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Vascular Access Part 1

Ultrasound guided intravenous (UGIV) access is a relatively new application of bedside ultrasound that has reveled in soaring enthusiasm by emergency providers.

Now one of the things I need to get out of the way early on is that UGIV is a rescue procedure.  Even though you could do this on all of your patients, you definitely should not do that.   Our ED nurses are amazing at what they do and one of the things they’re amazing at is placing IV’s.

Why does this happen?

Well, sometimes patients are just difficult sticks.1 However, when a reason is reported, the most commonly reported associated factors are edema, obesity, those who have had multiple IV sticks in the past due to chronic illness (like sickle cell and renal dialysis patients, for instance) and IV drug abusers, among others. 1-5 

Why should you care?

It has been estimated that there are between 100-200 million intravascular catheters placed each year,6-8  which means that as many as 25 million patients per year may require multiple sticks, and patients who need special intervention when placing an IV have been estimated to range between 4.8-8% of adult patients. That’s at least 4.8-8 million patients per year that will be difficult sticks.2,9

Insanity is doing the same thing over and over again and expecting different results

Like I mentioned earlier, ED nurses are really good at vascular access.  When patients tell me they’re a difficult stick and “need the IV team”, I tell them that our nurses are the IV team.  I always have our staff try 2-3 times before I’ll attempt an UGIV.  When you take all comers, the landmark technique has been reported to be initially successful 74-77% of the time.10,11,12,13  Those numbers looks decent, but if you flip those numbers, the landmark technique can initially fail 26-23% of the time.  Sure, you can just keep poking and poking until after 16 sticks you get that 26 gauge catheter in the patient’s thumb, but that probably isn’t the best care you can give.  The more sticks you subject your patients to, the more anxiety and pain they experience, the more they’re exposed to the deleterious effects of delays in treatment and complications, not to mention the squandering of the clinicians’ time.14

What are your options in patients with difficult IV access (DIVA’s)?

If you find yourself needing IV access and are unable to get an IV, you have a few options: Intraosseus access (IO), external jugular (EJ), central lines (CVC), and UGIV. 15  Each of these are tools in your medical quiver that should be used to save your patients lives, and they each have situations where they shine.  Do you have a crashing patient that needs immediate life saving intervention? Don’t hesitate to use the drill. Have a patient that needs centrally administered drugs, rapid volume replacement or central monitoring? Throw in the CVC. But, there are definitely increased complications associated with central lines 14 and if you need to do a CTA, many CVC’s don’t have the flow rate required for contrasted studies.  What about if you see a big, thick vein nestled on top of the sternocleidomastoid?  EJ’s work great when they’re visible.  One study directly compared EJ to UGIV in difficult stick patients and found that the two were identical as far as success rates.  However, that was only in patients in which you could easily visualize the EJ.  In all comers (including those in which the EJ could not be easily visualized), EJ IV placement was 50% successful compared to UGIV (in that arm) which had a success rate of 84%.16

So now we get to what we all care about: The illustrious UGIV.

What is the overall success of UGIV?

Out of all of the studies I found, there was only one that showed decreased success when using ultrasound in difficult access patients. Stein et al17 randomized 59 patients to get US or standard technique for patients with 2 previous IV attempts, and found no difference in success and a longer time to cannulation in the UGIV group. The main problem with this study was the training the participants received. The training for the study participants (who were attendings in 2005) consisted of 1 hour of didactics that included both UGIV and CVC techniques followed by 1 hour of training on an US phantom. After that they had some unspecified “observational period” where it seems like they may have done some UGIV attempts on actual patients before participating in the procedure.  So basically the participants in this study were practitioners that likely did not have a whole lot of experience with ultrasound in general, got minimal UGIV training, then did the study.

Fortunately, the preponderance of the evidence shows that in DIVAs, US performs better than landmark-based techniques.

success_of_usgiv_1

Besides increased success rates, there are few other patient-centered outcomes in which UGIV performs better than blind techniques.  A study by Bauman et al 18 found that UGIV was 2x faster, had fewer complications, less skin punctures, and increased satisfaction. Another study 19 found US to be quicker, include fewer sticks, and have greater satisfaction when compared to landmark-based techniques.

The discussion of US-guided peripherally IV placement is one that is a bit much to tackle in just one post, so I’m going to stop here.  I’ll be posting more on the actual technique on the next post.

Click here for Part 2

 

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References

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  2. Witting MD, Moayedi S, Beverly SK, Stover BJ, Miller AC. Incidence of advanced intravenous access in 2 urban EDs. Am J Emerg Med. 2015. [pubmed]
  3. Keyes LE, Frazee BW, Snoey ER, Simon BC, Christy D. Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access. Ann Emerg Med. 1999;34:(6)711-4. [pubmed]
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  5. Resnick JR, Cydulka RK, Donato J, Jones RA, Werner SL. Success of ultrasound-guided peripheral intravenous access with skin marking. Acad Emerg Med. 2008;15:(8)723-30. [pubmed]
  6. Weiner MM, Geldard P, Mittnacht AJ. Ultrasound-guided vascular access: a comprehensive review. J Cardiothorac Vasc Anesth. 2013;27:(2)345-60. [pubmed]
  7. Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc 2006;81:1159-71. [PubMed]
  8. Richardson DK. Vascular access nursing-practice, standards of care, and strategies to prevent infection: a review of flushing solutions and injection caps (part 3 of a 3-part series). J Assoc Vasc Access. 2007;12(2):74-84.
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  11. Jacobson AF, Winslow EH. Variables influencing intravenous catheter insertion difficulty and failure: an analysis of 339 intravenous catheter insertions. Heart Lung. 2005;34(5):345-59.
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Jacob Avila