based on prior experience or areas ofmisunderstanding (18). The nature of thison-demand teaching ensures its relevance to the trainee’s immediate learningneeds and retention, given the temporal proximity of the learning to the actualskills performance.
Our approach mirrors the “briefing, intraoperative teaching,debriefing” model, a practical way to teach this relatively low-stakesprocedure (19). As part of briefing, westart by asking the learner about quantitative experience and comfort level,recognizing the limitations of self-assessment. This encouraged self-reflection andassessment is known as metacognition; it has been shown to improve learning andskills retention and has been used successfully in the operating room setting (19–21). This conversation frames the discussion, allowing for more advancedtroubleshooting techniques to be highlighted if the level of skill warrants. We setthe expectation by telling the learner that we are going to explain the technique asif they have never placed an USPIV before, ensuring that the approach is clear whenwe move to the bedside. We highlight that although low stakes procedurally, USPIVplacement is a skill that requires significant experience to master and that we willbe giving real-time feedback and instruction at the bedside to support them througha successful IV insertion to encourage an open dialogue between the learner andinstructor. This establishes the learning environment and psychologic safety, whichhas been described in many educational settings to beneficial for learning (22–24). Specifically, the psychological safety that we aim to establishemphasizes the trainee’s ability to fully engage in the learning experiencewithout a sense of needing to preserve their image or be concerned about judgement.Because the procedure is relatively low risk and the learning is happening in realtime, it is crucial to establish an environment where the learner can ask questionsopenly, disclose weaknesses, try earnestly, make mistakes, and be primed to receivehonest constructive feedback from a supportive educator. This allows them to focuson deeply learning a skill rather than worrying about meeting certain expectationsor being judged (25).
During the briefing, we conduct a mini-simulation, allowing the trainee to practicesurveying vascular anatomy and gain familiarity with the IV apparatus. We use mentalimagery, cued by the description of the technique and supported by explanations andpictures of what the learner should expect to see based on where the ultrasound beamis directed; this has been described in surgical literature and is associated withimproved confidence and technical skill in some studies (26–31).
During the intraoperative teaching section, we support the learner as they performwhat they just simulated and imagined. We use cueing to highlight the key steps,facilitating real-time deliberate practice by the trainee. This component of thetraining is a form of guided discovery, where an expert provides verbal and evenhands-on guidance during the learning experience (32). The actual procedural performance is a live form of deliberatepractice education, where the learner is attentively guided to focus on repetitivelypracticing very specific aspects of a skill or procedure; the educator providesrigorous assessment and real-time feedback to the trainee that informs theirrepeated tries under direct supervision. Namely, during this USPIV procedure,dynamic needle tip positioning (DNTP) is the key skill that the learner is made toconcentrate on, hone, and repeat throughout the procedure to both successfully placethe IV and demonstrate skill development as assessed by the supervisor (33).
In the debriefing portion, we focus on positive feedback to reinforce what was donecorrectly and encourage self-reflection to engage the learner on areas ofimprovement (34). Effective debriefingshould result in the learner formulating objectives to guide future practice thatcan then be assessed during their next USPIV encounter. By allowing the learner torestate their main take-away lessons from the experience, we harness thelearner’s metacognition and obtain a commitment for their further practice.The educator also uses this opportunity to reinforce the most salient learningobjectives and to ensure the learner understands how to correct any errors madeduring the procedure.
What Is the Content?
Technique
Before the bedside
After gathering supplies (including extra IVcatheters; see Figure E1 in the data supplement forsuggested list), we orient the trainee to the ultrasound machine. Thisentails observing the trainee holding the linear array probe, ensuring theyare anchoring their hand to assist with stabilization. With less-experiencedtrainees, or those who do not anchor their hand while holding the ultrasoundprobe, we find the “afternoon tea technique” to be aneffective way to communicate how to lightly grip the probe while anchoringon the patient with their fifth digit (Figure 1) (35). We thenhave the trainee apply a tourniquet to the instructor’s upper arm andsurvey the vessels. Scanning the vessels on the instructor’s armallows for reiteration of the ultrasound grip technique, confirms thetrainee can identify relevant anatomy, helps the trainee practice orientingthe probe perpendicular to the course of a vessel while performing serialcompression, and allows the optimal gain and depth to be set on themachine.
Figure 1.
Ultrasound probe grip technique. The image on the left labeled“Wrong” displays the ultrasound probe being held awayfrom the patient’s arm and without an anchoring point againstthe patient. The resultant display on the ultrasound screen is morelikely to be like “probe heavy” or “probemoderate,” where the circular vessel is deformed into an ovalas a result of the pressure applied by the probe. The image labeled“Correct” shows the probe being held close to thepatient’s arm with the operator’s fifth digit anchoredproximally on the arm, allowing stabilization and preventingexcessive pressure from being applied, resulting in the ultrasounddisplay labeled “probe light.”
