Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access

Long guidewire peripheral intravenous catheters in emergency departments for management of difficult intravenous access: A multicenter, pragmatic, randomized controlled trial

BACKGROUND

A quarter of patients who present to emergency departments (EDs) have difficult intravenous access (DIVA), making it challenging for clinicians to successfully place a peripheral intravenous catheter (PIVC). Some literature suggests that guidewire PIVC improves first-insertion success rate.

AIM

The aim was to determine the clinical and cost-effectiveness of a novel long PIVC (5.8 cm) with a retractable coiled guidewire (GW-PIVC) for patients with DIVA, compared with standard care PIVCs.

METHODS

A pragmatic randomized controlled trial was conducted in two Australian EDs. Eligible participants were adults assessed as meeting DIVA criteria. Participants were randomized (1:1 ratio; stratified by hospital) to either GW-PIVC (long) or standard care group (short or long PIVC). The use of ultrasound was discretionary in the standard care group and was recommended in the GW-PIVC group due to the pragmatic design that was primarily testing the GW-PIVC rather than the ultrasound use. Primary outcome was first-insertion success and secondary outcomes included all-cause device failure, patient and staff satisfaction, and cost-effectiveness. The analysis was intention to treat.

RESULTS

A total of 446 participants were randomized and 409 received PIVCs. The use of GW-PIVC, compared with standard PIVC, had a lower first-insertion success rate (68% vs. 77%, odds ratio [OR] 0.65, 95% confidence interval [CI] 0.43-0.99, p < 0.05). There was no difference in PIVC failure (134.0 per 1000 catheter days [GW-PIVC] vs. 111.8 [standard PIVC] per 1000 catheter days, hazard ratio 1.18, 95% CI 0.72-1.95). Both participant (8/10 vs. 9/10, median difference [MD] -1.00, 95% CI -1.37 to -0.63) and clinician (8/10 vs. 10/10, MD -2.00, 95% CI -2.37 to -1.63) satisfaction was lower with GW-PIVCs compared with standard PIVCs. More nurses inserted standard PIVCs than GW-PIVCs (56.9% vs. 36.5%) and had less confidence in their ultrasound skills (28.0% vs. 46.6% self-claimed as advanced/expert users). The cost per participant of GW-PIVC insertions was 2.46 times greater than standard PIVC insertions ($AU80.24 vs. $AU32.57).

CONCLUSIONS

GW-PIVCs had significantly lower first-insertion success and non-significantly higher all-cause catheter failure. Additional training and device design familiar to clinicians are vital factors to enhance the likelihood of successful future implementation of GW-PIVCs.

Infiltration and Extravasation Risk with Midline Catheters: A Narrative Literature Review

Midline catheters have recently gained popularity in clinical use, with a common reason being the reduction of central venous catheter use and central line-associated bloodstream infections. At the same time, the number of nononcology vesicant medications has increased, and midline catheters are frequently being used for infusions of vesicant medications. The Infusion Nurses Society (INS) Vesicant Task Force identified midline catheter use as a possible risk factor for extravasation and concluded that a thorough literature review was necessary. This review highlights the variations in catheter terminology and tip locations, the frequency of infiltration and extravasation in published studies, and case reports of infiltration and extravasation from midline catheters. It also examines the many clinical issues requiring evidence-based decision-making for the most appropriate type of vascular access devices. After more than 30 years of clinical practice with midline catheters and what appears to be a significant number of studies, evidence is still insufficient to answer questions about infusion of vesicant and irritant medications through midline catheters. Given the absence of consensus on tip location, inadequate evidence of clinical outcomes, and importance of patient safety, the continuous infusion of vesicants, all parenteral nutrition formulas, and infusates with extremes in pH and osmolarity should be avoided through midline catheters.

Predictors of ultrasound-guided peripheral intravenous catheter failure: A secondary analysis of existing trial data

OBJECTIVES

Ultrasound-guided (US) peripheral intravenous catheters (PIVC) have a high failure rate with many failing prior to completion of therapy. Risk factors associated with catheter failure are poorly delineated. This study aimed to assess risk factors related to catheter failure including patient, procedure, catheter, and vein characteristics to further elucidate which variables may impact catheter longevity.

METHODS

This was a secondary analysis using an existing trial dataset that primarily compared survival of two catheters: a standard long (SL) and an ultra-long (UL) US PIVC. Adult emergency room patients with difficult intravenous access at a tertiary care suburban academic center were study participants. Kaplan-Meier was employed to estimate the median catheter survival time. Cox regression univariable and multivariable analyses were used to evaluate the primary outcome of catheter survival.

RESULTS

Among 257 subjects, 63% of PIVCs survived until completion of therapy. In a multivariable Cox regression model, length of catheter in vein >2.75 cm (adjusted hazard ratio [aHR] 0.58, 95% confidence interval [CI] 0.37-0.90, p = 0.01) was associated with improved survival. First stick success decreased the risk of catheter failure (aHR 0.68, 95% CI 0.44-1.06, p = 0.09) but was not statistically significant. Factors associated with the increased risk of catheter failure included: depth of vein >1.2 cm (aHR 1.68, 95% CI 1.06-2.66, p = 0.03) and PIVC placement in right extremity (aHR 1.64, 95% CI 1.07-2.51, p = 0.02).

CONCLUSIONS

This study demonstrated that catheter length in vein (>2.75 cm) was associated with improved US PIVC survival highlighting the value of longer catheters in US PIVC survival. Choosing targets in the non-dominant extremity with shallower depths (⩽1.2 cm) may also increase catheter survival.

Peripheral intravenous catheter infection and failure: A systematic review and meta-analysis

BACKGROUND

Peripheral intravenous catheters are the most frequently used invasive device in nursing practice, yet are commonly associated with complications. We performed a systematic review to determine the prevalence of peripheral intravenous catheter infection and all-cause failure.

METHODS

The Cochrane Library, PubMed, CINAHL, and EMBASE were searched for observational studies and randomised controlled trials that reported peripheral intravenous catheter related infections or failure. The review was limited to English language and articles published from the year 2000. Pooled estimates were calculated with random-effects models. Meta-analysis of observation studies in epidemiology guidelines and the Cochrane process for randomised controlled trials were used to guide the review. Prospero registration number: CRD42022349956.

FINDINGS

Our search retrieved 34,725 studies. Of these, 41 observational studies and 28 randomised controlled trials (478,586 peripheral intravenous catheters) met inclusion criteria. The pooled proportion of catheter-associated bloodstream infections was 0.028 % (95 % confidence interval (CI): 0.009-0.081; 38 studies), or 4.40 catheter-associated bloodstream infections per 100,000 catheter-days (20 studies, 95 % CI: 3.47-5.58). Local infection was reported in 0.150 % of peripheral intravenous catheters (95 % CI: 0.047-0.479, 30 studies) with an incidence rate of 65.1 per 100,000 catheter-days (16 studies; 95 % CI: 49.2-86.2). All cause peripheral intravenous catheter failure before treatment completion occurred in 36.4 % of catheters (95 % CI: 31.7-41.3, 53 studies) with an overall incidence rate of 4.42 per 100 catheter days (78,891 catheter days; 19 studies; 95 % CI: 4.27-4.57).

INTERPRETATION

Peripheral intravenous catheter failure is a significant worldwide problem, affecting one in three catheters. Per peripheral intravenous catheter, infection occurrence was low, however, with over two billion catheters used globally each year, the absolute number of infections and associated burden remains high. Substantial and systemwide efforts are needed to address peripheral intravenous catheter infection and failure and the sequelae of treatment disruption, increased health costs and poor patient outcomes.

A standardized educational program to improve peripheral vascular access outcomes in the emergency department: A quasi-experimental pre-post trial

OBJECTIVE

Difficult intravenous access (DIVA) patients are known to have disproportionately poorer vascular access outcomes. The impact of education and training on vascular access outcomes in this vulnerable population is unclear. We aim to demonstrate the success of a program (Operation (O) STICK) on improving vascular access outcomes in DIVA patients.

