I have been doing ultrasound guided sticks at my hospital.  I am also a PICC RN.  We do not currently have a policy in place.  I have been asked to write a policy and start out training the trainer in the ED and ICU.  Can anyone tell me what criteria is needed to validate non PICC RNs.  I was thinking at a minimum a class and written test for anatomy of veins, nerves, and best vein selection etc etc.  Then at least three successful sticks.   Can anyone share their practices.    Thanks, JEN

 Hi,  pretty sure I have

 Hi,  pretty sure I have recently emailed this to you but if not let me know. Thanks, kevin 

Kevin Arnold RN, BSN

assist with policy of u/s peripheral iv starts

Kevin: My facility certainly can benefit from your assitance  can you email me any help?  kdubore@comcast.net

Kimberly DuBore, RN, BSN
PICC Chick and Imaging Nurse

US IV policy

Shaun:  Like others I have been asked to produce a policy regarding US peripheral starts...Sound like you have done this... are you willing to Share?  I have had mulitple complaints from patients re: arterial and nerve sticks.  My Chief wants a policy inre gards to a class and anatomy of vessels ... can you help?



Kimberly DuBore, RN, BSN
PICC Chick and Imaging Nurse

I have been researching this

I have been researching this topic myself and came across this article. It compares the ultrsound insertions of both long and short catheters.  They did ultrasound examination at the time of removal.  I don't like the thrombosis rates.  Although the article doesn't state so it appears these are upper arm placements. 





 Shaun... Sorry been really

 Shaun... Sorry been really busy lately.  Sent you info tonight.  - kevin

Kevin Arnold RN, BSN

Ultrasound Guided IV's

Hello Philip,

Was wondering if you wouldn't mind sending me your training/protocol/policies for ultrasound guided IV placement?

We are working to develop these at our hospital and really could use any guidance you can offer.



Shaun rn,bsn

Email:  scwerner3@yahoo.com


Hi Kevin,


Any way you could send me a copy of all info (policies, procedures, competencies, etc).  We are trying to develop a program here at my hospital and anything you have would be greatly appreciated.


Thanks very much.


Email: scwerner3@yahoo.com


 So sorry, but time

 So sorry, but time limitations now do not permit me to provide lit search results as a free service. You can easily locate studies of this nature by searching PubMed. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Ultrasound Study in Our ER

Hi Lynn,

Our ED EBP team will be developing a program for training our emergency nurses with US-guided peripheral access tailored to our difficult access population.  I've gathered a lot of literature and am in reviewing them for our group.  I was wondering if you could provide the studies your mentioned, about complications with access in the hand, wrist, acf, or let me know where to find them?  Thanks, 

Bruce Schilling, RN, BSN, CEN

barnes-Jewish Hospital, Saint Louis, MO 

US IV Protocol



Thanks for your response on helping me with a Peripheral IV Ultrasound Guided Protocol.  My email address is:  brian.burdick@med.navy.mil  also could you send it to cheesehead0910@msn.com because sometimes email dont get through at work.


Brian Burdick



 Sure. Send me your email or

 Sure. Send me your email or post it. 

Kevin Arnold RN, BSN

Would love a copy

Kevin I would love a copy of your education. I really think this would benifit my own education and my hospitals.

Thank you in advance for all that you have done.


Leigh Milazzo RN, BSN, VA-BC

Vascular Access Nurse

Hillcrest Baptist Medical Center

There is also a policy with a

There is also a policy with a compenency checksheet under the resources tab on this site.

Daniel Juckette RN, CCRN, VA-BC

Brian, I have policy,


I have policy, competency, outcomes monitoring, and a teaching ppt if you would like to use it. Shoot me an email... kev1999@gmail.com



Kevin Arnold RN, BSN

ultrasound guided piv's

thanks Kevin. Very thorough and helpful :)

I agree with Kevin

I have to say I place them the same way Kevin does to the letter and I have never had issues with the gel or the marking. I must say that  ultrasound is great even for surface veins. 90% of mine are .5-1cm in depth. We will hopefully be trying the power wand soon so that will help me out as well.



Peripheral IV Utrasound guided

Hey All,


I see that you have all either implemented or are implementing Protocols and Training for Peripheral US IV placement.  I am a charge nurse in the ICU at Naval Medical Center San Diego.  I have been placing PICC lines for 5 years.  I am currently one of the only nurses to use US for peripheral placement.  I would like to create a protocol and training for our hospital (ICU and ED).  Any assistance with with would be greatly appreciated. 