We then move to practicing holding the IV insertion apparatus. The specifictechnique requires adjustment based on available catheters. Our hospitalcurrently carries the Introcan Safety 64 mm 18- and 20-gauge catheters,which allows the operator to hold the catheter between their index andmiddle finger, using their thumb to help control the angle of the needle(Figure 2). Insyte BD IVcatheters (48 mm, 18 and 20 gauge) are another common style, requiringalternative hand positioning (Figure2). Having an extra catheter in the supplies allows the traineeto practice holding and manipulating the catheter before going to thebedside.
Figure 2.
How to hold intravenous (IV) insertion device. (A)The IV catheter being held between the index and middle finger, withthe thumb placed on the back to aid in angulation. The fifth digitis extended and used to provide stabilization during IV insertion.(B) Another style of IV catheter in which thegrip positioning requires the catheter to be held between the middlefinger and thumb in a flexed position, with the index finger placedon the top of the catheter for additional stabilization. The fifthdigit is extended and used to provide stabilization during IVinsertion.
At this point, we review the concept of DNTP and highlight how to confirmproper needle position on the ultrasound display (11). We explain that DNTP is a short-axis techniquein which the probe is moved just past the tip of the needle and then held inplace while the needle is then inserted until it enters the plane of theultrasound beam and appears on the screen as a hyperechoic dot. Thesemovements are repeated to “walk” the needle tip down to thevessel. We reference Figure 3 to showthe appearance of a crescent-shaped vein representing the anterior vesselwall being tented in by the needle and an “empty” anechoicvessel a few millimeters proximal to confirm the location of the tip of theneedle.
Figure 3.
Confirming vessel wall tenting. (A) The vessel isbeing deformed by the catheter and needle. This creates acrescent-shaped anechoic lumen. (B) It can beconfirmed that it is the tip of the needle that is tenting in thevessel wall by fanning the ultrasound just proximal to the needletip, where the vessel resumes its round shape. Note that inB, the vessel is oval shaped, suggesting theoperator is applying too much pressure with the probe and iscompressing the vessel. The red dotted lines in the center imagecorrelate with the path of the ultrasound beam in Aand B.
The final step before transitioning to the bedside is a broad overview of thespecific steps for placement, with more details provided at the bedside inreal time or in the debrief after the procedure. We review the followingscript verbally:
After vessel selection, the needle is inserted at the center of theultrasound probe, nearly touching the edge, at a steep angle, andDNTP is used to guide the needle to the vessel. Once the needle ispositioned in the center of the vessel, the angle of the needle isdecreased to parallel the course of the vein, using the needle tipas the pivot point, and then DNTP is resumed until the needle isinserted entirely, or at a minimum, 2–3 cm.
We particularly stress that the operator should not be looking for a flash ofblood as an indication the IV is in the vessel and that we will use theultrasound to ensure the IV is properly placed. At this point, questions areanswered, and we proceed to the bedside.
At the bedside
1. Vascular survey and target vessel selection
The learner applies the tourniquet and surveysthe vessels and surrounding structures. We cue the operator to track theproposed target vessel with serial compression every centimeter toconfirm there are no venous clots that may preclude successfulcannulation. Ideal vessels for placement include those <1.6 cmbelow the skin, located medial or lateral to surrounding arteries andnerves, and >3 mm in diameter (36). Once a target is chosen, we have the operator clean theskin and the ultrasound probe.
2. Long IV insertion with steep approach and dynamic guidance
The operator first centers the vessel on the ultrasound screen anddemonstrates with proximal and distal fanning that the probe isperpendicular to the course of the vessel. We then remind them to insertthe needle at a 60- to 80-degree angle; if the vessel is <5 mmdeep, we tell them to insert the IV at a 30- to 45-degree angle to avoidpuncturing the vessel or injuring surrounding structures while passingthrough the skin. We are deliberate about giving feedback on thedirection of gaze throughout this step: the operator’s eyesshould be initially focused on the screen until the vessel is centeredand the probe is stabilized, then eyes shift to the ultrasound probe towatch the needle pass through the skin, then eyes shift back to theultrasound screen to find the needle tip. The operator then uses DNTP tofollow the needle tip to the target vessel. As the supervisors, weprovide active feedback throughout this process on the size of themovements made by the operator and ensure they do not inadvertentlydecrease the angle of the needle before reaching the vessel.
3. Tent in vessel wall and lower angle of needle to get parallel to theblood vessel
Once the target vessel is reached, we instruct the operator to insert theneedle until it appears to be at the center of the vessel, decrease theangle using the needle tip as the pivot point to parallel the course ofthe vessel, and then continue inserting using DNTP (Figure 4). To confirm the needle is tenting in thevessel wall, we have the operator fan the ultrasound just proximal towhere the tip of the needle is located and then back to the needle tip(Figure 3). This gives thesupervisor confidence that the operator has the needle inserted at theintended depth.