METHODS

This was a quasi-experimental pre-post interventional study conducted at a tertiary care emergency department (ED) with 120,000 annual visits and 1100 hospital beds. Adult patients requiring an ultrasound-guided (US) peripheral intravenous catheter (PIVC) in the ED were eligible participants. Traditional (palpation method) insertions were excluded. Using multivariable linear regression and inverse probability weighted (IPW) linear regression, the standard group inclusive of PIVCs inserted by staff without formalized OSTICK training were compared to the interventional group inclusive of PIVCs inserted by staff with training and competency in the OSTICK training model.

RESULTS

Data were collected over two time intervals: 4/1/21-9/30/21 (pre; non-OSTICK) and 10/1/22-3/31/23 (post; OSTICK). 2375 DIVA patients included 1035 (43.6%) non-OSTICK and 1340 (56.4%) OSTICK PIVCs. Overall, OSTICK PIVCs had a higher proportion of upper arm or forearm placements (94.6% vs 57.4%; p < 0.001), 20 gauge catheters (97.1% vs 92.3%; p < 0.001), and left-sided placements (54.4% vs 43.5%; p < 0.001). 62.7% of OSTICK PIVCs were placed by ED technicians, compared to 25.5% in the non-OSTICK group (p < 0.001). OSTICK PIVCs were placed on the first attempt 86.2% of the time and by the second attempt 95.4% of the time. In a subanalysis of 1343 hospitalized patients (689 (51.3%) OSTICK vs 654 (48.7%) non-OSTICK), OSTICK PIVCs survived for a median of 92% of the patient's hospital length of stay, compared to non-OSTICK PIVCs at 74% (p < 0.001).

CONCLUSIONS

Formalized vascular access training in the ED leads to improved adherence to best practices for PIVC insertion, high success of cannulation with minimal attempts, and improved PIVC functionality during hospitalization for DIVA patients. Importantly, these outcomes are sustainable as they were captured 12 months after implementation of the program.

Mono- and bi-plane sonographic approach for difficult accesses in the emergency department - A randomized trial

BACKGROUND

The insertion of peripheral intravenous (PIV) catheters is one of the most performed invasive procedures in acute healthcare settings. However, peripheral difficult vascular access (PDVA) is not uncommon and can lead to delays in administering essential medications. Ultrasound (US) has emerged as a valuable tool for facilitating PIV cannulation. Advancements in technology have introduced a technique known as bi-plane imaging, allowing the simultaneous display of both longitudinal and transverse views of vessels. We aimed to investigate whether the utilization of bi-plane imaging, as opposed to the single-plane approach, would yield superior results for PDVA in the emergency department (ED).

METHODS

This study was a single-center randomized controlled trial. We included adult patients admitted to the ED who required PIV cannulation. Patients were randomly assigned to undergo cannulation using either the mono-plane or bi-plane approach, both performed by skilled providers. The primary outcome of the study was to compare the first attempt success rates between the two techniques.

RESULTS

A total of 442 patients were enrolled, with 221 undergoing cannulation attempts using the mono-plane approach. Successful placement of a functioning PIV catheter was achieved in a single attempt for 313 out of 442 patients (70.8%). There was no significant difference in the success rates between the two study groups: 68.3% in the mono-plane group and 73.3% in the bi-plane group (p = 0.395). The median time required for a successful attempt differed between the groups, with 45 s (range 18-600) in the mono-plane group and 35 s (range 20-600) in the bi-plane group (p = 0.03).

CONCLUSIONS

Our study confirms that US is a highly effective tool for facilitating PIV cannulation in patients with PDVA presenting to the ED. However, our investigation into the use of bi-plane imaging did not reveal a significant improvement when compared to mono-plane imaging.

Evaluation of extended-length cannula inserted using ultrasound guidance in patients with difficult IV access

Historically, gaining peripheral intravenous (IV) access for patients with difficult intravenous access (DIVA) has been problematic and associated with increased complications, central venous access device insertion and reduced patient satisfaction. Consequently, extended-length peripheral intravenous catheters (PIVCs) have been developed, but to date no real-world data exploring their effectiveness with NHS patients has been published. This article reports on the results of introducing extended-length PIVCs, inserted using ultrasound guidance in patients with DIVA by a vascular access team. This began in 2019, across an adult tertiary hospital setting in the NHS with about 750 beds. The specialties at this hospital include, but are not limited to, emergency medicine; head and neck; vascular; diabetes and endocrinology; respiratory; care of the older person; stroke services; gastroenterology; and trauma and orthopaedics. The vascular access team recorded 1485 individual insertions between 2019 to 2022, with a mean dwell time of 6 days, a first attempt success rate of 91%, and a therapy completion rate of 75 and 78% for inpatient and outpatients respectively. Indications included administration of IV fluids, medication, blood products and access for investigations or procedures. Obtaining reliable IV access in patients with DIVA prevents treatment delays, cancelled or delayed procedures, both of which benefit patients and the healthcare organisation. The data presented in this study support the use of extended-length PIVCs in patients with DIVA and has led to the development of new referral pathways.

Performance of peripheral catheters inserted with ultrasound guidance versus landmark technique after a simulation-based mastery learning intervention

PROBLEM

Ultrasound-guided peripheral intravenous catheter (USGPIV) insertion is an effective method to gain vascular access in patients with difficult intravenous access (DIVA). While USGPIV success rates are reported to be high, some studies have reported a concerning incidence of USGPIV premature failures.

AIMS

The purpose of this study was to compare differences in USGPIV and landmark peripheral intravenous catheter (PIV) utilization and failure following a hospital-wide USGPIV training program for nurses.

METHODS

The authors performed a retrospective, electronic medical record review of all USGPIVs and PIVs inserted at a tertiary, urban, academic medical center from September 1, 2018, through September 30, 2019. The primary outcome was differences between USGPIV and PIV time to failure.

RESULTS

A total of 43,470 short peripheral intravenous catheters (PIVCs) were inserted in 23,713 patients. Of these, 7972 (16.8%) were USGPIV. At 30 days of follow-up, for PIVCs with an indication for removal documented, USGPIVs had higher Kaplan-Meier survival probabilities than PIVs (p < 0.001).

CONCLUSIONS

The use of simulation-based mastery associated with USGPIVs, demonstrated lower failure rates than standard PIVs after 2 days and USGPIVs exhibited improved survival rates in patients with DIVA. These findings suggest that rigorous simulation-based insertion training demonstrates improved USGPIV survival when compared to traditional PIVCs. SBML is an extremely useful tool to ensure appropriately trained clinicians acquire the necessary knowledge and skillset to improve USGPIV outcomes.

Outcomes of Ultrasound Guided Peripheral Intravenous Catheters Placed in the Emergency Department and Factors Associated with Survival

Background

Patients with difficult peripheral intravenous (IV) access are common in emergency departments (EDs). Ultrasound-guided peripheral intravenous catheters (USIVs) are frequently used in this population; however, information regarding the effect of patient and IV characteristics on the dwell time (DT) and survival probability (SP) of USIVs is limited.

Objective

Our study aimed to evaluate for associations between patient or IV characteristics and the DT and SP of USIVs.

Methods

Retrospective analysis was performed on a database from an ED nurse (RN) USIV training program at an urban, academic hospital. Patients over 18 years with an USIV placed during the study period were included. Subject demographics, history, IV characteristics, insertion, and removal times were collected. Data were analyzed using descriptive statistics and univariable and multivariable Cox regression. USIV survival times for variates of interest were estimated using Kaplan-Meier curves for three censoring points.

Results

The final analysis cohort was 388 patients. Mean age was 56.6 years, 66.5% were female, mean BMI was 29.9 kg/m², and 42.5% were obese (BMI ≥30). Median DT was 40.3 hours in admitted patients (N=340). SP for USIVs at 96 hours was 87.8%. A total of 21 of 340 (6.2%) USIVs failed. USIV location conferred a difference on DT in obese patients when dichotomized into upper arm versus antecubital fossa and forearm together (38.6 hours vs 44.6 hours, p=0.03). No factors were associated with a difference in USIV SP.

