Ultrasound for peripheral and arterial access

Bridging an Education Gap: Ultrasound-guided Peripheral IVs

PURPOSE

To provide ultrasound (US) education to anesthesia providers to increase usage for peripheral intravascular (IV) cannulation on difficult IV access patients.

DESIGN

This project reflects a qualitative descriptive quality improvement project with outcomes measured. Data in this project include the overall knowledge and competency scores from the provider's US survey before and after education and training were provided.

METHODS

A presentation was developed and provided to 38 certified registered nurse anesthetists (CRNA) via the hospital's online platform. Next, in-person simulations were conducted to facilitate the skills of US utilization. Each CRNA participating in simulations successfully performed the skill. The impact and success of the education bundle were collected via the disbursement of a Likert-scale survey via an automated data collection software.

FINDINGS

Seventeen of the 38 (45%) participants responded to the survey. Of these respondents, 88% of providers indicated that their US skills and confidence had increased following the intervention, and 100% of participants stated that the intervention was helpful in learning US-guided peripheral IV insertion.

CONCLUSIONS

Education and hands-on skills sessions increased provider confidence in US use. While this project focused on educational training of CRNAs, this is applicable to all health care providers who are responsible for IV cannulation. The project team members will disseminate these findings and plan to improve perioperative nurses' confidence in US-guided peripheral IV insertions; thus, improving efficiency in the operative setting.

The distal quarter of the forearm is the optimal insertion site for ultrasound-guided radial artery cannulation: A randomized controlled trial

BACKGROUND

Current guidelines recommend the use of ultrasound guidance for arterial cannulation. However, there are no recommendations on the best insertion site for radial artery cannulation in terms of catheter dwell time and incidence of complications.

METHODS

In this randomized controlled study 94 patients were randomly assigned into three groups, corresponding to three different sites of insertion for radial artery cannulation: hand wrist: (Site/group 1, n = 29), distal quarter part of the forearm (Site/group 2, n = 30) and the midpoint of the forearm (Site/group 3, n = 35). Age, height, weight, and diagnosis of each patient were recorded prior to insertions which were performed by a single investigator experienced in ultrasound-guided vascular access.

RESULTS

Radial artery diameters were similar (2.4 ± 0.4 vs 2.5 ± 0.3 vs 2.6 ± 0.4 mm), however skin to vessel distances were different between groups, and the depth of the radial artery increased progressively from distal to proximal sites. There was a significant difference between groups in terms of success rates at the first attempt. Only two cannulations were successful at first attempt, and overall, only 17 of 35 cannulations were successful at Site 1. Arterial cannula dislodgement rate was highest at Site 1(8/29, 26.7%), while the longest dwell time was at Site 2 with a median of 4 (IQR 3) days.

CONCLUSIONS

Considering the high removal rate at the wrist region and the high failure rate at the midpoint of the forearm, the distal quarter of the forearm can be identified as "the optimal insertion site' for ultrasound-guided radial artery cannulation.

10 best practice tips with radial arterial catheterization

Radial arterial catheters (RAC) are used extensively across critical care settings (Anesthesia, Intensive Care, Emergency Medicine) for continuous hemodynamic monitoring, allowing for immediate adjustments in vasopressor therapies and blood collection. Radial catheter failures are an ongoing significant issue for critical care clinicians with reported incidences at almost 25%. Common complications include loss of function, lack of blood return, poor quality waveforms and dislodgement, posing potential patient risks, and sudden loss of intra-arterial monitoring frequently requires prompt replacement. Contemporary research and technological improvements have highlighted several concepts to enhance the approach of RAC insertion and management while reducing immediate and late complications. The authors have prioritized the following 10 "best practice" aspects that may improve overall device function and reliability.

Effect of a thin-tipped short bevel needle for peripheral intravenous access on the compressive deformation and displacement of the vein: A preclinical study

BACKGROUND

Peripheral intravenous catheter (PIVC) insertion often fails on the first attempt. Risk factors include small vein size and dehydration, causing vein deformation and displacement due to puncture resistance of the vessel. The authors developed a short, thin-tipped bevel needle and compared its puncture performance with needles of four available PIVCs using an ex vivo model.

METHODS

The PIVC with the thin-tipped short bevel needle was compared to four available PIVCs using an ex vivo model which simulated the cephalic vein of the human forearm. The ex vivo model consisted of a porcine shoulder and porcine internal jugular vein, and was used for evaluation of the rate of vein deformation and vessel displacement during needle insertion.

RESULTS

An ex vivo model was created with a vessel diameter of 2.7-3.7 mm and a depth of 2-5 mm. The thin-tipped short bevel PIVC needle was associated with a significantly lower compressive deformation rate and venous displacement compared to the needles of the other four PIVCs.

