Overview
Definition:
Ultrasound-guided basilic vein cannulation is a technique employing real-time ultrasound imaging to identify and access the basilic vein for intravenous (IV) catheter insertion, particularly in patients with challenging peripheral venous access.
Epidemiology:
Difficult IV access affects approximately 10-25% of patients, with higher prevalence in the elderly, obese, chronically ill, and those with prior difficult venous access
Basilic vein is a common target for USG-guided cannulation due to its size and course.
Clinical Significance:
Ensures timely and reliable IV access for fluid resuscitation, medication administration, and monitoring in critically ill or complex patients
Reduces patient discomfort, vein damage, and the need for multiple venipuncture attempts, minimizing complications and improving treatment outcomes
Crucial skill for surgeons managing trauma, critically ill patients, and those requiring prolonged IV therapy.
Indications
Indications For Cannulation:
Patient presenting with difficult peripheral venous access
Need for reliable intravenous access in emergent or urgent situations
Requirement for long-term intravenous therapy or chemotherapy
Obesity with poor superficial venous visualization
Previous failed attempts at peripheral IV insertion
Patients with edematous extremities
Patients requiring frequent blood draws or infusions
Elderly or pediatric patients with fragile veins.
Contraindications:
Local skin infection or cellulitis at the cannulation site
Presence of a superficial arteriovenous fistula or graft in the arm
Severe coagulopathy (relative contraindication, requires careful assessment and potential correction)
History of deep vein thrombosis (DVT) in the ipsilateral arm
Patient refusal
Absence of skilled operator.
Patient Preparation:
Obtain informed consent
Explain the procedure, risks, and benefits
Position the patient comfortably, typically supine or with the arm abducted and externally rotated
Ensure adequate lighting and sterile environment
Prepare sterile ultrasound probe cover, gel, antiseptic solution, sterile drapes, and appropriate size IV catheter and dressing.
Ultrasound Technique
Probe Selection And Prep:
Use a high-frequency linear transducer (e.g., 7-12 MHz) for superficial structures
Apply sterile probe cover and sterile ultrasound gel.
Vein Identification:
Locate the basilic vein in the antecubital fossa or proximal forearm
Visualize the vein in B-mode (grayscale) to assess its size, depth, and patency
The basilic vein is typically superficial and medial to the brachial artery
Compressibility is a key indicator of a vein.
Needle Insertion Technique:
Perform sterile skin preparation and local anesthesia if indicated
Use an in-plane or out-of-plane approach for needle insertion
The in-plane approach, where the needle is parallel to the long axis of the transducer, is generally preferred for better visualization of the needle tip
Advance the needle under direct ultrasound guidance towards the identified vein lumen.
Cannulation Process:
Observe the needle tip entering the vein lumen on the ultrasound screen
A transient change in vessel caliber or appearance of blood flashback in the needle hub may occur
Once the needle is appropriately positioned within the lumen, advance the catheter over the needle into the vein, maintaining ultrasound visualization
Remove the needle and secure the catheter with a sterile dressing.
Postprocedure Care
Immediate Assessment:
Confirm successful cannulation by observing for blood return and ease of fluid infusion
Check for signs of extravasation or infiltration
Secure the catheter dressing to prevent dislodgement.
Monitoring:
Monitor the insertion site for signs of infection, phlebitis, or thrombosis
Assess for erythema, swelling, pain, or discharge
Evaluate the patency of the IV line regularly.
Documentation:
Record the date and time of cannulation, the vein accessed, catheter size, ultrasound guidance utilized, operator's name, and any complications encountered
Document patient's response and any subsequent IV site issues.
Complications
Early Complications:
Arterial puncture
Hematoma formation
Nerve injury
Phlebitis
Infiltration or extravasation
Accidental dislodgement of catheter
Air embolism (rare with peripheral access).
Late Complications:
Infection (local or systemic)
Deep vein thrombosis (DVT)
Post-thrombotic syndrome
Catheter occlusion
Phlebitis.
Prevention Strategies:
Meticulous sterile technique
Careful vein selection and identification
Proper needle angle and depth
Secure catheter fixation
Regular site assessment and monitoring
Patient education on IV site care
Early recognition and management of complications.
Key Points
Exam Focus:
DNB/NEET SS questions often focus on indications for USG-guided access, identification of specific veins (basilic, cephalic), steps of the procedure, and potential complications and their management
Understanding the difference between in-plane and out-of-plane approaches is crucial.
Clinical Pearls:
Use dynamic imaging to assess vein compressibility and flow
Slight angulation of the transducer can help visualize the entire needle shaft
Color Doppler can confirm arterial vs
venous flow if doubt exists
Practice is key to proficiency in ultrasound-guided vascular access.
Common Mistakes:
Failure to use sterile technique
Misidentification of the target vessel (especially mistaking an artery for a vein)
Inadequate visualization of the needle tip
Advancing the catheter without proper needle tip visualization
Failing to secure the catheter adequately.