Conclusion

Median USIV DT of 40.3 hours for admitted patients was higher than in previous studies. Only 7% of USIVs in our study failed. Overall, catheters survived longer than expected.

Assessing the utility of ultrasound-guided vascular access placement with longer catheters in critically ill pediatric patients

BACKGROUND

Critically ill pediatric patients can have difficulty with establishing and maintaining stable vascular access. A long-dwelling peripheral intravenous catheter placement decreases the need for additional vascular interventions.

AIM

The study sought to compare longevity, catheter-associated complications, and the need for additional vascular interventions when using ultrasound-guided longer peripheral intravenous catheters comparing to a traditional approach using standard-sized peripheral intravenous catheters in pediatric critically ill patients with difficult vascular access.

METHODS

This single-center retrospective cohort study included children 0-18 years of age with difficult vascular access admitted to the pediatric intensive care unit between 01/01/2018-06/01/2021.

RESULTS

One hundred and eighty seven placements were included in the study, with 99 ultrasound-guided long intravenous catheters placed and 88 traditionally placed standard-sized intravenous catheters. In the univariate analysis, patients in the traditional approach were at a higher risk of intravenous failure compared to those in the ultrasound-guided approach (HR = 2.20, 95% CI [1.45-3.34], p = .001), with median intravenous survival times of 108 and 219 h, respectively. Adjusting for age, patients in the traditional approach remained at higher risk of intravenous failure (HR = 1.99, 95% CI: [1.28-3.08], p = .002). Adjusting for hospital length of stay, patients in the ultrasound-guided approach were less likely to have additional peripheral intravenous access placed during hospitalization (OR = 0.39, 95% CI [0.18-0.85] p = .017).

CONCLUSION

In critically ill pediatric patients with difficult vascular access, ultrasound-guided long peripheral intravenous catheters provide an alternative to traditional approach standard-sized intravenous catheters with improved longevity, lower failure rates, and reduced need for additional vascular interventions.

Short peripheral intravenous catheter securement with cyanoacrylate glue compared to conventional dressing: A randomized controlled trial

BACKGROUND

Short peripheral intravenous catheters (PIVCs) fail prior to completion of therapy in up to 63% of hospitalizations. This unacceptably high rate of failure has become the norm for the most common invasive procedure in all of medicine. Securement strategies may improve PIVC survival.

METHODS

We conducted a prospective, single-site, parallel, two-arm randomized controlled investigation with a primary outcome of catheter failure comparing securement with standard semi-permeable dressing and clear tape (SPD) to standard semipermeable dressing and clear tape with cyanoacrylate glue (SPD + CG). Adult emergency department patients with a short PIVC and anticipated hospital duration ⩾ 48 h were enrolled and followed until IV failure or completion of therapy for up to 7 days. Secondary outcomes included complications and cost comparisons between groups. Primary outcome was assessed by intention to treat and per protocol analyses.

FINDINGS

350 patients were enrolled between November 2019 and October 2020. PIVC survival for SPD + CG was similar to SPD group with the absolute risk difference of IV failure in the intention-to-treat (-5.8%, p = 0.065) population and improved in the per protocol (-8.1%, p = 0.04) population, respectively. Kaplan-Meier survival analysis indicated there was a significant benefit of the SPD + CG at greater than 2 days of hospitalization (p = 0.04). Prior to 48 h, there was no survival enhancement to either group (p = 0.98) in the intention to treat population. In a multivariable analysis with piecewise Cox regression, when the IV was functional greater than 48 h, the risk of IV failure in the SPD + CG was 43% less than the SPD group (adjusted hazard ratio [HR] 0.57, 95% confidence interval [CI] 0.34 to 0.97; p = 0.04). Cumulative cost related to IV during hospitalization was similar between groups with a lower incremental rescue cost in the SPD + CG group.

INTERPRETATION

SPD combined with cyanoacrylate glue provides similar benefit to patients compared to SPD alone and potentially improves short PIVC survival when the IV was inserted >48 h. As this strategy is cost neutral, it could be considered in admitted patients, particularly those with longer anticipated hospital durations.

Ultrasound guidance versus landmark method for peripheral venous cannulation in adults

BACKGROUND

Peripheral intravenous cannulation is one of the most fundamental and common procedures in medicine. Securing a peripheral line is occasionally difficult with the landmark method. Ultrasound guidance has become a standard procedure for central venous cannulation, but its efficacy in achieving peripheral venous cannulation is unclear.

OBJECTIVES

To evaluate the effectiveness and safety of ultrasound guidance compared to the landmark method for peripheral intravenous cannulation in adults.  SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was 29 November 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs (RCTs in which participants are systematically allocated based on data such as date of birth or recruitment) comparing the effects of ultrasound guidance to the landmark method for peripheral intravenous cannulation in adults.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were first-pass success of cannulation, overall success of cannulation, and pain. Our secondary outcomes were procedure time for first-pass cannulation, procedure time for overall cannulation, number of attempts, patient satisfaction, and overall complications. We used GRADE to assess the certainty of the evidence.  Placing a peripheral intravenous line in individuals can be classed as 'difficult', 'moderate', or 'easy'. We use the terms 'difficult participants', 'moderate/moderately difficult participants' and 'easy participants' as shorthand to characterise the difficulty level in placing a peripheral line using the landmark method. We used the original studies' definitions of difficulty levels of peripheral intravenous cannulation with the landmark method. We analysed the results in these subgroups: 'difficult participants', 'moderate participants', and 'easy participants'. We did this because we expected the effect of ultrasound-guided peripheral venous cannulation to be largest in participants classed as 'difficult' and smaller in participants classed as 'moderate' and 'easy'.  MAIN RESULTS: We included 14 RCTs and two quasi-RCTs involving 2267 participants undergoing peripheral intravenous cannulation. Participants were classed as 'difficult' in 12 studies (880 participants), 'moderate' in one study (401 participants), and 'easy' in one study (596 participants). Two studies (390 participants) did not restrict by landmark method difficulty level. The overall risk of bias assessments ranged from low to high. We judged studies to be at high risk of bias mainly because of concerns about blinding for subjective outcomes. In difficult participants, ultrasound guidance increased the first-pass success of cannulation (risk ratio (RR) 1.50, 95% confidence interval (95% CI) 1.15 to 1.95; 10 studies, 815 participants; low-certainty evidence), and the overall success of cannulation (RR 1.40, 95% CI 1.10 to 1.77; 10 studies, 670 participants; very low-certainty evidence). There was no clear difference in pain (mean difference (MD) -0.20, 95% CI -1.13 to 0.72; 4 studies, 323 participants; very low-certainty evidence; numerical rating scale (NRS) 0 to 10 where 10 is maximum pain). Ultrasound guidance increased the procedure time for first-pass cannulation (MD 119.9 seconds, 95% CI 88.6 to 151.1; 2 studies, 219 participants; low-certainty evidence), and patient satisfaction (standardised mean difference (SMD) 0.49, 95% CI 0.07 to 0.92; 5 studies, 333 participants; very low-certainty evidence; NRS 0 to 10 where 10 is maximum satisfaction). Ultrasound guidance decreased the number of cannulation attempts (MD -0.33, 95% CI -0.64 to -0.02; 9 studies, 568 participants; very low-certainty evidence). Ultrasound guidance showed no clear difference in the procedure time for overall cannulation (MD -24.9 seconds, 95% CI -323.1 to 273.3; 8 studies, 413 participants; very low-certainty evidence) and overall complications (RR 0.64, 95% CI 0.37 to 1.10; 5 studies, 431 participants; low-certainty evidence).  In moderate participants, ultrasound guidance increased the first-pass success of cannulation (RR 1.14, 95% CI 1.02 to 1.27; 1 study, 401 participants; moderate-certainty evidence). No studies assessed the overall success of cannulation. There was no clear difference in pain (MD 0.10, 95% CI -0.47 to 0.67; 1 study, 401 participants; low-certainty evidence; NRS 0 to 10 where 10 is maximum pain). Ultrasound guidance increased the procedure time for first-pass cannulation (MD 95.2 seconds, 95% CI 72.8 to 117.6; 1 study, 401 participants; high-certainty evidence). Ultrasound guidance showed no clear difference in overall complications (RR 0.83, 95% CI 0.38 to 1.82; 1 study, 401 participants; moderate-certainty evidence). No studies assessed the procedure time for overall cannulation, number of cannulation attempts, or patient satisfaction.  In easy participants, ultrasound guidance decreased the first-pass success of cannulation (RR 0.89, 95% CI 0.85 to 0.94; 1 study, 596 participants; high-certainty evidence). No studies assessed the overall success of cannulation. Ultrasound guidance increased pain (MD 0.60, 95% CI 0.17 to 1.03; 1 study, 596 participants; moderate-certainty evidence; NRS 0 to 10 where 10 is maximum pain). Ultrasound guidance increased the procedure time for first-pass cannulation (MD 94.8 seconds, 95% CI 81.2 to 108.5; 1 study, 596 participants; high-certainty evidence). Ultrasound guidance showed no clear difference in overall complications (RR 2.48, 95% CI 0.90 to 6.87; 1 study, 596 participants; moderate-certainty evidence). No studies assessed the procedure time for overall cannulation, number of cannulation attempts, or patient satisfaction.  AUTHORS' CONCLUSIONS: There is very low- and low-certainty evidence that, compared to the landmark method, ultrasound guidance may benefit difficult participants for increased first-pass and overall success of cannulation, with no difference detected in pain. There is moderate- and low-certainty evidence that, compared to the landmark method, ultrasound guidance may benefit moderately difficult participants due to a small increased first-pass success of cannulation with no difference detected in pain. There is moderate- and high-certainty evidence that, compared to the landmark method, ultrasound guidance does not benefit easy participants: ultrasound guidance decreased the first-pass success of cannulation with no difference detected in overall success of cannulation and increased pain.

