Great questions. 1. You can set back a short distance if you want. However, I would generally not set back a substantial distance. Some recommend this, suggesting using trigonometry (well, eyeball trig) to determine how far away from the vessel to start, sticking from there, and "meeting" the plane of the ultrasound near the vessel. However, this basically means you're making most of the stick without guidance. You can use that approach to decide where to stick, but I would still bring the probe with you, so that you'll meet the beam soon after breaking skin and can follow your tip down. 2. All needles will have a different echogenicity, and some are quite poor. I find regular peripheral IVs are often cheap needles and not well optimized for ultrasound. Introducer needles, and particularly micropuncture needles, are usually much better -- scored tips for echogenicity, good bevel angles, etc. This may be balanced by the relative superficiality of most PIV attempts, but still. Tips if you can't see well: bounce your needle a lot to create more tissue movement and angle the ultrasound back towards you to create a more perpendicular angle with the needle.

​@@criticalconcepts5368 really appreciate the tips. With peripheral IVs, I feel like I'm stabbing blindly and can't find the needle tip when I'm only relying on finding wherever the tissue moves. How do I know where the needle tip is if I'm only looking at wherever the tissue is moving?

@@phantastiquely This is definitely a classic situation. Ideally you'd see the hyperechoic dot of the needle, but you sometimes don't, depending on many factors like technique, equipment, etc. With practice you CAN use tissue movement to guide yourself, however. Again, a brisk, jerky, short-amplitude, in-an-out bouncing movement of the needle helps (I set up this bouncing pretty much the entire time I'm in the skin) by increasing the amount and visibility of tissue deflection. Just like seeing a needle dot, if you see tissue movement, it means you're looking at some portion of the needle -- you'll then need to scan the probe forward (towards the tip), and once you no longer see that movement, you'll know you've left the needle. Then advance the needle slightly until you see it again, then march the probe forward slightly until you lose it, repeat. Same process as following the needle itself, just a less precise marker for it.

@@criticalconcepts5368 thank you for your help! I'll take a *stab* at it again when I start ICU next month

Oh boy. You got me; I've never counted my elements. Any of the commercial freestanding machines work fine for vascular access, as do most of the modern handheld devices (I have a Butterfly). Quality becomes more of an issue for diagnostic studies like echo.

Probably too late, but I recommend a Sonosite if you just want it for vascular access, it's an expensive machine, but it is incredible the people you can get even use a regular IV on, that previously we wouldn't have been able too with just our eyes. There are also some light weight tablet type of US for vascular access, we bought one, but my vascular access team has found them better than nothing, but the picture is so grainy it is really hard to see what you are doing, especially on patients with really difficult vasculature.

@@bettysmith4527 Thank you for your response! I have been using a Butterfly IQ+ and it has been more than adequate for my needs.

I mean, yeah. How do you drive without looking at your hands?