CONCLUSION

The thin-tipped short bevel needle induced lower compressive deformation and displacement of the vein than the conventional needles. This needle has the potential to improve the first-attempt success rate of peripheral intravenous catheterization in patients with difficult venous access.

A novel track guidance ultrasound facilitates radial arterial cannulation: A prospective randomized controlled trial

BACKGROUND

Ultrasound guidance for radial arterial cannulation is currently considered a best practice approach despite its clear advantages over the blind and palpation technique, the success rate is related to several factors, including clinician's experience and technical ability. The study aimed to explore the use of a novel track guidance ultrasound that may increase the success rate of radial arterial cannulation.

METHODS

A randomized controlled trial was conducted, in which 80 adults scheduled for elective surgery requiring radial arterial cannulation were recruited and randomly assigned to either the experimental group, which utilized novel track ultrasound guidance (group T, n = 40), or the control group, which utilized traditional ultrasound guidance (group U, n = 40). The novel track guidance ultrasound comprises a positioning track and a guided track. The radial artery could be positioned at the center of the positional track on the ultrasound image, and the direction and angle of needle are fixed and toward the center of the positioning track. The primary endpoint of the study was the first-pass cannulation success rate, while the secondary endpoints included the failure rate of cannulation, the number of radial artery punctures, the time of cannulation, and the incidence of hematoma.

RESULTS

The success rate of cannulation at the first attempt in group T (35 of 40 (87.5%)) was significantly higher than that in group U (23 of 40 (57.5%); p = 0.003). Although seven patients in Group U (7 of 40 (17.5%)) experienced failed cannulation compared to one in Group T (1 of 40 (2.5%)), the difference in failure rate between the two groups did not reach statistical significance (p = 0.06).

CONCLUSIONS

The implementation of novel track ultrasound guidance has demonstrated a notable improvement in the success rates at the first attempt while reducing the frequency of punctures and cannulation times.

Comparison of ultrasound guided dorsal radial artery cannulation and conventional radial artery cannulation at the volar aspect of wrist: A pilot randomized controlled trial

BACKGROUND

Distal radial artery cannulation at the "anatomical snuffbox" carries several theoretical advantages over conventional radial arterial cannulation at the wrist. However, these two techniques have not been evaluated in perioperative settings.

METHODS

In this randomized controlled trial, n = 200 patients requiring arterial cannulation for perioperative monitoring were recruited. Patients were randomized to either ultrasound guided distal radial artery cannulation group (group D) or ultrasound guided conventional radial artery cannulation group (group W). Primary outcome of this study was first attempt cannulation success rate.

RESULTS

First attempt cannulation success rate was significantly lower in distal radial artery cannulation (57% in group D and 77% in group W; p = 0.003). Use of alternative cannulation site was significantly higher in group D when compared to group W (p = 0.015) and number of attempts for successful cannulation was significantly higher in group D when compared to group W (p = 0.015). None of the patients in any group developed thrombosis and related complications and intraoperative catheter dislodgement. Time to puncture the artery (p < 0.0001), total cannulation time (p < 0.0001), and actual catheter insertion time (p < 0.0001) were significantly higher in group D in comparison to group W.

CONCLUSION

Distal radial artery cannulation was associated with lower first attempt cannulation success rate and requires longer time to perform. As distal radial artery is a new technique, further studies are required in different clinical settings.

Ultrasound-Guided Radial Arterial Catheterization in Patients With Regurgitant and Stenotic Left-Sided Cardiac Valvular Lesions

Background. The pulse characteristics of arterial circulation might affect radial artery catheterization's success rate. Therefore, we hypothesized that the success rate of radial artery catheterization would be lower in the left-sided severe stenotic valvular lesion group than severe regurgitant valvular lesion group. Methods. This prospective study was conducted among patients with left-sided cardiac valvular lesions undergoing cardiac and non-cardiac surgery. The patients with left-sided severe valvular stenosis and left-sided severe valvular regurgitation were included in the study. Radial artery cannulation was performed using an ultrasound-guided out-of-plane short-axis approach. The outcome measures were success rate, number of attempts, and cannulation time. Result. One hundred fifty-two patients were recruited for the study, and all were eligible for final analysis. The first attempt success rate was non-significantly higher in the stenotic valvular lesion group than the regurgitant group (69.7% vs 56.6%; P = .09). Furthermore, the number of attempts (median; 95% CI) was significantly higher in the regurgitant group (1; 1.2-1.43 vs 1; 1.38-1.67; P = .04). However, it may not be of clinical relevance. Moreover, the cannulation time and the number of redirections of the cannula were comparable. Heart rate was significantly higher in the regurgitant group (91.8 ± 13.9 vs 82.26 ± 15.92 beats/min; P = .00), while the incidence of atrial fibrillation was significantly higher in the stenotic lesion (P = .00). No failure was reported, and the incidence of periarterial hematoma was comparable. Conclusion. The success rate of ultrasound-guided radial arterial catheterization is comparable in left-sided stenotic valvular and regurgitant lesion groups.

