Algorithm for determining viability of using ultrasound technique

1. Inclusion Criteria and Procedures for Utilization of Ultrasound to Secure Peripheral IV’s in the ED Why some patients are not good candidates for ultrasound guided IV’s • Algorithm for determining viability of using ultrasound technique • for securing peripheral IV access in the ED patient. Procedure for insertion of ultrasound guided peripheral IV. Qualifications and training guidelines for practitioners

2. Process for determining viability of using ultrasound guidance to obtain peripheral IV access in ED patients Patient arrives in ED with no IV access ED staff attempts access Yes No ED staff successful? End Call IV team Consider insertion of ultrasound guided peripheral access Does patient have known history of kidney disease? No Yes IV team successful? Yes Yes No See p. 3 See p. 4 End

3. Algorithm for determining viability of ultrasound technique in securing IV access in patients with possible kidney disease. Proceed with Ultrasound Guided peripheral IV insertion. See CPG on p.6 No Has patient ever been diagnosed with CRI, CRF or ESRD? Yes Yes Consult Nephrologist Does patient have nephrologist? No Yes Does Nephrologist approve of procedure? Has patient ever had a kidney transplant? Yes No No Consider other forms of access such as EJ, IO, femoral, or consult surgery for IJ/subclavian. Consider consulting on call nephrologist Lab-work available? Yes No Yes Creatinine >1.2? No Proceed with Ultrasound Guided peripheral IV insertion. See CPG on p.6

4. Why ultrasound guided IV’s should not be used in all patients While using an ultrasound machine to help locate a vein is completely safe, using it to help guide the needle can be problematic. The ultrasound machine allows easy access to the deeper veins of the upper arm such as the cephalic, basilic and brachial veins. Because these veins are so deep they can be difficult to assess for phlebitis or infiltration. By the time a problem is identified, often a considerable amount of damage has already been done to the muscle and other structures of the arm. This is why no vesicants are to be used when infusing medicine through a midline catheter. Another issue is the fact that patients with kidney disease, particularly those who are currently on or will someday be treated with hemodialysis. The best method for administering hemodialysis to patients is by securing arteriovenous grafts, especially the brachiocephalic in the upper arm. Accessing the large veins in the upper arm on these patients risks damage to or loss of potential sites to perform these grafts. Once the vein has been damaged, as can happen with any attempt at canulation, it may no longer be used. This forces nephrologist to use inferior forms of access such as tunneled subclavian shaldon catheters which are prone to infection and have much shorter lifespans. Click here to see an algorithm that will help determine if using the ultrasound technique is appropriate for a specific patient.