Ultrasound-Guided Great Saphenous Vein Access: Revisiting an Old Friend in a New Location

BACKGROUND

Early recognition of difficult intravenous (i.v.) access and use of ultrasound-guided techniques prior to multiple attempts are important steps in improving patient care in the emergency department (ED). Success rates for ultrasound-guided peripheral i.v. (PIV) cannulation are affected by depth, size of target vessel, and predictability of anatomy. The great saphenous vein (GSV) in the medial distal thigh may provide an alternative site for ultrasound-guided cannulation in cases of difficult peripheral venous access.

OBJECTIVES

Our objective was to determine the feasibility of ultrasound-guided GSV PIV placement as an alternative site for patients with difficult i.v. access.

METHODS

Participants were prospectively enrolled from a convenience sample of patients presenting to the ED in June and July 2019. Inclusion criteria were age 18 years and older, and a history of difficult i.v. access or two unsuccessful nursing staff attempts. Ultrasound-guided access was conducted with an in-plane or out-of-plane approach on the basis of proceduralist preference.

RESULTS

Twenty patients were enrolled; 1 patient withdrew consent prior to cannulation. GSV cannulation was successful in 14 (73.7%) of the 19 patients. Phlebotomy, blood transfusion, i.v. medications including norepinephrine, and i.v. computed tomography contrast medium were successfully performed via GSV access. No reported infection, thrombosis, or extravasation was identified throughout the cannulation dwell time, hospitalization, or for 72 h after discharge.

CONCLUSION

Ultrasound-guided GSV PIV placement is a feasible alternative in situations of difficult i.v. access. No unforeseen complication or safety issue was identified. Blood products, medications, and contrast medium were successfully administered safely.

Management of difficult intravenous access: a qualitative review

BACKGROUND

A perennial challenge faced by clinicians and made even more relevant with the global obesity epidemic, difficult intravenous access (DIVA) adversely impacts patient outcomes by causing significant downstream delays with many aspects of diagnoses and therapy. As most published DIVA strategies are limited to various point-of-care ultrasound techniques while other "tricks-of-the-trade" and pearls for overcoming DIVA are mostly relegated to informal nonpublished material, this article seeks to provide a narrative qualitative review of the iterature on DIVA and consolidate these strategies into a practical algorithm.

METHODS

We conducted a literature search on PubMed using the keywords "difficult intravenous access", "peripheral vascular access" and "peripheral venous access" and searched emergency medicine and anaesthesiology resources for relevant material. These strategies were then categorized and incorporated into a DIVA algorithm.

RESULTS

We propose a Vortex approach to DIVA that is modelled after the Difficult Airway Vortex concept starting off with standard peripheral intravenous cannulation (PIVC) techniques, progressing sequentially on to ultrasound-guided cannulation and central venous cannulation and finally escalating to the most invasive intraosseous access should the patient be in extremis or should best efforts with the other lifelines fail.

CONCLUSION

DIVA is a perennial problem that healthcare providers across various disciplines will be increasingly challenged with. It is crucial to have a systematic stepwise approach such as the DIVA Vortex when managing such patients and have at hand a wide repertoire of techniques to draw upon.

Reducing Delays in a Pediatric Procedural Unit With Ultrasound-Guided Intravenous Line Insertion

OBJECTIVES

Delay in vascular access is a leading cause of procedure delay in our pediatric procedure and infusion center. Use of ultrasound decreases time to peripheral intravenous catheter (PIV) insertion; however, ultrasound availability in our center was limited to an external venous access team (VAT). The objective of this project was to reduce PIV-related delays by 25%.

METHODS

Stakeholders convened and theorized that creating a unit-based nurse team specializing in ultrasound-guided peripheral intravenous catheter (USgPIV) insertion would facilitate faster access and a reduction in delayed procedures. An initial plan-do-study-act cycle was performed, training 2 nurses in USgPIV placement. Subsequent cycles were focused on increasing availability of USgPIV-trained nurses. The outcome measure was the rate of procedures delayed by PIV placement, analyzed on a statistical process control U-chart. The process measure was the percentage of USgPIV placements requiring consultations to the VAT, analyzed on a statistical process control P-chart. The balancing measure was the success rate per method of insertion. Comparisons of success rates were conducted by using a χ² test and Fisher's exact test.

RESULTS

The mean rate of procedures delayed because of vascular access fell by special cause variation from 10.8% to 6.4%. The mean VAT consultation rate fell from 86.4% to 32.0%. The VAT had higher rates of overall success (100% vs 87%; P = .01) and first-attempt success (93% vs 77%; P = .03) compared with unit nurse USgPIV placement.

CONCLUSIONS

Unit-based USgPIV placement in a pediatric procedural center was successfully implemented, with a significant decline in procedures delayed by PIV access.

Ultrasound-Guided Peripheral Intravenous Catheter Insertion: The Nurse's Manual

Peripheral intravenous catheter placement is a skill that is used daily in the hospital. However, many nurses face the challenge of cannulating increasingly complex and difficult-to-access vasculature. Although emergency department clinicians have been using ultrasound to facilitate this procedure for the last 18 years, ultrasound-guided peripheral intravenous catheter placement has not been as rapidly adopted in the critical and acute care nursing realms. Given the benefits of this procedure, including increased patient satisfaction and reduced use of central catheters, its use should be encouraged among all acute care clinicians. The aim of this article is to provide the bedside nurse with a basic understanding of the techniques involved in placing ultrasound-guided peripheral intravenous catheters in patients with difficult venous access.

Education in the placement of ultrasound-guided peripheral venous catheters: a systematic review

BACKGROUND

Placing a peripheral vein catheter can be challenging due to several factors, but using ultrasound as guidance increases the success rate. The purpose of this review is to investigate the knowledge already existing within the field of education in ultrasound-guided peripheral vein catheter placement and explore the efficacy and clinical impact of different types of education.

