Patients for whom intravenous access is difficult are frequent users of the Emergency Department. When common sites of peripheral access are sclerosed or inaccessible, alternative measures of access include placement of a central venous catheter. The paradigm of placing a central line for every patient for whom landmark peripheral techniques fail can result in decreased patient satisfaction, inefficient use of ED nursing and physician resources and the serious complications of central venous access.


  • Failed landmark technique
  • Anticipated difficult access
  • Central Venous Access undesirable.

Overview of Central and Peripheral IV Access:

Possible Complications:

  • Arterial puncture
  • Hematoma
  • Infection

upper arm vein sono anatomy


  • Any familiar site of IV access can be used (antecubital fossa, dorsum of hand, etc.)
  • The basilic vein is particularly suited to ultrasound guided iv placement
  • Avoid the brachial veins due to proximity of the brachial artery.


  1. Gather equipment and Ultrasound Machine
  2. Scout out vein (locate, check for thrombus, scan proximally and distally)
  3. Determine depth of target vein using markers on side of US screen.
  4. Out of Plane US guidance
    • Puncture skin and identify needle tip
    • Advance probe until needle tip no longer visualized
    • Advance needle until tip visualized again
    • Repeat previous two steps until vein is entered
    • Confirm tip is in vein with saline flush injection

    Short axis technique

  5. In-Plane US guidance
    • Visualize vein in Short Axis
    • Rotate 90 degrees for Long Axis
    • Use ski lift technique to puncture skin
    • Advance needle tip under direct visualization

    Long axis technique

Selected References:

Keyes L, Frazee B, Snoey E, Simon B, Christy D. Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access. Ann Emerg Med. 1999;34(6):711-714.

Blaivas M, Brannam L, Fernandez E. Short-axis versus long-axis approaches for teaching ultrasound-guided vascular access on a new inanimate model. Acad Emerg Med. 2003;10(12):1307-1311.

Brannam L, Blaivas M, Lyon M, Flake M. Emergency nurses’ utilization of ultrasound guidance for placement of peripheral intravenous lines in difficult-access patients. Acad Emerg Med. 2004;11(12):1361-1363.

Blaivas M, Lyon M. The effect of ultrasound guidance on the perceived difficulty of emergency nurse-obtained peripheral IV access. J Emerg Med. 2006;31(4):407-410.

Resnick JR, Cydulka RK, Donato J, Jones RA, Werner SL. Success of ultrasound-guided peripheral intravenous access with skin marking. Acad Emerg Med 2008;15(8):723-730.

Chenkin J, Lee S, Huynh T, Bandiera G. Procedures can be learned on the Web: a randomized study of ultrasound-guided vascular access training. Acad Emerg Med 2008;15(10):949-954.

Panebianco N, Fredette J, Szyld D, Sagalyn E, Pines J, Dean A, et al. 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.

Bauman M, Braude D, Crandall C. Ultrasound-guidance vs. standard technique in difficult vascular access patients by ED technicians. Am J Emerg Med. 2009;27(2):135-140.

Witting M, Schenkel S, Lawner B, Euerle B. Effects of vein width and depth on ultrasound-guided peripheral intravenous success rates. J Emerg Med. 2010;39(1):70-75.

Schofer JM, Nomura JT, Bauman MJ, Hyde R, Schmier C. The “Ski Lift”: A technique to maximize needle visualization with the long-axis approach for ultrasound-guided vascular access. Acad Emerg Med 2010;17(7):e83-e84.

May 2024