Ultrasound-assisted peripheral line placement


  • Ultrasound is a useful adjunct for visualizing vasculature in patients with difficult vascular access


  • Patients with difficult access, multiple unsuccessful attempts
  • Commonly required in patients with obesity or history of IVDU


  • Ipsilateral radical mastectomy, fistulas
  • Overlying cellulitis
  • Burns, thrombosis, edema, sclerosis, phlebitis

Equipment Needed

  • High frequency ultrasound transducer (7.5 - 10 mHz)
  • Probe cover
  • IV catheter (longer ones more useful and less likely to be pulled out accidentally, minimum of 1.75 inches)
  • Alcohol Pad / Chlorhexidine
  • Tourniquet
  • NS Flush
  • Tubing, Caps
  • Tape, Tegaderm


  • 3:1:3 rule - look for veins that are a minimum 3 mm in diameter, 1 cm deep (1.5 cm max), 3 mm long (and straight)
    • Basilic vein and deep brachial are good targets for upper arm
    • External jugular in neck
    • If no suitable peripheral veins or external jugular, can consider EZ IJ
      • Similar procedure as ultrasound guided IV but use a longer peripheral ultrasound catheter and should only stay in for <24 hours, must obtain CXR to rule out pneumothorax
  • As a general rule the depth of the vein equals the distance from the probe at which you should enter the skin at a 45 degree angle
Basilic veins
  • Can be done in cross-section, longitudinal section, or utilizing a combination of the two
    • Cross-section allows easier approach to the vein and works well for superficial veins in particular, but the user must be careful to find the needle tip at all times (by fanning the probe and seeing the needle tip disappear and then re-appear) because otherwise you may be looking at any point along the needle and not know where the tip is located; easy to go through back wall.
    • Longitudinal section allows good visualization of the vein and needle depth (to avoid back-walling), but it can be difficult to keep the needle tip in plan during the entire approach and for superficial veins it is difficult to find the needle before entering the vein
    • An effective combination of these two techniques involves gaining access to the vein in cross-section and then changing to longitudinal section to follow the needle into the vein and avoid going through back wall
      • It is important to not stop once you see flash in catheter. This should be your cue to switch to longitudinal section (if not already done) and continue to advance catheter at least several millimeters up to a centimeter further under visualization. Doing so will significantly increase success rate.


  • Hematoma
  • Arterial puncture
  • Nerve damage
  • Bacteremia


See Also

External Links


Liu S. and Zane R. Peripheral Intravenous Access. In : Roberts and Hedges’ Clinical Procedures in Emergency Medicine, Chapter 21, 385-396.e1