Ultrasound-Guided Antecubital Line

See Also

Indications

Standard peripheral access difficult
1. Difficult IV Access (DIVA) occurs in 5-8% of patients
Alternative to central venous access when standard peripheral lines are difficult

Anatomy
Antecubital fossa venous access sites

Cephalic Vein (lateral, radial aspect)
1. Preferred if accessible (very superficial)
2. Often cannulation here has already been attempted by standard peripheral IV techniques without success
Basilic Vein (medial, ulnar aspect)
1. Most common site for Ultrasound-guided antecubital access
2. Access site may need to be above antecubital fossa (proximal to confluence of vessels)
Deep Brachial Vein (midline antecubital)
1. Third-line access site if Cephalic Vein and Basilic Vein not accessible
2. Adjacent to the deep brachial artery
3. Near proximity to the Median Nerve

Efficacy

Ultrasound guided peripheral IV has reduced the need for Central Line by 80%
1. Shokoohi (2013) Ann Emerg Med 61(2): 198-203 +PMID:23141920 [PubMed]
Extravasation is more common with deep brachial vein IVs (see below)

Precautions
Extravasation Risk

Deep Brachial Vein Lines (Midline Venous Catheters) may have a higher rate of Intravenous Contrast extravasation
Use as long of an intravenous catheter as possible
1. Thread as much of the catheter inside the vein
Use Ultrasound in both in-plane (long axis) and out-of-plane (short axis) to reduce extravasation risk
1. Approach the vessel in short axis (out-of-plane)
2. Thread the catheter inside the vessel in long axis (in-plane)
References
1. Swaminathan and Avila in Herbert (2021) EM:Rap 21(1):7-8
2. Hardie (2014) Emerg Radiol 21(3):235-8 [PubMed]

Preparation
Ultrasound cart venous access supplies (per Dr. Dewitz reference)

Skin Preparation
1. Chlorhexidine
2. Tourniquets
3. Tuberculin syringes (25 gauge needle)
  1. For Lidocaine injection of insertion site (clear syringe of air bubbles)
Ultrasound preparation
1. Major healthcare groups recommend sterile probe cover AND single-use sterile gel
  1. American College of Emergency Physicians (ACEP)
  2. European Society of Radiology Ultrasound Working Group
  3. American Institute of Ultrasound (AIUM)
2. Sterile Ultrasound probe cover (pore size to block 30 nm Hep C, 50 nm HBV, 110 nm HIV)
  1. Standard Ultrasound probe covers ($7, pore size <30 nm)
  2. Sterile gloves ($1-2)
    1. Use only first half of glove, wrapping fingers out of the way
  3. Condoms ($0.40, pore size 110 nm)
    1. Blocks HIV, but not HBV or HCV
  4. Non-sterile glove (with single-use sterile Ultrasound gel)
    1. Infection rates were similar to standard peripheral IV (5.2 per 1000)
    2. Adhikari (2010) J Ultrasound Med 29(5): 741-7 +PMID:20427786 [PubMed]
  5. Avoid Tegaderm
    1. May damage transducer
    2. Not designed as probe cover
      1. However, manufacturer does list as barrier protection against viruses >27 nm
3. Sterile gel packets (Ultrasound gel single-use, surgi-lube or similar lubricant)
  1. Used as Ultrasound acoustic gel and lubricant
  2. Most infections are due to Ultrasound gel contamination (when single use packs are not used)
Procedure
1. Syringes (10 cc)
2. Vascular Access needles
  1. Long needles are critical (per Dr. Dewitz reference)
    1. Vein depth >1.5 cm
      1. Introducing catheter in Central Line kits: 18 gauge, 2.5 inch (6.35 cm)
    2. Vein depth <1.5 cm
      1. BD Angiocatheter: 18 gauge, 1.88 inch (4.8 cm)
  2. Standard IV angiocatheters (1.3 inch, 3 cm) are not long enough
    1. Approximately 3 cm of catheter should be within vessel
    2. Accessing vessel through skin requires 1-2 cm simply to reach vessel (assuming 45 degree approach)
Dressings
1. Venigard catheter holder
2. Tegaderm
  1. Applied to venigard to prevent snagging
3. Benzoin
  1. As needed to hold dressing in place