Brian Burdick, LT, NC , USN


education material for ultrasound guided piv's



Kevin, Could you please email me the education material you've been sharing for the ultasound guided peripherals. It would be much appreciated. My email is sgoodman @psu.edu  Thanks you very much

Sue G C.R.N.I

Hi Kevin, I started using us

Hi Kevin, I started using us for diff Iv insertions since 2003' and in 2006-2009 had been developing a program for teaching and perfecting insertion (trouble shooting).  the biggest obstacle was catheter length and with the deeper access, avoiding intuma damage that leads to future infiltration.  I would like to chat with you to share experiences and discuss each others process.  You can reach me at bradphrn@gmail.com.   Brad d.

Bradford A. Dungan

Ultrasound Guided peripheral IV sticks

 A full educational program on Ultrasound Guided PIV Placement with written material and simulation exercises will be available on www.piccexcellence.com within the next month. This class is online and designed to meet a policy educational requirement. Created in conjunction with Irene Muirhead it includes tools and sample forms to help get any US PIV program going.

Nancy Moureau




Nancy L. Moureau, BSN, CRNI, CPUI, VA-BC

PICC Excellence, Inc

emailed everyone up to

emailed everyone up to here..please let me know if you didnt get it.


Kevin Arnold RN, BSN

ultrasound guided Pivs

Hi Kevin, is there  any way I can see your education regarding IV's inserted with ultrasound?  I have done a couple, with my PICC experience, but would love to see what suggestions you have for a more successful cannulation? Thanks,Tessy, tessy465@aol.com

Kevin-Educational Tools Hi

Kevin-Educational Tools

Hi Kevin-I would also love a copy of any tools (p&p, presentation, etc) you have.  Could not find them on the old site. 

Thanks so much, Jeannette




Jeannette Andrews, RN, CRNI, VA-BC

Kevin-Educational Tools Hi

Kevin-Educational Tools

Hi Kevin-I would also love a copy of any tools (p&p, presentation, etc) you have.  Could not find them on the old site. 

Thanks so much, Jeannette




Jeannette Andrews, RN, CRNI, VA-BC

U/S guided PVC insertion

Hi All,

I have also been asked to develop teaching tools and policies for ED, Radiology and chemo unit staff in the skill of u/s guided cannulation.

Great points re correct vein selection ongoing battle to champion change in this area.

Any info available would be much appreciated, please email me (gavin.jackson@health.wa.gov.au)

Hoping to get to AVA this year depending on staffing, so hope to meet some of you there.



Gavin Jackson

IV Therapy CNC

Sir Charles Gairdner Hospital

Perth, Western Australia

I am a PICC nurse in

I am a PICC nurse in training. I have access to a SiteRite US. I don't use it everytime. I do, however, when I get the call that 2 other nurses have tried and had no luck.
I would add to ensure the initiates are competent in identifying arteries versus veins.

Art Hansen BSN, RN, CRNI

Name: paigebertrand


I would be willing to share

I would be willing to share my US guided PIV Procedure and Competency Verification Checklist through the site if the webmaster will contact me for it.

Daniel Juckette RN, CCRN, VA-BC


Hi JEN, I was going through similar situation about a month ago. One of my good friends wanted to carry out the procedures himself. So I didin't really look deep into it. But there's this site i checked out in a review iu22 but didn't have time to really see what it offered. I am not sure if it is exactly what you want.

Pat, I am still putting


I am still putting together some of my outcome stats each week, but I can email it to you if you like. The classroom slides are complete. Please post your email or send me an email at kev1999@gmail.com and I will send it your way.


Kevin Arnold RN, BSN

Sono guided peripheral IV placement.

I would like a copy of your presentation for AVA. We are researching the possibility of using sonon to place peripherals, however , we deal in high volumes of CT patients that need access for high pressure injections. Would appreciate yourinput.



Ultrasound guided peripheral IV


We are very interested in your information, guidlines, policies, and/or training information on this topic.

Could you please send me a link or email us your information.

Thank you!

Angela Wright, RN, BSN, VA-BC



Ultrasound Guided IV Placement

I am the Coordinator for the Ultrasound Guided IV Placement for Nurses in the Duke Emergency Department.  We started developing the training 5 years ago and have trained approximately 60 RN's to perform this skill as well as many of the Emergency Medicine Residents.  We have a 3 hour didactic and then clinical performance guidelines for check-off.   We teach the skill and a proven "method" which, if adheared to, results in high success rates of placing reliable venous access.  We have also adapted this skill to arterial punctures for ABG's, and have trained RT's who place arterial lines. Please let me know if we can be of any assistance.