Feasibility, Efficacy, and Safety of Peripheral Venous Access for Chronic Double-Filtration Plasmapheresis with Regional Citrate Anticoagulation

INTRODUCTION

Peripheral venous access (PVA) is recommended as a first-line vascular approach for therapeutic plasmapheresis with centrifugation methods but not filtration, which usually requires high blood flow. We evaluated the feasibility, efficacy, and safety of double-filtration plasmapheresis (DFPP) with PVA, using ultrasound guidance and regional citrate anticoagulation (RCA), i.e., PVA-RCA-DFPP in patients undergoing chronic DFPP. Secondly, we assessed the number of central venous catheters (CVCs) avoided.

METHODS

A single-center retrospective study evaluated 22 adult patients on chronic DFPP to perform PVA-RCA-DFPP. They were classified into 3 groups: successful (i.e., completion of sessions with PVA), primary failure (i.e., no sessions completed), secondary failure (i.e., ≥1 session with PVA completed but secondary return with CVC or arteriovenous fistula).

RESULTS

Among the 22 patients included (64% men), 7 patients (32%) were classified as primary failures (2 patient refusals, 5 inadequate PVAs), 1 patient (5%) as a secondary failure (due to uncomfortable venipunctures), and 14 patients (64%) as successful. In the successful group including 12 patients treated for chronic inflammatory demyelinating polyneuropathy (CIDP) and 2 patients for familial hypercholesterolemia (FH) (2 patients), 116 sessions were performed, with a median treated plasma volume of 4.3 L [IQR 3.6-4.6] (45 mL/kg) for a median duration of 134 min [IQR 122-144], and a median blood flow of 94 mL/min [IQR 87-103]. For the CIDP group, 90% of sessions achieved a plasma volume >1 TPV, and for the FH group 91% of sessions achieved an LDLc reduction >60%. Eleven sessions out of 116 (9%) were interrupted, mostly due to PVA dysfunction (5/11) and circuit clotting (4/11). Session interruptions decreased significantly between each patient's first and following sessions (29% to 7%, p = 0.009).

CONCLUSION

Chronic PVA-RCA-DFPP can be performed safely and efficiently, avoiding the use of CVCs.

Preventing radial arterial catheter failure in critical care - Factoring updated clinical strategies and techniques

Radial artery catheterization is a frequently performed procedure for critically ill patients. The correct function of arterial catheters is essential to provide accurate and continuous hemodynamic monitoring, facilitating intermittent blood sampling and helping to optimize the workload for critical care nurses and physicians. However, they are not without their own problems. This narrative practice review discusses several clinical aspects that are not frequently considered but may contribute to enhanced catheter functionality, less device-related failure and more acceptable dwell times. Ultrasound has demonstrated unequivocal efficacies and safety with the procedure, improving first attempt success rates with children, the obese or patients with unstable clinical vital signs and shock. Moreover, anatomic variations of the radial artery are not rare, and ultrasound-guided catheterization reduces the incidence of insertion-related complications such as hematoma, posterior wall puncture, intimal dissection, and radial nerve injury. Ultrasound guidance offers several immediate benefits by enhancing the most appropriate insertion techniques, allows for the correct catheter to vessel ratio measurements to be performed and reduces the angle of insertion, which may affect catheter failure due to inappropriate catheter length. A deeper and more proximal cannulation site at least 4 cm from wrist joint, avoiding the area of wrist flexion, reduces mechanical complications related to patient movements and may improve catheter functionality and dwell along with a better area for stabilization and securement.

Comparison of the dilatory effect of three strategies on peripheral veins of the upper extremity in adults

BACKGROUND

Dilated veins are associated with increased success of peripheral intravenous cannulation, due to its improved visibility and palpability. Comparison of three strategies to achieve venodilation (tourniquet, electrical stimulation, or a combined strategy) on increase in venous size.

METHODS

A total of 54 volunteers participated in this cross-over observational study with healthy adults, measuring venous cross-sectional area and diameter at six different sites of the upper extremity. Measurements are performed with ultrasound after performing any dilation strategy, and compared with its non-dilated venous size. An increased cross-sectional area of 25 square millimetres was denoted as clinical relevant, which was detected with paired t testing, Wilcoxon signed rank testing or with ANOVA testing.

RESULTS

The cephalic vein is the greatest at all sites (t=12.43, df=39, P<0.001 for the crosssectional area), unless the largest increase in venous size was obtained in the basilic veins (t=12.11, df=39, P<0.001 for the cross-sectional area). The largest increase in venous size was obtained after electrical stimulation followed by tourniquet application at all measurement sites. Percentage-wise increased the basilic vein with 44% in cross-sectional area and 21% in diameter, which were 37% and 17% for the cross-sectional area and diameter of the cephalic vein.