Preparation

See Ultrasound preparation above
Sterile gauze
Chux pads
Obtain from nurse
1. IV Tubing (prefilled with saline)
2. Blood draw tubes and appartus needed
3. Lidocaine 1% (optional)
  1. Clear bubbles from syringe (significantly interfere with Ultrasound image)

Technique
Right antecubital

Apply Tourniquet high on arm
Position patients arm extended, supinated and abducted
Lay chux under arm
Chlorhexidine preparation to antecubital fossa
1. Prepare upper arm to antecubital fossa
2. Prepare arm to also include a few cm distal to the antecubital fossa
Prepare Ultrasound
1. Ultrasound machine should be on your side of the patient, directly in front of you
2. Apply Ultrasound gel to transducer (will be within probe cover and does not need not be sterile)
3. Apply probe cover to surface of transducer (scanning head)
4. Apply sterile gel on skin for lubrication and acoustic transmission
5. Place transducer in transverse (short axis) with indicator facing towards your left (patient's right or 9:00 position)
6. Identify optimal vessel for access (see anatomy above)
  1. Avoid trying to cannulate anything smaller than 3mm diameter (too small)
  2. Distinguish vein from artery
    1. Compression may distinguish vein from artery (but unreliable in dehydrated patients)
    2. Doppler (or color flow) is preferred to distinguish vein from artery
  3. Determine vessel lie or course
    1. Follow vessel proximally in short axis (transverse) and then in long axis
Images
Needle preparation
1. Choose needle size based on vessel depth (see above)
2. Attach 10 cc syringe to needle
Needle insertion
1. Position the transducer such that the target vessel is in the center in the Ultrasound image
  1. Transducer is in short access with indicator to your left
2. Insert the needle at exact midline of transducer
  1. Transducer should have side marked with exact midline
  2. Direct the needle at 45 degree angle in line with vessel course (as defined above)
  3. Bevel should be either up or down
3. Follow the needle tip by slowly tilting the transducer towards upper arm
4. Advance needle with jack hammer technique
  1. Small ocillations of forward movement enhance the visualization of the needle
  2. Small foward movements decrease possibility of entering posterior vessel wall
  3. Aspirate while advancing needle
5. Observe needle enter vessel
  1. On entry, adjust angle to be more shallow (20 degrees) for further needle advancement
  2. Rotate transducer to long axis
  3. Advance catheter into lumen under observation
  4. Hand off Ultrasound transducer for secure placement in Ultrasound cart cupholder
Procedure completion
1. Needle removal
  1. Hold pressure over the proximal vessel while withdrawing needle (prevents bleeding)
  2. Hold the catheter hub to prevent withdrawing from vessel
  3. Apply IV extension tubing
2. Clean and completely Dry Skin
  1. Chlorhexidine can help remove the surgilube
3. Secure IV
  1. Apply IV catheter clear dressing (e.g. Veni-gard)
  2. Apply Tegaderm over Veni-Gard to prevent snagging
4. Clean transducer
  1. Remove Ultrasound probe cover
  2. Apply probe disinfectant (e.g. T-Spray or gray-topped Alcohol-free germacidal wipes)

References

Dewitz (2012) Ultrasound-Guided Vascular Access Video, GulfCoast Ultrasound, VL-90-UGVAHD
1. https://www.gcus.com/products/about.asp?product=306/Ultrasound-Guided-Vascular-Access
Goldstein (2006) Ultrasound Guided Peripheral Access
1. http://www.isrjem.org/Dec06_VenousAccess_Goldstein_postprod.pdf
Lin and Mirsch in Herbert (2019) EM: Rap 19(1): 9-10
Keyes (1999) Ann Emerg Med 34(6):711-714 [PubMed]
Riley (2012) Crit Ultrasound J 4(1): 3 [PubMed]
Spiegel (2020) Ann Emerg Med 75(4):538-45 [PubMed]