Figure 4.
Summary of ultrasound intravenous insertion. (A)The needle is inserted into the center of the vessel at a steepangle. Note the catheter or needle tip may not puncture thevessel wall. (B) The angle of the needle islowered to parallel the course of the vessel while maintainingthe tip of the needle in the center of the vessel.(C) The needle is inserted further into thevessel. Note the tip of the needle may pierce the vessel wall,but the catheter is not within the vessel yet, and attempting tothread the catheter at this point would likely result in thecatheter threading into the subcutaneous tissue.(D) As the needle is inserted farther, theneedle and catheter pierce the vessel wall.
4. Anterior wall puncture
It is critical for the operator to maintain insertion pressure on theneedle while dynamically tracking to prevent the catheter fromrebounding before it punctures the anterior wall of the vessel. Thesupervisor should take note of how much of the IV catheter has beeninserted into the skin. If there is consistent observation of a similarlength of exposed catheter, we instruct the operator to anchor the IVapparatus against the skin before each advancement of the ultrasound. Asthe IV is inserted, a tactile “pop” may be appreciated bythe operator, often occurring between 1 and 2 cm after initial contactwith the vessel wall (Figure4).
5. Continue DNTP until IV is mostly or entirely inserted beforeattempting to thread catheter
We advocate tracking of the needle tip through the lumen of the vesseluntil the catheter is fully inserted, or the operator can ensure thatthere are at least 2–3 cm of catheter in the vessel. If theneedle tip is inserted off-center, the operator is directed toultrasound over the needle tip and slowly pivot the needle until thehyperechoic dot is in the center of the vessel before continuing dynamictracking. Repeating this process throughout insertion allows theoperator to gain appreciation for the magnitude of motion needed toreposition the needle. Once fully inserted, the ultrasound probe isplaced aside, and the ultrasound hand is used to thread the remaining IVcatheter into the blood vessel and to stabilize the catheter as theneedle is removed.
6. Confirm placement using flush test
To confirm placement, in addition to imaging the catheter in short andlong axis, we attach a saline flush, image proximal to the tip of thecatheter, provide gentle compression to ensure the structure is venous,and then briskly flush 10 ml saline. The vessel will expand or becomebright as the saline traverses the ultrasound beam, confirming venousplacement (37–40).
Post-procedure debrief
Regardless of the success, we believe debriefingallows for technique reinforcement. Feedback post-procedure has consistentlybeen demonstrated to improve effectiveness oflearning (19, 34, 41, 42). We ask the operator what wentwell and what could be done differently next time, or areas for improvement,which helps gauge degree of insight to frame the subsequent discussion.
What Can be Challenging?
Here are two commonly experienced challenges encountered andhow we approach ongoing skill development:
1. The learner is having trouble with DNTP
DNTP results in the needle alternating betweenbeing in and out of plane. There is a tendency for learners not to wantto “lose” the tip of the needle and instead maintain theultrasound beam on what they believe is the needle tip throughout theinsertion process but in fact is the needle shaft. We remind operatorsthat if they visualize the needle but advance it before repositioningthe ultrasound probe, the true tip of the needle will lie beyond thepath of the ultrasound beam. This concept is reinforced during thepost-procedure debrief by holding up the probe and using a pen to act asthe needle, making it clearer that the tip is being moved past the planeof the ultrasound beam.
If the learner is moving the ultrasound too far with each movement, wewill often hold the top of the ultrasound probe and deliberately fan theultrasound while verbally calling out what is seen on the ultrasoundscreen. This allows the learner to gain an appreciation for themagnitude of each micromovement needed to move the needle tip in and outof plane without “taking over” the procedure. We reviewFigure 5 in thepost-procedure debrief to reinforce that the tip of the needle ispinpoint in size and that micromovements should be used.
Figure 5.
Images comparing ultrasound appearance of (A andB) needle shaft to (C)needle tip. The hyperechoic structure in the center of thevessel is the intravenous catheter insertion device. The probelocation and representative image are shown below.(A) The posterior wall of the vessel isinterrupted because of posterior acoustic shadowing, suggestingthe probe is positioned over the shaft of the needle, not thetip. (B) The needle is very bright and largerthan how you would expect the tip to appear. The probe ispositioned over the bevel of the needle, not directly at thetip. (C) Visualizing of this pinpoint structureis the tip of the needle.
2. The learner expresses they are unable to see or find theirneedle
When the needle tip is within the subcutaneoustissue, it can be challenging to visualize the tip itself, because it ishyperechoic and may appear like surrounding tissue. To find the needle,we encourage the trainee to gently bounce the needle without advancingit and slowly slide the ultrasound probe from the point the needleenters the skin toward the tip of the needle until the tissue is nolonger shifting, which is often just past the tip of the needle (VideoE1). In our experience, unless the needle is passing through muscle,this maneuver is rarely painful. During this maneuver, the supervisorshould point to the specific location on the ultrasound screen wherethey are seeing movement, allowing the trainee to begin to appreciatethe subtle changes associated with needle movement.