METHODS

In accordance with PRISMA-guidelines, a systematic search was performed using three databases (PubMed, EMBASE, CINAHL). Two reviewers screened titles and abstracts, subsequently full-text of the relevant articles. The risk of bias was assessed using the Cochrane Collaboration risk of bias assessment tool and the New Ottawa scale.

RESULTS

Of 3409 identified publications, 64 were included. The studies were different in target learners, study design, assessment tools, and outcome measures, which made direct comparison difficult. The studies addressed a possible effect of mastery learning and found e-learning and didactic classroom teaching to be equally effective.

CONCLUSION

Current studies suggest a potential benefit of ultrasound guided USG-PVC training on success rate, procedure time, cannulation attempts, and reducing the need for subsequent CVC or PICC in adult patients. An assessment tool with proven validity of evidence to ensure competence exists and education strategies like mastery learning, e-learning, and the usage of color Doppler show promising results, but an evidence-based USG-PVC-placement training program using these strategies combined is still warranted.

Extended dwell and standard ultrasound guided peripheral intravenous catheters: Comparison of durability and reliability

Background Vascular access is a critical component of emergency department (ED) care. Ultrasound guided placement of peripheral intravenous (USIV) catheters is increasingly common. However, USIV are thought to suffer from reduced durability and higher complication rates. Extended dwell catheters (EDC) are long peripheral IVs placed under combined ultrasound and wire guidance. The goal of this study is to compare dwell times and complication rates of EDC to standard peripheral USIV. Methods We performed a retrospective cohort study at a tertiary care adult ED comparing IV placements during a 17-month period (8/1/2018-12/31/2019), stratified by standard USIV versus EDC. The primary outcome was catheter dwell time and secondary outcomes included need for inpatient vascular access team (VAST) consultation, peripherally inserted central catheter (PICC) insertions, and radiocontrast extravasations. Multivariable Cox regression time-to-event analyses were used to evaluate dwell times, adjusting for age, gender, BMI and end-stage renal disease. Results 359 EDC and 4190 standard USIV were included for analysis. Most USIV (95.6%) and EDC (98.3%) were placed by ED technicians trained in ultrasound vascular access. EDC median dwell time (5.9 days [95%CI: 5.1-6.7]) exceeded standard USIV (3.8 days [95% CI: 3.6-4.0]). Patients with EDC placed in the ED required less VAST consultation (0.84 vs 0.99 charges/encounter), had similar rates of PICC line use (8.0% vs 8.4% of encounters) and had no radiocontrast extravasation events. Multivariable Cox regression demonstrated survival benefit (longer dwell time) favoring EDC (HR 0.70 [95%CI 0.60-0.81]). Conclusion Use of EDC results in longer dwell time and reduces subsequent use of vascular access resources, while maintaining low complication rates. EDC demonstrate superior durability which may justify their selection over standard USIV in some patients.

The Effect of Catheter Length Placed Into the Vein on Peripheral Ultrasound-Guided Catheter Survival Time: A Prospective Observational Study

INTRODUCTION

Establishing and maintaining peripheral intravenous access in patients with no visible or palpable veins can be arduous. Intravenous catheters placed with ultrasound do not survive as long as traditionally placed catheters. This study was performed to determine the relationship between the catheter length placed into the lumen of the vein using ultrasound and catheter survival.

METHODS

This was a nonrandomized prospective observational study of admitted patients with difficult intravenous placement in 2017. Subjects had ultrasound-guided peripheral intravenous placement in the emergency department or intensive care unit. The main outcome was the time of catheter survival. Data were analyzed using descriptive statistics and Cox regression.

RESULTS

A total of 98 patients with an average age of 63 years were enrolled. The total number of cases examined was 97 (N = 97), of which 29 intravenous catheters were removed for catheter-related problems (events). The mean (SD) survival time for catheters placed using ultrasound was 3,445 minutes (2,414) or 2.39 days. Peripheral catheter survival was not significantly related to the in-vein length of the catheter (X² = 0.03, P = 0.86) nor was it significantly related to any of the covariates.

DISCUSSION

The survival time of ultrasound-guided intravenous access doubled in the present study from 1674 minutes in a previous 2013 study. The results may have been due to clinician expertise and experience with the peripheral ultrasound-guided method and the use of updated equipment.

Long peripheral catheters for intravenous access in adults and children: A systematic review of the literature

BACKGROUND

Long peripheral catheters are peripheral intravenous catheters of 6-15 cm in length. They are commonly inserted into the forearm, antecubital fossa or upper arm using a direct Seldinger technique. They have proven to be valuable for peripheral intravenous catheters, particularly in patients with difficult intravenous access.

METHODS

We conducted a systematic review of studies reporting the use of long peripheral catheters. The following keywords were used: 'long', 'Seldinger', 'guidewire', 'peripheral', 'venous', 'intravenous', 'IV', 'vascular', 'cannula' and 'catheter'.

RESULTS

Three hundred forty-one publications were identified; 16 were included in the systematic review. There were 11 adult studies and 5 paediatric studies documenting 1288 long peripheral catheters in 1271 patients. Majority of studies (12/16) were conducted in acute care settings, (emergency department, n = 6; intensive care unit, n = 3; high dependency unit, n = 1; surgical unit, n = 2). The most frequently studied long peripheral catheter was 8 cm in length and 20 G in size. Nine studies recruited patients with difficult intravenous access; 11 studies used ultrasound guidance. Insertion success rate and mean procedural time ranged between 86% and 100% and 8 and 16.8 minutes, respectively. Average catheter duration ranged between 4 and 14.7 days (mean) and 1.1 and 9 days (median). Catheter failure occurred in 4.3-52.5% of long peripheral catheters, with leakage, infiltration and dislodgement being the most frequent causes of failure. In 3 randomised controlled trials, long peripheral catheters outperformed peripheral intravenous catheters in terms of duration and failure rate.

CONCLUSION

Long peripheral catheters are safe and reliable in both adults and children. In addition, long peripheral catheters may provide improved quality of care over peripheral intravenous catheters for multi-day intravenous therapy.

Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations

BACKGROUND

Both the interest and actual extent of use of point-of-care ultrasound, PoCUS, among general practitioners or family physicians are increasing and training is also increasingly implemented in residency programs. However, the amount of research within the field is still rather limited compared to what is seen within other specialties in which it has become more established, such as in the specialty of emergency medicine. An assumption is made that what is relevant for emergency medicine physicians and their populations is also relevant to the general practitioner, as both groups are generalists working in unselected populations. This systematic review aims to examine the extent of use and to identify clinical studies on the use of PoCUS by either general practitioners or emergency physicians on indications that are relevant for the former, both in their daily practice and in out-of-hours services.

METHODS

Systematic searches were done in PubMed/MEDLINE using terms related to general practice, emergency medicine, and ultrasound.

RESULTS

On the extent of use, we identified 19 articles, as well as 26 meta-analyses and 168 primary studies on the clinical use of PoCUS. We found variable, but generally low, use among general practitioners, while it seems to be thoroughly established in emergency medicine in North America, and increasingly also in the rest of the world. In terms of clinical studies, most were on diagnostic accuracy, and most organ systems were studied; the heart, lungs/thorax, vessels, abdominal and pelvic organs, obstetric ultrasound, the eye, soft tissue, and the musculoskeletal system. The studies found in general either high sensitivity or high specificity for the particular test studied, and in some cases high total accuracy and superiority to other established diagnostic imaging modalities. PoCUS also showed faster time to diagnosis and change in management in some studies.

CONCLUSION

Our review shows that generalists can, given a certain level of pre-test probability, safely use PoCUS in a wide range of clinical settings to aid diagnosis and better the care of their patients.

