Samantha Brothers, MS4
The Article: Constantino, et al. “Ultrasonography-Guided Peripheral Intravenous Access Versus Traditional Approaches in Patients with Difficult Intravenous Access.” Annals of Emergency Medicine, vol. 46, no. 5, 2005.
The Idea: Peripheral intravenous access is a commonly performed procedure in the emergency department that is typically carried out by nurses. However, sometimes a patient’s body habitus or co-morbid conditions make the procedure difficult, causing nurses to turn to physicians to attempt the procedure before they are committed to receiving a central line instead. With ultrasound becoming an increasingly utilized imaging modality, having already been shown to be beneficial for establishing central venous access, it leads us to believe that it would also improve the success rate of peripheral line placement. This study compares the success rate, procedure timing, and satisfaction of patients when using ultrasound guided placement versus the traditional landmark palpation approach when placing peripheral IVs.
The Study: Prospective, non-blinded, systematically allocated study that took place in 2 urban, tertiary care, university Eds between October 2003 and March 2004.
Design: Patient’s were systematically allocated to study versus control group based on day of presentation to the ED. Those who presented on an odd day were enrolled into the study group where they would receive ultrasound guided peripheral IV placement. Those who came into the ED on an even day were placed into the control group and underwent peripheral IV placement via traditional methods of landmark palpation. Patient’s were eligible for the study if nursing was unable to establish intravenous access after 3 attempts on a subgroup of patients who were obese, had chronic medical conditions, or history of intravenous drug use. Children and pregnant patients were excluded. Other exclusion criteria included inability to give consent or need of central venous access as determined by their physician.
Those in the study group underwent ultrasound guided IV placement, performed in real time with a 2-person technique where one physician held the probe in the transverse plane of the vessel to be cannulated while other placed an 18 gauge, 1.25 inch angiocatheter. In the control group, veins were visually inspected and palpated before attempting to cannulate, being allowed 3 total attempts. In an effort to reduce the number of patients who would need central line placements if the traditional approach failed to achieve cannulation, control group patients were allowed to opt in to a rescue pathway using ultrasound guided peripheral IV placement. Procedures were carried out by emergency medicine physicians and residents of varying experience.
The primary outcome was the rate of successful cannulation. Secondary outcomes included number of percutaneous sticks required, time of procedure (including time from first puncture to success as well as time of physician notification by nurse to success), overall patient satisfaction, and complications.
Results: 60 patients were enrolled, 39 into the study group and 21 into the control group.
Cannulation success rate was 97% for the US guided group, versus 33% in the control group. Of the 14 failures in the control group, 11 opted for the rescue pathway and all 11 were successfully cannulated using ultrasound guidance.
Median total time from first puncture to successful cannulation was significantly less in the study group with a median time of 4+/- 5.6 minutes versus 15 +/- 11.8 minutes in the control group. Even when accounting for time to prepare the ultrasound machine, total time to success was still significantly less for the US guided group.
There were fewer punctures required in the study group (1.7 +/-0.7) versus the control group (3.7+/-2).
Patient satisfaction was also significantly higher in the study group with a median rating of 8.7 on a 1-10 scale, versus 5.7 in the control group.
No significant complications in either group.
The Take Away: Using ultrasound to guide peripheral IV placement on patients who are difficult to cannulate not only significantly increases success rate, but also improves patient satisfaction with the procedure, likely due to decreased procedure time and decreased percutaneous sticks. This study shows that US-guided IV placement can be practically and efficiently carried out in the ED setting as it does not require more time nor does it require more experienced physicians to be available as this procedure was successfully carried by attending and resident physicians, both experienced and inexperienced. Limitations include larger sample size in the study group and lack of follow up and inability to detect delayed complications.