During the insertion process there is a tendency for inexperiencedlearners to pick the probe entirely off the skin. We discourage this fortwo reasons: 1) when they pick the probe up, the tissuemoves, which can alter the position of the needle relative to the targetvessel; and 2) slow, deliberate sliding and fanning ofthe probe are necessary for mastery of DNTP. Thus, leaving the probe incontact with the skin allows the operator to gain more experience overthe course of a single procedure attempt.
Below are a series of questions that are often asked by learners, withsuggested answers and explanations.
The Patient Moves When I Try to Puncture Their Skin. How Can This BeMinimized?
We often use ice placed over the target vessel1–2 minutes before sterile preparation or sterile ethyl chloride sprayimmediately before venipuncture to desensitize the superficial skin layer.Although counterintuitive to the heat typically applied to superficial veins toinduce vasodilation, we find most deep vessels will not constrict significantly,and even in those that do the decrease in pain experienced results in lessmovement during insertion, although this has not been studied.
Why Not Just Use Pythagorean Theorem to Determine Where to Insert theNeedle?
Although the Pythagorean theorem method has beendescribed, we often observe errors in location of needle insertion (usually toofar back from the center of the probe), resulting in the needle reaching thevessel before it crosses the ultrasound beam (43). In addition, the Pythagorean theorem relies on a 45-degreeapproach; we recommend taking a steeper approach to minimize catheter length inthe subcutaneous tissue (44, 45).
Why Should I Not Use the “Flash” of Blood (Blood Visualizedwithin the IV Apparatus) as an Indication I Can Thread the Catheter?
Blood within the IV often indicates the needle tipwithin the vessel but not the catheter itself, and attempting to thread thecatheter off at this point often results in pushing the needle out of the vein,with catheter insertion into the surrounding subcutaneous tissue rather than thelumen of the vein (Figure 4). We findthat learners have greater success when not observing for a flash.
Why Should I Continue to Advance the Catheter in the Vein after I Puncturethe Anterior Wall?
Once the needle has punctured the anterior wall of thevessel, continuing to insert the needle into the vein helps in two ways:1) When you remove the ultrasound probe from the skin, thesubcutaneous tissue is no longer compressed and can result in the needledislodging from the vessel as it shifts back to its resting position. Thefarther the needle is inserted into the vein beyond the puncture point, the moreit is “speared” and held in place when the probe is removed.2) The farther the needle is inserted in the vein, the lesslikely it is to slide out of the vessel if the needle is inadvertently, evenminimally, retracted before the IV is threaded all the way in. The needle tip isbeing followed within the lumen of the vessel, so it is usually notuncomfortable for patients while advancing farther. In addition to the describedbenefits, it allows more deliberate practice with DNTP during a single procedureattempt.
How Many USPIVs Will I Need to Place before I Am Competent?
The available literature, which focuses mostly on nursesand emergency medical services personnel, suggests four attempts for a successrate of 70% and 15–26 attempts for success rate of 88%(13).
Why Is This the Approach?
We present our method of teaching USPIV placement at thebedside, using a short-axis dynamic ultrasound technique, with a particular focus ona steep initial approach and advancing the needle and catheter device almostentirely into the vessel before attempting to thread the catheter. This variationcombines principles of the JITT approach with a three-step briefing, intraproceduralteaching, debriefing model for procedural skills teaching (46, 47). Brieflypracticing components, particularly ultrasound and catheter holding technique,before proceeding to the bedside creates the opportunity for technique reinforcementat the bedside, while allowing the learner to focus on more-advanced components ofthe skill set required to independently place USPIVs. The insertion technique itselfcreates a similar opportunity for deliberate practice of the micro-skill surroundingneedle localization and advancement, maximizing the learning potential of eachexperience. Post-procedure debriefing allows revisiting teaching points that weredelivered in real time and the ability to demonstrate alternative approaches ortechniques that may be used during future USPIV placements.
Success using this method of instruction has been demonstrated across multipleinstitutions in both the ICU population and hospital ward patients in whom landmarkIV placement has been unsuccessful. This teaching approach promotes carefulattention to needle location and fine motor ultrasound skill and can be accomplishedin real time at the bedside.
Acknowledgment
Evan Makkas completed the illustration in Figures3 and and4.4. Dr. Brian McNicholshelped develop the insertion technique described in the paper.
Footnotes
This articlehas a related editorial.
This article has a data supplement, which is accessible from this issue’stable of contents at www.atsjournals.org.
Author disclosures areavailable with the text of this article at www.atsjournals.org.
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