Ultrasound-guided peripheral venous cannulation in critically ill patients: a practical guideline

BACKGROUND

Up to one-third of critically ill patients have difficult intravenous access (DIVA). This occurs often in obese patients, those with generalized edemas or in patients with previous venous cannulations. In DIVA patients, the conventional technique often fails. In contrast, ultrasound-guided cannulation has demonstrated a high success rate, improving patient satisfaction and even a reduction in the need of central venous lines. However, a high rate of premature catheter failure has been shown in cannulations performed by ultrasound guidance and thus a comprehensive knowledge of several aspects related to this procedure is mandatory to improve cannulation success, avoid complications and lengthen the survival of the catheter.

MAIN TEXT

Several practical issues related to peripheral venous cannulation are described: peripheral venous anatomy, vein size and catheter selection, distance from skin to vein, insertion angle and selection of the catheter length, cannulation technique itself (out-of-plane or in-plane) and checking catheter position.

CONCLUSION

Key concepts regarding ultrasound-guided peripheral vein cannulation should be well known for practitioners, aiding in improving cannulation success and catheter dwell time, and avoiding complications.

A patient's decision aid for vascular access placement in the emergency department

BACKGROUND

Vascular access device placement is one of the most routinely performed procedures in the emergency department. Despite its high usage, most patients have limited knowledge about vascular access device placement. Patient decision aids have been utilized heavily in non-emergency department settings to provide basic clinical information regarding a patient's medical care options. In this study, we investigated whether exposure to a patient decision aid on vascular access devices and patients' experiences with vascular access devices would influence their vascular access device preference during an acute care episode.

METHODS

Patients in this institutional review board-approved study were enrolled prospectively in the emergency department at a busy level 1 trauma institution. A patient decision aid on vascular access device was constructed using criteria developed by the International Patient Decision Aid Standards. All participants were exposed to the patient decision aid and were asked to complete two questionnaires, and two tests.

RESULTS

Fifty subjects (50) were enrolled prospectively in the emergency department. The mean pretest score was 17.2% (95% confidence interval, 0.54-1.18), while the mean post-test score was 72.4% (95% confidence interval, 3.15-4.09). We found that patients who were exposed to the patient decision aid preferred landmark-based peripheral intravenous lines over ultrasound-guided peripheral intravenous lines in this data set.

CONCLUSION

The result from this analysis indicated that most patients visiting the emergency department are not knowledgeable about their options related to vascular access device placement. The observed increase in the average correct responses on the post-test indicates that a patient decision aid can be an effective educational tool in the emergency department.

Recommendations on the Use of Ultrasound Guidance for Central and Peripheral Vascular Access in Adults: A Position Statement of the Society of Hospital Medicine

PREPROCEDURE

1)We recommend that providers should be familiar with the operation of their specific ultrasound machine prior to initiation of a vascular access procedure. 2)We recommend that providers should use a high-frequency linear transducer with a sterile sheath and sterile gel to perform vascular access procedures. 3)We recommend that providers should use two-dimensional ultrasound to evaluate for anatomical variations and absence of vascular thrombosis during preprocedural site selection. 4)We recommend that providers should evaluate the target blood vessel size and depth during preprocedural ultrasound evaluation.

TECHNIQUES

General Techniques 5) We recommend that providers should avoid using static ultrasound alone to mark the needle insertion site for vascular access procedures. 6)We recommend that providers should use real-time (dynamic), two-dimensional ultrasound guidance with a high-frequency linear transducer for central venous catheter (CVC) insertion, regardless of the provider's level of experience. 7)We suggest using either a transverse (short-axis) or longitudinal (long-axis) approach when performing real-time ultrasound-guided vascular access procedures. 8)We recommend that providers should visualize the needle tip and guidewire in the target vein prior to vessel dilatation. 9)To increase the success rate of ultrasound-guided vascular access procedures, we recommend that providers should utilize echogenic needles, plastic needle guides, and/or ultrasound beam steering when available. Central Venous Access Techniques 10) We recommend that providers should use a standardized procedure checklist that includes the use of real-time ultrasound guidance to reduce the risk of central line-associated bloodstream infection (CLABSI) from CVC insertion. 11)We recommend that providers should use real-time ultrasound guidance, combined with aseptic technique and maximal sterile barrier precautions, to reduce the incidence of infectious complications from CVC insertion. 12)We recommend that providers should use real-time ultrasound guidance for internal jugular vein catheterization, which reduces the risk of mechanical and infectious complications, the number of needle passes, and time to cannulation and increases overall procedure success rates. 13)We recommend that providers who routinely insert subclavian vein CVCs should use real-time ultrasound guidance, which has been shown to reduce the risk of mechanical complications and number of needle passes and increase overall procedure success rates compared with landmark-based techniques. 14)We recommend that providers should use real-time ultrasound guidance for femoral venous access, which has been shown to reduce the risk of arterial punctures and total procedure time and increase overall procedure success rates. Peripheral Venous Access Techniques 15) We recommend that providers should use real-time ultrasound guidance for the insertion of peripherally inserted central catheters (PICCs), which is associated with higher procedure success rates and may be more cost effective compared with landmark-based techniques. 16)We recommend that providers should use real-time ultrasound guidance for the placement of peripheral intravenous lines (PIV) in patients with difficult peripheral venous access to reduce the total procedure time, needle insertion attempts, and needle redirections. Ultrasound-guided PIV insertion is also an effective alternative to CVC insertion in patients with difficult venous access. 17)We suggest using real-time ultrasound guidance to reduce the risk of vascular, infectious, and neurological complications during PIV insertion, particularly in patients with difficult venous access. Arterial Access Techniques 18)We recommend that providers should use real-time ultrasound guidance for arterial access, which has been shown to increase first-pass success rates, reduce the time to cannulation, and reduce the risk of hematoma development compared with landmark-based techniques. 19)We recommend that providers should use real-time ultrasound guidance for femoral arterial access, which has been shown to increase first-pass success rates and reduce the risk of vascular complications. 20)We recommend that providers should use real-time ultrasound guidance for radial arterial access, which has been shown to increase first-pass success rates, reduce the time to successful cannulation, and reduce the risk of complications compared with landmark-based techniques.

POSTPROCEDURE

21) We recommend that post-procedure pneumothorax should be ruled out by the detection of bilateral lung sliding using a high-frequency linear transducer before and after insertion of internal jugular and subclavian vein CVCs. 22)We recommend that providers should use ultrasound with rapid infusion of agitated saline to visualize a right atrial swirl sign (RASS) for detecting catheter tip misplacement during CVC insertion. The use of RASS to detect the catheter tip may be considered an advanced skill that requires specific training and expertise.

TRAINING

23) To reduce the risk of mechanical and infectious complications, we recommend that novice providers should complete a systematic training program that includes a combination of simulation-based practice, supervised insertion on patients, and evaluation by an expert operator before attempting ultrasound-guided CVC insertion independently on patients. 24)We recommend that cognitive training in ultrasound-guided CVC insertion should include basic anatomy, ultrasound physics, ultrasound machine knobology, fundamentals of image acquisition and interpretation, detection and management of procedural complications, infection prevention strategies, and pathways to attain competency. 25)We recommend that trainees should demonstrate minimal competence before placing ultrasound-guided CVCs independently. A minimum number of CVC insertions may inform this determination, but a proctored assessment of competence is most important. 26)We recommend that didactic and hands-on training for trainees should coincide with anticipated times of increased performance of vascular access procedures. Refresher training sessions should be offered periodically. 27)We recommend that competency assessments should include formal evaluation of knowledge and technical skills using standardized assessment tools. 28)We recommend that competency assessments should evaluate for proficiency in the following knowledge and skills of CVC insertion: (a) Knowledge of the target vein anatomy, proper vessel identification, and recognition of anatomical variants; (b) Demonstration of CVC insertion with no technical errors based on a procedural checklist; (c) Recognition and management of acute complications, including emergency management of life-threatening complications; (d) Real-time needle tip tracking with ultrasound and cannulation on the first attempt in at least five consecutive simulation. 29)We recommend a periodic proficiency assessment of all operators should be conducted to ensure maintenance of competency.

