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1. Patient name
2. Select the probe a/ linear array = Superficial depth, high frequency usually 8 to
10 MHz, very good picture high resolution , use in vascular and enrve blocks
b/ curvilinear abdominal pelvic exams, lower resolution
but high depth , lower frequency,2 to 4 MHz
c/ cardiac phased = lowest frequency , great depth, good
3. Before you start, adjust the brightness and/or contrast on your monitor . Start
with 90-100% contrast, then adjust the brightness. Turn the brightness to its
highest point, then concentrate on the very bottom of the greyscale bar; it will
be the darkest point. Slowly turn the brightness down until the darkest level is
black and no longer visible. The top should be white, but not over-saturated. If
you have a contrast adjustment (many portable machines do not), you can set
this to your liking.
4. Preset choose the preset in your machine . For musculoskeletal and needle
guidance, do not use OB/GYN, abdominal, cardiac, and urology settings
when using a linear probe because these settings are for deeper
structures . Look for any preset associated with superficial imaging such
as small parts, breast, venous, peripheral vascular, thyroid, nerve
5. Adjust the depth setting. Start with deep settings , find what you are looking

for and adjust the depth to bring this item to the center of the screen. In the
right side of the screen you will have the depth markings on centimeters, if you
are looking for the yugular vein , do not go to 20 cm, it is not there anymore,

you are way out , but in a big patient looking for the abdominal aorta, well,
different history.
6. Frequency . It allows to increase resolution at the expense of penetration, or
increase penetration at the expense of resolution. If you choose high frequency, your
resolution, the quality of your image improves but your penetration decreases and
viceversa . Each probe has a range of frequencies in which it operates . Some
machines will show the actual frequency range (represented by MHz),;others dont
show the frequency and offer one of three choices: Res, Gen, or Pen . Res
translates to the highest frequency band available on the transducer. These settings
are used for superficial imaging. Gen represents mid-range frequencies that are
often the default setting. Pen represents the transducers lowest range of
frequencies and is for deeper tissue or difficult-to-image patients. Try the different
settings in each image you take. Youll want the highest possible frequency setting
that allows you to see the anatomy youre viewing. Use lower frequencies when you
need penetration in the image. Use higher frequencies when you are looking at
superficial imaging. High frequencies provide the best resolution, but you lose
penetration. Low frequencies provide the best penetration at the expense of image
7. Dont fear the gain control. The gain knob will likely be your most-used
imaging control. This adjusts the overall brightness of the ultrasound image. Get in
the habit of adjusting it, youll be surprised at how a simple twist can make a world
of difference in your image quality.Aim for fluid to look black, a couple of
hyperechoic white spots and the rest should look grey
8. TGC: Time Gain Compensation controlsWith the exception of SonoSite and
many tablets, each machine has 5-10 slide controls grouped together. These are TGC
or Time Gain Compensation controls. They adjust gain in specific areas of the image
(near-, mid-, and far-field). The best way to see what a control does is to slide one of
the controls all the way to the right, then all the way to the left while looking at a
live image. Youll see that a certain section of the image turns very bright, then very
dark.When you receive the ultrasound, the TGC controls appear as they do in the
image on the left, in a straight line down the middle. Most techs adjust these to leftof-center for the nearfield (top), and slowly move to right-of-center as image quality
decreases deeper in the image. The idea is to have lower gain in the nearfield, and
higher gain deeper in the image where image quality is weaker.SonoSite users: The
general equivalent of TGC are two separate gain knobs that control nearfield gain
and farfield gain.

Ultrasound Focus position, focal zones The focal position tells the ultrasound
the depth at which youd like the highest resolution. As you move the focal position up
and down, youll see a triangle or dot move up or down the left or right side of the
image. Youll see the image resolution improve in the area of the selected focal
position.Focal zones allow you to have multiple focus points. As you increase the
number of focal zones, your frame rate will decrease and the image will refresh slowly.