CONCLUSIONS

In general, the largest sized veins are situated in the upper arm, of which the cephalic vein has the largest cross-sectional area and diameter. The combination of electrical stimulation followed by tourniquet application resulted in the greatest increase in venous size and is therefore considered as most effective to improve peripheral intravenous cannulation success.

The impact of a notched peripheral intravenous catheter on the first attempt success rate in hospitalized adults: Block-randomized trial

INTRODUCTION

Peripheral intravenous cannulation is the preferred method to obtain vascular access, but not always successful on the first attempt. Evidence on the impact of the intravenous catheter itself on the success rate is lacking. Faster visualization of blood flashback into the catheter, as a result of a notched needle, is thought to increase first attempt success rate. The current study aimed to assess if inserting a notched peripheral intravenous catheter will increase first attempt cannulation success up to 90%, when compared to inserting a catheter without a notched needle.

DESIGN

In this block-randomized trial, adult patients in the intervention group got a notched peripheral intravenous catheter inserted, patients in the control group received a traditional non-notched catheter. The primary objective was the first attempt success rate of peripheral intravenous cannulation. Intravenous cannulation was performed according to practice guidelines and hospital policy.

RESULTS

About 328 patients were included in the intervention group and 330 patients in the control group. First attempt success was 85% and 79% for the intervention and control group respectively. First attempt success was remarkably higher in the intervention group regarding patients with a high risk for failed cannulation (29%), when compared to the control group (10%).

CONCLUSION

This study was unable to reach a first attempt success of 90%, although first attempt cannulation success was higher in patients who got a notched needle inserted when compared to those who got a non-notched needle inserted, unless a patients individual risk profile for a difficult intravenous access.

Experience of ultrasound performed by infectiologists, an innovating approach for the management of patients

INTRODUCTION

Ultrasound imaging has many clinical applications, but there is a lack of data about its use by infectiologists. The aim of this study was to describe ultrasound performed routinely by infectiologists and to assess the diagnostic performance of ultrasound with aspirate and fluid analysis in prosthetic joint infections.

METHODS

Retrospective study between 1^st June 2019 and 1^st June 2020 in an infectious and tropical diseases unit in a tertiary University Hospital.

RESULTS

One hundred and thirty-one ultrasounds were performed on 127 patients by the infectious diseases team. These included 64 musculoskeletal ultrasounds (31 in native joints and 33 in prosthetic joints including 15 knees, 13 hips and 5 spacers) and 33 led to a fluid aspirate. Fourteen lung ultrasounds were done, 11 confirmed pneumopathy and 7 resulted in pleural puncture. Twenty-three vascular ultrasounds were done, 17 to insert a catheter, and four to perform a blood test. Five ultrasounds explored adenopathy, of which one node tuberculosis and one Bartonella infection were diagnosed. In prosthetic joint infections, sensitivity and specificity of ultrasound with fluid aspirate and analysis were respectively 100% and 100% for the knee and 40% and 100% for the hip.

CONCLUSION

Ultrasound performed by infectiologists is useful and contributes to a faster diagnosis. Furthermore, the specificity of ultrasound with aspirate and fluid analysis is very high in prosthetic joint infection. Ultrasound training courses should be considered for infectiologists including residents.

Characteristics of expert nurses' assessment of insertion sites for peripheral venous catheters in elderly adults with hard-to-find veins

AIM

To clarify the characteristics of expert nurses' assessments when selecting an insertion site for a peripheral venous catheter (PVC).

METHODS

Participants were 11 competent (control group) and 13 expert nurses. Using a simulated patient, we recorded the procedures participants followed when selecting a site for a PVC insertion. The researchers interviewed the nurses after the procedure by asking targeted questions about the site selection to clarify the factors influencing that selection. During the interview, a video of that nurse's procedure was observed, and each step performed during the procedure was investigated.

RESULTS

We identified three assessment characteristics specific to expert nurses that influenced their PVC site selection: (a) focusing on a patient's unique characteristics and choosing the appropriate procedure for that individual; (b) avoiding complications and paying attention to the patient's daily self-care needs; and (c) carefully considering the patient's fear and fatigue during site selection and catheter insertion. Other assessments, based on the general knowledge and skill acquired by nurses in selecting a PVC site, were common to both groups: arm selection based on the patient's preference and site selection to avoid nerve injuries or complications. The control group's approach was assessed on the basis of their confidence in selecting a site for a PVC insertion.

CONCLUSIONS

Expert nurses assessed the patient's individual characteristics and daily self-care needs and helped mitigate the patient's anxiety. Our findings provide a basis for educational programs that share how expert nurses assess sites for a PVC insertion.