Long peripheral catheters for deep arm vein venous access: A systematic review of complications

PURPOSE

Long peripheral catheters (LPCs) offer a quick, simple and cost-effective alternative for venous access in intensive care patients with difficult venous access, but the decision to use them must be balanced against an assessment of harm. The aim of this systematic review was to synthesise reports of complications associated with LPCs.

METHODS

The electronic databases MEDLINE, EMBASE and CINAHL were searched systematically for randomised controlled trials, cohort studies and case control studies published in the period 1966 to 24th July 2018 reporting LPC associated occlusion, catheter related blood stream infections, phlebitis and infiltration. Study quality was assessed using the Methodological Index for Non-Randomised Studies. The studies were described and participant characteristics; type of catheter; setting; average dwell time; and rates of occlusion, catheter related blood stream infection, phlebitis and infiltration were extracted as summary measures.

RESULTS

Five cohort studies and one randomised controlled study, comprising a total of 350 participants, fulfilled the inclusion criteria. Dwell time ranged from 1 to 15days and the reported complication rate was 3-14%. The most common complication was catheter occlusion (4%), followed by phlebitis (1%), infiltration (0.9%), and catheter related blood stream infection (0.3%). Significant heterogeneity, particularly in identification and reporting of complications, means results should be interpreted with caution.

CONCLUSION

There is a lack of intervention specific and adequately powered randomised controlled trials investigating LPCs in an intensive care setting. Until the results of such studies are available, LPCs should be used as an alternative to ultrasound-guided PVCs in well monitored acute care environments.

Accepted but Unacceptable: Peripheral IV Catheter Failure

Peripheral intravenous (IV) catheter insertion, the most common invasive hospital procedure performed worldwide, is associated with a variety of complications and an unacceptably high overall failure rate of 35% to 50% in even the best of hands. Catheter failure is costly to patients, caregivers, and the health care system. Although advances have been made, analysis of the mechanisms underlying the persistent high rate of peripheral IV failure reveals opportunities for improvement.

Central venous catheter placement after ultrasound guided peripheral IV placement for difficult vascular access patients

OBJECTIVES

Ultrasound guided peripheral intravenous catheters (USPIV) are frequently utilized in the Emergency Department (ED) and lead to reduced central venous catheter (CVC) placements. USPIVs, however, are reported to have high failure rates. Our primary objective was to determine the proportion of patients that required CVC after USPIV. Our secondary objective was to determine if classic risk factors for difficult vascular access were predictive of future CVC placement.

METHODS

We performed a retrospective review for patients treated at a large academic hospital. Patients were identified by electronic health record and were restricted to age older than 21 years, had received USPIV, and admittance. Exclusion criteria included an existing CVC. Descriptive statistics, t-tests, chi-square proportions, and logistic regression were performed to test associations.

RESULTS

Of 363 eligible patients, 20 were excluded allowing for 343 for analysis. Of 343, 45 (13.1% 95% CI 9.9-17.1%) required CVC after USPIV. For secondary outcomes, no expected characteristics (diabetes, end-stage renal disease, IV drug abuse, peripheral vascular disease, or sickle cell disease) were predictive of CVC placement. The only predictive variables were admission to ICU/stepdown and length of stay. Each additional day of hospitalization had an OR 1.11 (95% CI 1.06-1.16%) of having a CVC placed.

CONCLUSION

Of those admitted after USPIV placement, approximately 7 out of every 8 patients did not require a subsequent CVC. Of the nearly 1 in 8 patients that required a CVC, factors associated with CVC placement were admission to a higher level of care and length of stay.

Standard long IV catheters versus extended dwell catheters: A randomized comparison of ultrasound-guided catheter survival

INTRODUCTION

Establishing peripheral intravenous (IV) access is a vital step in providing emergency care. Ten to 30% of Emergency Department (ED) patients have difficult vascular access (DVA). Even after cannulation, early failure of US-guided IV catheters is a common complication. The primary goal of this study was to compare survival of a standard long IV catheter to a longer extended dwell catheter.

METHODS

This study was a prospective, randomized comparative evaluation of catheter longevity. Two catheters were used in the comparison: [1] a standard long IV catheter, the 4.78 cm 20 gauge Becton Dickinson (BD); and [2] a 6 cm 3 French (19.5 gauge) Access Scientific POWERWAND™ extended dwell catheter (EDC). Adult DVA patients in the ED with vein depths of 1.20 cm-1.60 cm and expected hospital admissions of at least 24 h were recruited.

RESULTS

120 patients were enrolled. Ultimately, 70 patients were included in the survival analysis, with 33 patients in the EDC group and 37 patients in the standard long IV group. EDC catheters had lower rates of failure (p = 0.0016). Time to median catheter survival was 4.04 days for EDC catheters versus 1.25 days for the standard long IV catheter. Multivariate survival analysis also showed a significant survival benefit for the EDC catheter (p = 0.0360).

CONCLUSION

A longer extended dwell catheter represents a viable and favorable alternative to the standard longer IVs used for US-guided cannulation of veins >1.20 cm in depth. These catheters have significantly improved survival rates with similar insertion success characteristics.

First-Attempt Success, Longevity, and Complication Rates of Ultrasound-Guided Peripheral Intravenous Catheters in Children

OBJECTIVE

The aim of this study was to examine the success rates, longevity, and complications of ultrasound-guided peripheral intravenous lines (USgPIVs) placed in a pediatric emergency department.

METHODS

The study analyzed 300 USgPIV attempts in an urban tertiary-care pediatric emergency department. Data regarding USgPIV placement were collected from a 1-page form completed by the clinician placing the USgPIV. The time and reason for USgPIV removal were extracted from the medical record for patients with USgPIVs admitted to the hospital. A Kaplan-Meier survival analysis was performed.

RESULTS

This study demonstrated a success rate of 68% and 87% for the first and second attempts with USgPIV. Fifty-five percent of patients had 1 or more prior traditional intravenous access attempt. Most USgPIVs placed on patients admitted to the hospital were removed because they were no longer needed (101/160). We calculated a Kaplan-Meier median survival of 143 hours (6 days; interquartile range, 68-246 hours). The failure rate at 48 hours was 25%.

CONCLUSION

Ultrasound-guided intravenous access is a feasible alternative to traditional peripheral intravenous access in the pediatric emergency setting. We observed a high first-stick success rate even in patients who had failed traditional peripheral intravenous access attempts, few complications, and a long intravenous survival time.

Prevalence of difficult venous access and associated risk factors in highly complex hospitalised patients

AIMS AND OBJECTIVES

To estimate the prevalence of difficult venous access in complex patients with multimorbidity and to identify associated risk factors.

BACKGROUND

In highly complex patients, factors like ageing, the need for frequent use of irritant medication and multiple venous catheterisations to complete treatment could contribute to exhaustion of venous access.

DESIGN

A cross-sectional study was conducted.

METHODS

'Highly complex' patients (n = 135) were recruited from March 2013-November 2013. The main study variable was the prevalence of difficult venous access, assessed using one of the following criteria: (1) a history of difficulties obtaining venous access based on more than two attempts to insert an intravenous line and (2) no visible or palpable veins. Other factors potentially associated with the risk of difficult access were also measured (age, gender and chronic illnesses). Univariate analysis was performed for each potential risk factor. Factors with p < 0·2 were then included in multivariable logistic regression analysis. Odds ratios were also calculated.

RESULTS

The prevalence of difficult venous access was 59·3%. The univariate logistic regression analysis indicated that gender, a history of vascular access complications and osteoarticular disease were significantly associated with difficult venous access. The multivariable logistic regression showed that only gender was an independent risk factor and the odds ratios was 2·85.

CONCLUSIONS

The prevalence of difficult venous access is high in this population. Gender (female) is the only independent risk factor associated with this. Previous history of several attempts at catheter insertion is an important criterion in the assessment of difficult venous access.

