Ultrasound-assisted peripheral line placement


  • Ultrasound is a useful adjunct for visualizing vasculature in patients with difficult vascular access[1]
  • Success is higher in veins that are more superficial and wide[2]
  • More prone to failure and extravasation; ideally use extra long catheters (>2.5 cm)[3]
    • Failure of the IV is high when <30% of the catheter length is in the vessel and minimized when >65% of the catheter is intravascular[4][5]


  • 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
  • Gauze (to remove US gel)


  • 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.
        • An alternative strategy is the "lantern method" in which the probe is moved proximally after the needle tip is observed until it disappears, then the needle is advanced until it is again observed on the screen. These two movements are alternated until the needle and catheter are adequately inside the vessel


  • High rate of IV failure
  • Hematoma
  • Arterial puncture
  • Nerve damage
  • Bacteremia


{{#widget:YouTube|id= riizCYcXhRU}}

See Also

Vascular access types

External Links



  1. Liu S. and Zane R. Peripheral Intravenous Access. In : Roberts and Hedges’ Clinical Procedures in Emergency Medicine, Chapter 21, 385-396.e1
  2. Panebianco NL, Fredette JM, Szyld D, Sagalyn EB, Pines JM, Dean AJ. What you see (sonographically) is what you get: vein and patient characteristics associated with successful ultrasound-guided peripheral intravenous placement in patients with difficult access. Acad Emerg Med. 2009;16(12):1298-1303. doi:10.1111/j.1553-2712.2009.00520.x
  3. Bahl A, Hijazi M, Chen NW, Lachapelle-Clavette L, Price J. Ultralong Versus Standard Long Peripheral Intravenous Catheters: A Randomized Controlled Trial of Ultrasonographically Guided Catheter Survival. Ann Emerg Med. 2020;76(2):134-142. doi:10.1016/j.annemergmed.2019.11.013
  4. Pandurangadu AV, Tucker J, Brackney AR, Bahl A. Ultrasound-guided intravenous catheter survival impacted by amount of catheter residing in the vein. Emerg Med J. 2018;35(9):550-555. doi:10.1136/emermed-2017-206803
  5. Pandurangadu AV, Tucker J, Brackney AR, et alUltrasound-guided intravenous catheter survival impacted by amount of catheter residing in the vein. Emergency Medicine Journal 2018;35:550-555.