Nancy Moureau, BSN, CRNI
Nancy Moureau is an internationally recognized speaker on Peripherally Inserted Central Catheters and issues of intravenous practice. She received her PICC insertion training at MD Anderson Cancer Center in Houston, Texas. Nancy has been a member of INS since 1985, received her CRNI in 1987 and currently practices at Greenville Memorial Hospital. Nancy’s current work includes management of PICC Excellence, Inc., an educational company specializing in PICC, midline and intravenous training programs. Nancy actively consults with manufacturers, distributors, home health companies, infusion pharmacies, attorneys and hospitals on PICCs and other issues dealing with intravenous therapy education. PICC Excellence is a resource for questions and education. Visit us online at www.piccexcellence.com

Objectives
The goals and objectives of this ultrasound training program are for you to learn:

• What ultrasound is and how it works
• How to use all the controls to get the best image on the ultrasound screen
• Various probe movements, when to use them and what these movements can do for your assessment of the veins
• Which veins are located in the upper arm and how to decide which vein to select
• How to scan the arm looking for the best access site
• How to hold the needle and the probe during access
• How to use ultrasound with the Modified Seldinger Technique
• How to scan for unintentional IJ placement prior to breaking the sterile field
• Tips and tricks that will increase the success rate of your ultrasound guided insertions

Ultrasound technology has made it possible to easily and accurately identify veins, arteries and nerve bundles of the upper arm. For anyone inserting vascular access devices, ultrasound is a welcomed addition increasing success rates and avoiding complications associated with blind sticks. Clinicians began using ultrasound for PICC insertions in the middle to late 1990s. Guy LaRue, in Seattle, WA, was one of the first clinicians to incorporate ultrasound into an out-patient peripherally inserted catheter program. Adding ultrasound to his insertion program increased his access success rate from 80% to more than 99%. Ultrasound usage with vascular access is currently supported by a number of national and international groups.

The Agency for Healthcare Research and Quality (AHRQ) released patient safety guidelines that endorse the use of ultrasound guidance for central line placement. The recommendation specified the use of real-time ultrasound guidance during central line insertions as a means of preventing insertion related complications.

The CARI Draft Guidelines, Caring for Australians with Renal Impairment, a division of the Australian Kidney Foundation, states, “Insertion of central venous haemodialysis catheters should be performed under direct vision, either surgical or ultrasound guidance. Blind insertion should be discouraged.”

The DOQI (Diagnostic Outcome Quality Initiative) Guidelines from the National Kidney Foundation mention ultrasound. “Real-time ultrasound-guided insertion is recommended to reduce insertion-related complications.”

The INS (infusion Nurses Society) Standards of Practice state, “The nurse should consider using visualization technologies that aid in identifica-tion and selection.”

The Centers for Disease Control (CDC) Guidelines for the Prevention of Intravascular Device Related Infections Aug 9, 2002, states “In a meta-analysis of eight studies, the use of bedside ultrasound for the placement of CVCs substantially reduced mechanical complications compared with the standard landmark placement technique. Consideration of comfort, security, and maintenance of asepsis as well as patient-specific factors (e.g., pre-existing catheters, anatomic deformity and bleeding diathesis), relative risk of mechanical compli-cations (e.g., bleeding and pneumothorax), the availability of bedside ultrasound and the risk for infection should guide site selection.”

Adding ultrasound guidance to an existing Peripherally Inserted Central Catheter (PICC) program increases the rate of successful insertions to an average of 90% and greater. Ultrasound guidance reduces insertion risks to patients by providing clear visualization of veins and aiding identification of potentially problematic anatomic issues. The advantages are clear; once you become proficient using ultrasound guidance, you will never go back to the old way of blind insertions.