Phillip L. Stone RN CN-IV

Ultrasound Program Coordinator


How soon do you need them?  I

How soon do you need them?  I am presenting on this topic at AVA this year...so i am currently polishing my materials. If you can wait a week or so, I should be done with them. I will probably put them on a hidden page in one of my web sites (www.ivaccess.com or www.ivtags.com) to make them easy to find.  In addition, i can resubmit them to this site and email them.

If you need something immediatly, I can send you now my 98% finished version. Just let me know.


Kevin Arnold RN, BSN

Training materials

Kevin......I am unable to find the training materials you use for ultrasound guided peripheral IV catheter insertion.  Would you please re-post them or send to me at almakooistra@hotmail.com


Alma Kooistra RN CRNI

sent email Jen/Matt.

sent email Jen/Matt.

Kevin Arnold RN, BSN

Kevin-Educational Tools

I'd love a copy of any tools you have.  I searched the site for your old postings, but did not come across them. 

Thanks in advance,

Jenn Marusich

Team Leader-VAT



Educational Tools

For Kevin and Michelle,

I would love to see your training materials for U/S guided PIV insertions. I have been using the U/S for PIVs for about four years with good success, but also have run into some of the same issues. It sounds like you guys have worked out some of the bugs. Any info you are will to send me I would appreciate.

Matt Gibson RN, CRNI, VA-BC



Matt Gibson RN, CRNI, VA-BC

This is not available yet,

This is not available yet, but it is in the publications process. I wrote a chapter on IV therapy for a major ED textbook. I am not sure when it will be out but it does discuss this issue. That would be one resource to use as a step to change this culture. There are other studies that show higher rates of complications in the hand, wrist and ACF. If your hospital relies on evidence, that could help to change their thinking. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

If anyone has found a way to

If anyone has found a way to get traction convincing ER Staff that the antecubital veins aren't the only veins for initial IV/Lab in the ER, I would appreciate access to any resources that helps with that culture change. It doesn't really matter if you can place peripheral IVs with ultrasound if all the antecubltal veins are already punctured.

Daniel Juckette RN, CCRN, VA-BC

Renee / Janette, I have

Renee / Janette,

I have emailed the documents as requested.


I agree with Lynn on preservation of the veins even during PIV placement. One of my presentations points is the general rule of thumb in where to look first, second, third....last. I teach all of our RNs to use the basilic/brachial veins as a last resort.


To anyone that has used my presentation, I will be adding more content soon (pictures, etc). I also will be presenting this topic at AVA in October. I will include all of my materials in that presentation.






Kevin Arnold RN, BSN

I have just read several

I have just read several studies on PIV with US inserted in ED. One thing that struck me is many of these used the basilic or brachial veins of the upper arm for US insertion of a short PIV. My concern is what that is doing to these veins and their later use of a PICC if the patient needs it. These were physician-insertion studies. So you might want to get clarification from these ED doctors about where their preferred insertion site is and then think about how that might influence future PICC needs for each patient. Just a thought, Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

ultrasound guided PIVs

We are about to start our program and I have been charged with gathering policy, competency etc information. We plan to have our MDs in the ER train the nurses. I would be very grateful for any and all information. Thank you JMoss


PIV placement with ultrasound

I am doing the same thing that Kevin describes with the gel and I used to use the same thing to make a mark. But now I made cards with our name badge machine. Instead of saying the employee's name, they say "ultrasound marker". Then I use it to mark the skin over the vein by pressing gently for 5 seconds. Then I scrub the site and put the gel above and don't stick through it. If the vein is large enough, I don't even need to use the ultrasound again, unless I don't get it right away, because the mark shows me where it is. I mark above and below where I plan to canulate so I can see which way the vein goes. Then I double check the mark to be sure the vein is really where I think it is. I also use the 1.75" Braun catheter if the vein is over 1 cm deep, otherwise the site does not last long. I disinfect the marker card and reuse it. I have used water based lube packets for this but it is too hard to get it off and get the tape to stick. I much prefer real ultrasound gel that we purchase in 1 oz packets as it is much less slimy and I also get a better image. It is non-sterile and comes in a box of 100. After I place the line, I just use a chloraprep swab to remove it from just above the site. I don't have trouble holding my traction with the dominant little finger (bent and transverse to the arm) while placing the line and and holding the probe with my left hand. I always do it by myself but it does take practice. It has taken me about 50 lines to be better at it (faster at getting it done) and I frequently use the longitudinal view after I have entered the vein with a transverse view to see the exact angle. I am still experimenting to see which I prefer and sometimes I start with the longitudinal view. I always use a local because it takes me longer to get access than a typical start. The biggest thing to get used to is that you have to be sure the angle is the same that you would expect to use for any other IV, and not as deep as you would use with a PICC typically.