Auto Optimization Many ultrasounds come with a feature that automatically

optimizes the gain and overall contrast of the image. This feature analyzes the tissue in

the image and attempts to provide you with the most optimized image. This feature is
usually called one of the following variations: Auto Optimize, Auto Tuning, or Tissue

If youve made a disaster of the image, reset to the

original preset you selected. Simply go back to the exam or
preset screen, and select the preset which you originally
chose. This will reset all of your changes, allowing you to
start over.
Tissue Harmonics Imaging. Allows the ultrasound to identify body tissue and
reduce artifact in the image. Harmonics is useful in most situations, particularly on
difficult-to-image patients where theres a lot of noise in the image. Note, however,
that it doesnt always help for very superficial tissue or very deep tissue (it varies
depending on the transducer). The best way to see what harmonics does is to turn it on
and off in different situations to see what helps. How do you use it? A machine with
harmonics will have a THI, Harm, HI, or similar button/control on the machine.
When its enabled, it is typically adjusted via the Frequency control. The frequency
display will likely change from displaying frequency range (in MHz) to Low, Mid, and
High or Pen, Gen, and Res. Low and Pen are for deep tissue while High and
Res are for superficial imaging. Drawbacks? Deep penetration. The image can
outright disappear completely when looking at deep tissue. In this case, youll want to
turn it off for the most difficult-to-image pati ents (particularly obstetrics).

Speckle Reduction Imaging Speckle Reduction Imaging (SRI, uScan, XRES, etc)
uses an algorithm to identify strong and weak ultrasound signals. It provides a
smoother, cleaner image. why use it? You can identify tissue better. It makes
measurements easier and provides a much cleaner image. Most machines with Speckle
Reduction have it on for nearly all of their presets. Rarely will you have it off.How
to use it: Most machines offer varying levels of Speckle Reduction. The lowest levels
reduce small amounts of artifact and lightly enhance tissue, while the strongest levels
can look over-processed. Most often it is set near mid-level. This is a post-processing
technology, which means you can adjust its level after the image is frozen. I recommend
you take an image, freeze it, then adjust its Speckle Reduction levels to see its effect on
the image.Drawbacks? When set too high, the image can look like crumpled paper.
Compound Imaging What is it? Compound Images combines three or more images
from different steering angles into a single image. Why use it? Compound imaging
increases image resolution by using the multiple lines of site to eliminate artifacts,
shadows, and increase edge detail.Drawbacks? Its not always effective in extreme
superficial imaging. It isnt available for sector transducers. The deeper the penetration,
the less effective it is. The more lines of sight, the slower your frame rate. Compound
Imaging is available only on linear and convex transducers.
Extra bonus: Some machines allow you to use it for 2D Beam Steering which can
make a large difference in needle visualization because the beam will reflect
perpendicular to the needle. The result is a very bright image of the needle.


1. Cephalic Vein (lateral, radial aspect).Preferred if accessible (very superficial)
1. Basilic Vein (medial, ulnar aspect) Most common site for Ultrasound-guided
antecubital access.Access site may need to be above antecubital fossa (proximal to
confluence of vessels)
2. Deep Brachial Vein (midline antecubital) .Access site if Cephalic Vein and Basilic
Vein not accessible.Adjacent to the deep brachial artery .Near proximity to the
Median Nerve
Skin preparation . Appy Tourniquet high on arm . Position patients arm extended,

supinated and abducted . Lay chux under arm . Chlorhexidine preparation to

antecubital fossa including few cm proximal and distal.T uberculin syringes (25
gauge needle) for Lidocaine injection of insertion site (clear syringe of air
Ultrasound preparation . Ultrasound machine should be on your side of the patient,

directly in front of you. Apply Tegaderm 10x 12 cm to surface of transducer (scanning

head) to get a sterile barrier .Place sterile surgilube ultrasound lubricant gel on skin
Procedure .Syringes (10 cc) 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
2. Standard IV angiocatheters (1.3 inch, 3 cm) are not long
1. Approximately 3 cm of catheter should be within
2. Accessing vessel through skin requires 1-2 cm
simply to reach vessel (assuming 45 degree

1. Place transducer in transverse (short axis) with indicator facing towards your left
(patient's right or 9:00 position)
2. 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.Follow vessel proximally in short axis
(transverse) and then in long axis

.Choose needle size based on vessel depth (see above).Attach 10 cc syringe to
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
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
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
2. Rotate transducer to long axis
3. Advance catheter into lumen under observation
4. Hand off Ultrasound transducer for secure placement in Ultrasound cart
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 Tegaderm from transducer
2. Spray with disinfectant