Central venous catheterization

Nurse-Performed Ultrasound-Guided Technique for Difficult Peripheral Intravenous Access in Critically Ill Patients: A Randomized Controlled Trial

Highlights

Abstract

Purpose: The aim of this study was to compare nurse-performed ultrasound (US)-guided technique with standard of care (SOC) technique for difficult peripheral intravenous (PIV) access among patients admitted to the intensive care unit (ICU).

Materials and Methods: This was a randomized, prospective, open-label single-site study. ICU nurses completed a standardized training program for US-guided PIV access placement before patient enrollment. ICU patients with difficult PIV access were randomized to either nurse-performed US-guided technique or SOC technique. Primary outcome was success rate on the first attempt. Secondary outcomes were success rate after 2 attempts and frequency of complications after successful placement.

Results: A total of 60 patients were enrolled; 30 were randomized to receive US-guided technique, and 30 to SOC technique. Success rate on the first attempt was significantly higher with US-guided technique compared with SOC technique (70% vs 40%; P < 0.05). Success rates after 2 attempts were 73.3% for US-guided technique and 46.6% for SOC technique (P = 0.065). Extravasation after successful placement occurred in 13.6% of patients with US-guided technique, and 28.6% of patients with SOC technique (P = 0.394).

Conclusions: Among ICU patients with difficult PIV access, US-guided PIV access placement by nurses who underwent standardized training was more successful than placement with SOC technique.

Percutaneous Ultrasound-guided Central Venous Catheters: The Lateral In-plane Technique for Internal Jugular Vein Access

Purpose

To describe the possible ultrasound guidance techniques for the insertion of central venous catheters (CVCs), with emphasis particularly to the lateral short axis in-plane technique.

Methods

Numerous articles have shown significant benefits of using ultrasound guidance for venous access. Two main approaches to vein puncture are available, when considering visualization of the needle during its entry into the vein under the ultrasound beam: in-plane and out-of-plane, which can be combined with two types of vein visualization, placing the ultrasound probe on the vein long axis or short axis.

Results

Advantages and limitations in internal jugular vein (IJV) cannulation for long-term dialysis CVCs are described for the above-mentioned approaches and visualizations. The lateral short axis in-plane technique has virtually no limitations, ensuring most benefits.

Conclusions

The lateral short axis in-plane technique should be considered the first-line technique for IJV cannulation.

Changes in the relationship between the right internal jugular vein and an anatomical landmark after head rotation

Background

This study was performed to ultrasonographically demonstrate the changes in relationship between the right internal jugular vein (IJV) and an anatomical landmark in two different head positions: neutral and rotated.

Methods

This was a randomized clinical trial. One hundred patients scheduled for elective surgery under general anesthesia with endotracheal intubation were enrolled in this study. The patients were placed in the supine position with a neutral head position and without a pillow. The apex of the triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle and clavicle was marked (AL point : anatomical landmark point). Ultrasonography of the neck anatomy was performed and the skin was marked at the central point of the IJV (US point: ultrasonography point). The other investigator measured the distance from the AL point to the US point (AL-US distance). The patient's head was then turned 30° to the left; the same procedure was repeated and the AL-US distance was again measured. The changes in AL-US distance were calculated.

Results

The AL-US distance increased significantly after 30° head rotation compared with that in a head neutral position. The mean ± SD of the AL-US distance was 0.28 ± 0.78 cm in the neutral head position and 0.83 ± 1.03 cm in the head rotated position.

Conclusions

The anatomical landmark point becomes more distant from the actual right IJV point and moves more medially after head rotation. We suggest minimizing the angle of head rotation and taking this distance into consideration when using the landmark-guided method.