We show all of our nurses how to find the veins with the ultrasound. We teach about the nerve and the artery and instruct them to stay full away from them and any brachial veins. It is about a 10 minute explanation. They are only to find veins that are 1cm or less deep and then mark them with the card. Then they are to use their regular technique of lab draw or IV start and either insert on the mark or try to feel for the vein depending on the depth. If it is over 0.5cm deep then they should try and find a vein that is at least 0.4cm big to go in on the marking, otherwise they will need the more advanced guidance for a smaller or deeper vein. I call it "basic Ultrasound finding technique". Ultrasound-guided placement is much more advanced and it is what I use if they can't get a line or labs or if the patient only has brachial veins, and what I use for PICC placement.

Michelle Todd, CRNI--Head PICC Nurse, Vibra Specialty Hospital of Portland somanysmiles@hotmail.com

ppt, policy, and vidoes

Hi Kevin,

Can you provide me with your ppt, policy, competency, and videos?  I have been asked by our education department to get information on what other hospitals are doing.  My email is rwalsh@ehr.org




PIV catheter selection

I was asking specifically about the selection of gauge and length for PIV catheters.

Daniel, thank you for offering to share your ultrasound guided vascular access procedure and competency checklist.




Our experience is that

Our experience is that ultrasound-guided PIVs are not an "occasional use" skill set. Our nurses who do them do not place PIVs any other way. Like PICC placement, a consistent procedure and frequent repetitions are the best predictor of high success and low complication rates. Our hospital policy is that no one should receive a 3rd stick without calling for ultrasound guidance. iIf the patient has been stuck twice by each of 3 different nurses plus lab, they are hysterical and and the best potential sites are already gone. Trying ultrasound at that point is just continuing the abuse. We have a written procedure and competency validation checklist. I can provide it if you send me an email address. Our nurses practice on simulators and then are precepted in US guidance for PIVs, just like with PICCs.

 Braun Introcan that is 45mm long is available in both 20 and 22 gauge. We usually don't have any difficulty placing them in the mid forearm cephalic. For most patients you can access it at .5 to 1cm depth and have little difficulty getting more than 50% of the catheter in the vein. Use of a securement device is required. If you can only find 1.5cm or deeper veins in the forearm,  then push for a CVAD. If the antecubitals are ruined the upper arm cephailc is worth a try, but it's much harder to position for placement and harder to secure. Getting serious about vein preservation over a lifetime means minimizing the number of sticks every time. Patient satisfaction scores are directly affected by the number of punctures (and bruises) they go home with.


Daniel Juckette RN, CCRN, VA-BC

What type of catheter are you

What type of catheter are you asking about? PIV or PICC? The standard of practice is now and has always been that the smallest size and shortest length of catheter that will accommodate the prescribed therapy be chosen. There has been some suggestions about comparing vein internal diameter to catheter outer diameter and discussions at conferences but I don't think this has been published yet. So a standard can not quantify this yet. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Selecting catheter length and gauge

I often hear the following recommendations:

a) at least half of the catheter length should be left into the vein

b) the catheter outside diameter should be less than 30% of the vessel lumen

Are these general best practice rules? are these recommendations captured in any of the standards?

Thank you,


true, there are times whena

true, there are times whena 1.88 inch catheter is not long enough; however, our hospital only stocks the 1.16 inch cathlone which is definitely not long enough.  I have had great success with maintaining IV's with the 1.88 inch catheter.  Thanks for the info on the device you mentioned, I will look into it.  I have a question - we occassionally place a midline, but seem to have a lot of complications with them - leakage, thrombus etc.  I do not feel it is techniques related, but rather nurses who refuse to comply by the infusion guidelines we set up for midlines - even though they state they are.  What is your take on this, is there possibly something we as clinicians are doing that may be contributing to this.  We place just as if we were placing a PICC line with all the precautions in place, but still always have a problem with a mid line several days after placement.  We do not place very many of these at all, I would just like to get some input.  thanks.


Frequently a 1.88 inch

Frequently a 1.88 inch catheter is not long enough often resulting in infiltation or worse extravasation. At the recent LITE conference there was a very interesting product introduced called the M/29 midterm catheter that as demonstrated seemed like a safe and effective alternative. It is being marketed as a Midline Catheter System and information can be found at www.flexicath.com.

Robbin George RN, VA-BC Vascular Access Resource Department Alexandria Hospital Virginia 

Robbin George RN VA-BC