RELEVANCE TO CLINICAL PRACTICE

The prevalence of difficult venous access in complex patients is 59·3%. Significant risk factors include being female and a history of complications related to vascular access.

Ultrasound-Guided Peripheral Intravenous Line Placement: A Narrative Review of Evidence-based Best Practices

Peripheral intravenous line placement is a common procedure in emergency medicine. Ultrasound guidance has been demonstrated to improve success rates, as well as decrease complications and pain. This paper provides a narrative review of the literature focusing on best practices and techniques to improve performance with this procedure. We provide an evidence-based discussion of preparation for the procedure, vein and catheter selection, multiple techniques for placement, and line confirmation.

Impact of Ultrasound on Short Peripheral Intravenous Catheter Placement on Vein Thrombosis Risk

Approximately 90% of hospitalized patients have a short peripheral intravenous catheter (SPC) placed. Methods of inserting the catheter have evolved over time and now include the use of ultrasound (US)-guided procedures for placement. Little is known about the impact that US-guided procedures have on the vein. This study compared the rate of venous thrombosis in patients with and without US-guided catheter placement. This prospective, single-blind, observational study assessed for venous thrombosis in 153 veins from 135 patients. Veins were evaluated by a research nurse blinded to the method of placement between 48 and 72 hours after the SPC was placed. The Fisher exact test showed a significant difference between vessel compressibility and catheter insertion method (P = .0012). The proportion of noncompressible veins was significantly greater when US was used in comparison with freehand SPC insertion. The Mantel-Haenszel chi-square value of 10.34 (P = .0013) showed that US insertion technique is associated with a higher likelihood of noncompressible veins. This pilot study provides compelling evidence that the use of US to assist with catheter placement is associated with a higher rate of noncompressible veins at day 2 or 3. Further studies are needed with a larger sample to determine the generalizability of the results from this pilot study.

Needle Phobia

Venipuncture is generally associated with some degree of pain, discomfort, and/or apprehension. Yet most patients accept it with tolerance, even nonchalance. A few, not only pediatric patients, exhibit a higher degree of anxiety and face the procedure with tears, tension, and a variety of bargaining techniques (ie, stick on the count of 3; use only this vein). But for 1 group of people, venipuncture is associated with such fear that avoidance of the procedure is practiced. The end results are detrimental to the patient and may have an impact on society as well. These are patients the American Psychiatric Association classifies as needle phobic. What can a nurse with no training in psychiatry do to assist these patients? To form an appropriate professional response, it's beneficial for practitioners to recognize the different pathways that lead to needle phobia and the issues related to the disorder.

Decreasing Peripherally Inserted Central Catheter Use With Ultrasound-Guided Peripheral Intravenous Lines: A Quality Improvement Project in the Acute Care Setting

An ultrasound-guided peripheral intravenous (UGPIV) quality improvement project occurred in an 849-bed tertiary care hospital with a goal to reduce the use of central lines, in particular, peripherally inserted central catheters (PICCs). Since implementation, PICCs have decreased by 46.7% overall, and 59 nurses in-hospital are competent in placing UGPIVs. Placement of UGPIVs by the bedside nurse is a key initiative in decreasing PICC use and, potentially, infections.

Accepted but unacceptable: peripheral IV catheter failure

Peripheral intravenous (IV) catheter insertion, the most common invasive hospital procedure performed worldwide, is associated with a variety of complications and an unacceptably high overall failure rate of 35% to 50% in even the best of hands. Catheter failure is costly to patients, caregivers, and the health care system. Although advances have been made, analysis of the mechanisms underlying the persistent high rate of peripheral IV failure reveals opportunities for improvement.

Innovative algorithm to evaluate the capabilities of visual, near infrared, and infrared technologies for the detection of veins for intravenous cannulation

Intravenous cannulation is the process of inserting a cannula into a vein to administrate medication, fluids, or to take blood samples. The process of identification and of locating veins plays an important role during the intravenous cannulation procedure to reduce health care costs and the suffering of patients. This paper compares the three technologies used to assess their suitability and capability for the detection of veins to support the cannulation process. Three types of cameras are used in this study; a visual, an infrared, and a near infrared. The collected images, 103 in total, from the three technologies have been analyzed using a wide range of image processing techniques and compared with identification templates to evaluate the performance of each technology. The results show that the near infrared technology supported by suitable LED illumination is the most effective for the visualization of veins. However, infrared thermography is found to be successful when followed by a cold stimulation.

Ultrasound-guided "short" midline catheters for difficult venous access in the emergency department: a retrospective analysis

BACKGROUND

Acutely ill patients admitted to the emergency department (ED) constantly require at least one fast and reliable peripheral intravenous (PIV) access. In many conditions (morbid obesity, underweight state, chronic diseases, intravenous drug abuse, adverse local conditions, etc.), PIV placement may be challenging. Ultrasound guidance is a useful tool for obtaining a peripheral intravenous access in the emergency department, particularly when superficial veins are difficult to identify by palpation and direct visualization, though standard peripheral intravenous cannulas are not ideal for this technique of insertion and may have limited duration. Long polyurethane catheters inserted with ultrasound guidance and direct Seldinger technique appear to have several advantages over short cannulas in terms of success of insertion and of duration.

METHODS

A retrospective analysis was conducted on all the ultrasound-guided peripheral venous accesses obtained by insertion of long polyurethane catheters in patients admitted to the emergency department of our university hospital during 1 year. The main indication to the procedure was the urgent need of a peripheral venous access in patients with superficial veins difficult to palpate and/or visualize. All relevant data concerning the insertion and the maintenance of these peripheral lines were collected from the chart.

RESULTS

Seventy-six patients were included in this review. The success rate of insertion was 100 %, with an average of 1.57 punctures per each successful cannulation. The mean time needed for the complete procedure was 9.5 min. In 73 % of patients, the catheter was used for more than 1 week; a minority of catheters were removed prematurely for end of use. No major infective or thrombotic complication was reported.

CONCLUSIONS

In our experience, 8- to 10-cm-long polyurethane catheters may offer a fast and reliable peripheral venous access in the emergency department, if placed by ultrasound guidance and with the Seldinger technique. Further studies with prospective, randomized, and controlled design are warranted to confirm our results.

Power Injection Through Ultrasound-Guided Intravenous Lines: Safety and Efficacy Under an Institutional Protocol

BACKGROUND

After an index case of contrast-associated compartment syndrome, an urban hospital instituted a protocol limiting high-speed injection to intravenous (IV) lines started proximal to the forearm and testing those lines before contrast injection.

OBJECTIVE

In this article, we estimate the safety and efficacy of high-speed injection using this protocol in patients with IV lines inserted under ultrasound guidance.

METHODS

In an ambispective study, we enrolled prospective cohorts of ED patients requiring high-speed radiographic contrast media injection (≥3.5 mL/sec) into two groups: those with IV lines placed under ultrasound guidance and those with IV lines placed using traditional inspection and palpation. We also performed a retrospective review involving those groups. In addition, we reviewed hospital records for all patients with compartment syndrome between January 2010 and December 2011. We calculated 95% confidence intervals using normal approximation or exact calculation.

RESULTS

Between November 2013 and August 2014, the ED referred 32 patients to the Department of Radiology for computed tomography angiography involving high-speed contrast injection through ultrasound-guided IV lines. Of these, 25 of 32 (78%) had successful injection (7 failed in the Department of Radiology) vs. 26 of 27 (96%) with catheters inserted using traditional methods (risk difference 0.18 [95% confidence interval -0.01 to 0.38]). Based on retrospective records, we estimated 79 additional cases. We found no cases of compartment syndrome during either period, for an incidence estimate of 0 per 100 cases (95% confidence interval 0-3).

CONCLUSION

A hospital policy for high-speed contrast injection through ultrasound-guided IV lines has a safe record. However, 22% of patients with ultrasound-guided IV lines were refused for CT.